Regulatory Reform
Norman Lamb Excerpts(9 years, 8 months ago)
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The Minister of State, Department of Health (Norman Lamb)
I beg to move,
That the draft Legislative Reform (Clinical Commissioning Groups) order 2014, which was laid before this House on 13 March 2014, in the last Session of Parliament, be approved.
The draft legislative reform order seeks to amend the National Health Service Act 2006 in two ways. First, it will allow clinical commissioning groups to form a joint committee when exercising their commissioning functions jointly. The 2006 Act already allows two or more CCGs to exercise their commissioning functions jointly, but makes no provision for them to do so via a joint committee. Secondly, it will allow CCGs to exercise their commissioning functions jointly with NHS England and to form a joint committee when doing so. The Act already allows NHS England and CCGs jointly to exercise an NHS England function and to do so by way of a joint committee, but it makes no provision for them jointly to exercise a CCG function.
This draft order has already been scrutinised by the Regulatory Reform Committee, and I was pleased with its recommendation that it be approved under the affirmative resolution procedure.
I should say from the outset that the proposed arrangements are voluntary. One party cannot impose the arrangements on another. This allows CCGs to retain their autonomy and to continue to make decisions that are in the best interests of their local populations. They can decide whether to enter a joint committee arrangement with other CCGs. At the moment, the lack of provision for CCGs to form joint committees is placing a burden on CCGs and preventing them from working in the most effective and efficient way. Without the power to form joint committees, CCGs have had to find other means of reaching joint decisions that are binding. That means that they often end up seeking legal advice to ensure that they are on a firm footing, and that adds to cost and complexity without a proper process in place.
As an interim measure, therefore, some CCGs are forming committees in common whereby a number of CCGs may each appoint a representative to such a committee. Those representatives then meet, and any decisions reached are taken back to their respective CCGs for ratification. This leads to additional costs in terms of people’s time in sitting on multiple committees, administrative resources, and extra financial cost. Clearly, such arrangements are burdensome, particularly when compared with the simplicity of a joint committee. Primary care trusts, the predecessors of CCGs, were able to form joint committees at which all participating PCTs were bound by the decisions reached, subject to the terms of reference of that committee.
Graham Stringer (Blackley and Broughton) (Lab)
The Minister’s advice that all the members of a committee acting in common have to report back is at odds with the letter from the Department of Health to a committee dated 8 April 2014, where part of its case is that decisions have to be taken unanimously. That is quite different from having to report back, and it undermines his case about the administrative burden.
Norman Lamb
Currently, because there is no provision for a joint committee, the participating CCGs have to enter into some sort of arrangement that allows them, under their constitutional arrangements, to approve whatever plan of action is discussed and agreed at the committee in common. There could be a process for each CCG to delegate responsibility to the person attending the committee in common to take the decision at the committee on a unanimous basis, as the hon. Gentleman suggests. Alternatively, there could be an arrangement whereby they have to go back to their own CCG and then have a further committee meeting to endorse the proposal that has been discussed at the committee in common. However it is done, it adds complexity and additional cost to the process. It does not stop anything happening; it just makes it more complicated than it has to be.
As I said, such arrangements can be burdensome. Primary care trusts, the predecessors of CCGs, were able to form joint committees at which participating PCTs were bound by the decisions reached. We therefore want to allow CCGs—I stress that we are allowing them, not imposing anything on them, and it is entirely up to them to decide whether they want to participate—a route through which they can take decisions in a properly constituted forum when they are collaborating with other CCGs.
Similarly, the lack of any power for CCGs to exercise their functions jointly with NHS England is causing inflexibility. NHS England and CCGs may wish to act jointly to commission better out-of-hospital services, for example. Making sure that services are integrated around the needs of the patient is the best way of ensuring that care is provided in a safe and compassionate way that most benefits the person involved.
Sometimes there are issues that straddle the commissioning responsibilities of NHS England—the specialised end of the commissioning spectrum—and the responsibilities of the local CCG, and it seems to me that it is worth trying to secure joint working on both sides of that divide in the most effective way possible. The amendment would allow CCGs and NHS England, as co-commissioners, to develop and agree strategic plans and delivery processes that take into account the effects of services across the whole pathway—from specialist to local commissioning—supporting design and continuity of services across primary, secondary and community care.
For example, CCGs and NHS England may wish to review service delivery across specialised services commissioned by NHS England and any impact a redesign may have on non-specialised acute services commissioned by CCGs, in order for services to be designed and delivered to achieve the best possible outcome for the population served. The inability of NHS England and CCGs to jointly exercise a CCG function, and to form a joint committee when doing so, makes it more difficult to make timely decisions, which can delay the ability to improve patient safety. The proposed amendments will encourage the formation of new commissioning partnerships, allowing the most effective approach to be used.
When CCGs agree to form a joint committee, they will have the freedom to agree terms of reference, including voting arrangements. They could, therefore, agree between them to allow decisions to be reached by a majority. Equally, however, if a CCG wants to be absolutely sure that there would be no adverse effect on the area it serves, it could, as part of the agreement to enter the joint committee, require unanimity before anything is approved. This will not dilute the emphasis on local decision making.
It is important that patients, members of the public and other stakeholders are able to see how joint committees operate and, in particular, how decisions are made. CCGs must specify in their constitutions the arrangements made for the discharge of their functions and for ensuring that there is transparency about the group’s decisions and the manner in which they are made. That applies whether CCGs are discharging their functions individually or as part of a joint committee with other CCGs.
CCGs already have a duty to involve patients and the public in plans and decisions about commissioning arrangements. This involvement can be by way of consultation, by the provision of information or in other ways. We would still expect CCGs to make suitable arrangements to make sure that that duty is complied with when exercising their functions in a joint committee. In other words, the duty is exactly the same: arrangements for public involvement apply equally to decisions made by CCGs in a joint committee as they do to those made by CCGs individually. There is no reason why decisions taken in joint committees should be any less transparent than any decisions taken individually. The creation of joint committees would enable CCGs to take binding decisions without the need for separate ratification of complicated delegation structures.
CCGs are still accountable as individual organisations—they do not lose that by entering a joint committee. Joint arrangements mean that each CCG is still liable for the exercise of its commissioning functions, even where they are being exercised jointly with another CCG or with NHS England. To be clear: joint working does not abrogate a CCG of their responsibilities as a statutory, independent and accountable organisation. The proposed arrangements will not lead to reconfiguration by the back door; they will not affect the existing processes, the tests that any significant service redesign needs to follow or the role of the overview and scrutiny committee locally.
The proposed amendments build on existing powers by giving CCGs greater flexibility and control in the way they work. They return, in a sense, to the arrangements that were in place with primary care trusts. The changes will support more effective and efficient joint working and allow discussions about service redesign to take place across the local health economy. As CCGs become more established organisations, they need to have more flexibility to work together and with NHS England. In any commissioning structure, there will always be some decisions that need to be taken locally and some that span a wider population.
Liz Kendall
No. I will make some progress. The hon. Gentleman may want to listen to what the Secretary of State for Health admitted in a letter to the chair of Healthwatch England on 11 August:
“The Health and Social Care Act, when it established CCGs, did not make provision for CCGs to form joint committees and other CCGs. PCTs previously had this provision in legislation and many formed joint committees to progress partnership work.
Health organisations, including CCGs, have expressed concerns about CCGs’ inability to form joint committees that are able to make binding decisions. This inability has brought many practical challenges in working together on issues that cut across boundaries, such as continuing healthcare, patient specific funding requests and service change”
across the country. I do not know whether the Minister wants to explain why the Health and Social Care Act removed that provision, as the Health Secretary admitted in the letter to Healthwatch England. Does he want to stand up? If not, I will make some progress.
The Minister was fortunate not to be on the Committee that looked at the Health and Social Care Bill twice, so he will not know that Opposition Members repeatedly warned during its passage that CCGs would often be too small to secure effective changes to services across wider areas. We have consistently made it clear that the only way we can get the big changes we need to be able to improve care for patients, including by specialising some services in regional centres and shifting others out of hospitals into the community and towards prevention, is by working in partnership across larger areas.
In principle, we support the need for collaboration and for CCGs to come together both with one another and with NHS England, particularly in wanting to commission good services across primary, secondary, community and specialist care. However, serious concerns have been raised about the draft order by local healthwatch organisations, Healthwatch England and some of the organisations that responded to the consultation, and my hon. Friends may want to raise real concerns. I will go through the concerns in some detail.
The Minister has talked about the fact that CCGs will remain autonomous, but many of them are concerned that that is not written into the draft order. Many CCGs feel that they are coming under increasing pressure from NHS England and some of its local offices. They are concerned that the draft order might take away their autonomy, forcing them into committees and decisions that they do not think are in the best interests of local people.
Liz Kendall
If the Minister will give me two seconds, before I allow him to intervene I want to read out what NHS Clinical Commissioners—the independent collective voice of CCGs—said in its response to the consultation. It said that it
“would not want the Legislative Reform Order to become a ‘back door mechanism’ for reconfigurations.”
It asked for
“some assurance the change will continue to respect the decisions of CCGs as statutory bodies”,
and it insisted that
“CCGs must not be pushed into shared arrangements with NHS England if it is not in the interests or needs of their population”.
I have heard the Minister’s words about that, but the draft order has not been changed. Perhaps he would like to say more about it.
Norman Lamb
It is worth putting it on the record again that this does nothing to change the legal duties of a CCG and nothing to put any pressure on a CCG to enter any arrangement, either with other CCGs or with NHS England. If a CCG feels under pressure, it has every right to resist it, if it feels that to do so is in its interests or those of its local community. This is entirely voluntary. With regard to the legal duties, nothing changes.
Liz Kendall
If one of the 22 CCGs in the east midlands, part of which I represent, decided that it did not want to come together to commission one body to perform NHS continuing health care, for example, because it did not like it, could it say no?
Norman Lamb
Absolutely. There is nothing in the proposed amendment that could force any CCG to do anything. I suspect that in such circumstances common sense might prevail, as everyone recognises that on something such as NHS continuing health care, collaboration makes a lot of sense, as the shadow Minister indicated, but there is nothing to force anyone to do that.
Liz Kendall
Will the Minister also clarify that if NHS England wanted to form a joint committee with CCGs in the area, it could not force them into it?
Norman Lamb
This is a good exchange of views. Again, I can confirm that this is about a voluntary arrangement between a CCG or CCGs and NHS England. There is no compulsion at all.
Liz Kendall
I am very grateful to the Minister, who has perhaps been much clearer on that point than the Minister in the other place was.
The Minister has been clear that CCGs will not be forced into joint committees, but the second concern relates to majority voting in the committees. He will know that the Regulatory Reform Committee’s report cites a couple of CCGs that have been concerned that
“Joint committees would be able to take majority decisions on behalf of their constituent CCGs and NHS England, and so individual CCGs might find themselves accountable for implementing policies that their members did not consider to be in the best interests of the local population.”
To put it bluntly, if one or two CCGs on the committee disagree, they can be outvoted. Is that the case, and would it be possible for NHS England to have the casting vote on a committee?
Norman Lamb
It is helpful to respond straight away on these specific points. Again, I stress, as I think I made clear at the beginning, that it is up to the participating CCGs to determine what voting arrangements should be in place. If they felt that unanimity was required in order to protect the interests of the community they serve, they could make that a condition of entering the joint committee. It is entirely up to the participating CCGs to agree the rules.
Liz Kendall
I am grateful to the Minister for that helpful clarification.
The third concern has been raised by the Association of Directors of Adult Social Services and by the Local Government Association. They are concerned that any joint arrangements between CCGs, or between CCGs and NHS England, must be fully aligned with the geographical boundaries and strategies of local health and wellbeing boards. That is not only because we have to get health and social care working together, with council care services and the NHS, but because of accountability issues. Perhaps the Minister will say something about that later.
The last two concerns about the draft order are, for me, the greatest. The fourth is about how the joint committees will be held to account for the decisions they take and how patients, the public, local healthwatch, health and wellbeing boards and Members of this House can know what decisions are taken and hold the joint committees to account, because I understand that they will not be required to meet in public. I raise that concern because it has been raised in two letters from the chair of Healthwatch England to the Secretary of State. In her first letter on 16 July, she wrote:
“I am concerned about the impact this reform could have on the statutory role of local Healthwatch, the integrity of local accountability mechanisms, and meaningful public involvement in decisions about service redesign.”
She goes on:
“Whilst I recognise the important role CCG collaborations can play in the effective commissioning of health and social care and the transformation of traditional service models, I am sure you will agree that it is vital they are accompanied by strong accountability and engagement mechanisms. This is of particular importance given the scale of decisions being made by joint committees, and our anticipation that many more of these joint arrangements will be put in place. Without these safeguards in place, the public are far less likely to understand, or be accepting of, the changes that happen in their community.”
She recommends that the draft order be strengthened, and makes four proposals:
“Ensure CCGs acting in collaborative arrangements have in place adequate mechanisms meaningfully to engage the…community.”
She suggests a
“mandatory non-voting constitutional seat on Committees…for local Healthwatch”
and a
“duty on all lead or co-ordinating commissioners to have due regard to existing local agreed priorities…(including Joint Strategic Needs Assessments and Health and Wellbeing Plans).”
Finally, there should be
“a duty on all lead or co-ordinating commissioners to act within existing local accountability mechanisms”
including local health and wellbeing boards.
When the Secretary of State replied to Anna Bradley, he said he felt that mechanisms for public accountability were in place and that there would be no proposed strengthening of the order. In her reply to him on 20 August, Anna Bradley stated:
“I do not yet share your confidence that the new joint committee arrangements will address our concerns about transparency and accountability.”
The Government said throughout the Health and Social Care Act 2012 and all their reforms that there should be “No decision about me without me”, but the patient and public voice, local and national Healthwatch, has said it does not believe that that strong patient and public voice will be effective under the proposed order. The Minister needs to respond to that.
Finally—this is a particular concern of mine—one decision that joint committees can take concerns individual patient-specific funding requests for things such as NHS continuing health care. Any hon. Member whose constituent has applied for that kind of funding, or funding for a number of different areas, knows that it can be difficult to get to the bottom of those decisions. I had a particular problem with Greater East Midlands commissioning support unit, which manages continuing health care for the 22 CCGs in the east midlands. I have barely been able to get any information out of it about the bad decisions it has taken, and that is a real worry because I am concerned that the joint committees will repeat that. How will we know how those decisions are taken or hold them to account?
Norman Lamb
Perhaps the hon. Lady will give me details of that concern in her local area. It is important that we hold the different parts of the system to account, and she should be able to establish the position. I am happy to pursue that matter for her if she would like.
Liz Kendall
I am grateful to the Minister. I will forward him my concerns, just as I have done to my local CCGs and the chief executive of NHS England.
To conclude, Healthwatch raised these concerns in relation to a particular issue in Greater Manchester and the Healthier Together project, where 12 CCGS have grouped together to reconfigure services. The local healthwatch is concerned that under the draft order some of the problems it has seen with Healthier Together could be replicated. For example, I understand that governance meetings for Healthier Together started to take place in public only in March 2014. That was after major decisions—such as the model for service reconfiguration—were discussed in a closed session of that committee. The local healthwatch remains concerned about the lack of clarity on planned public involvement in Healthier Together in future, and, like the local healthwatch, Healthwatch England is concerned that the joint committees will not be accountable to patients and the public.
Hon. Members across the House will say that previous primary care trusts were sometimes not open and accountable, and I may have shared some of those concerns. This is a chance to put things right, but I am concerned that the draft order is not strong enough and I know other hon. Members will also raise that point.
Richard Fuller
I am not an expert, but in that particular instance I do not think I would fear the joint committee making a different recommendation from the current committee in common, although it has yet to come back with its report. The point is that the hon. Gentleman and others have aired important questions for the Minister to answer. He has answered some of them, and that has been the purpose of the debate today.
Underpinning all this is the fact—whose importance I hope the Minister will emphasise in his response—that people want important health decisions to be taken locally. They can be persuaded of, and they can understand, the issue of common advance, but they want to know that a decision is being taken locally. I think that the Minister dealt with this in his response to the shadow Minister, but I would be grateful if he answered these points quite specifically. First, am I right in thinking that he said that decisions on the part of commissioning groups to go into joint committees were voluntary, rather than compulsory, and that it would therefore remain possible for them to continue to set up committees in common if they so wished? My second question—
Richard Fuller
I am happy to give way to the Minister iteratively, or he can wait until I have given him the full menu. Which would he prefer?
Norman Lamb
The answer to that question is yes, absolutely; I repeat that this is a voluntary act by any CCG. To address one of the concerns raised by the shadow Minister, let me say that there may well be circumstances in which CCGs want the rules of the game established at the start of the joint committee saying that there will be circumstances in which they can withdraw from that committee. So there are no circumstances in which any CCG needs to feel that it will be oppressed in any way by its neighbouring CCGs, NHS England or anyone else.
Richard Fuller
I am grateful for that clarification. My second question is on the issue of voting on the joint committees. To be effective, is it a requirement that joint committees should be based on unanimous voting only and that all CCGs would have to agree, or will joint committees be substantially based on majority voting? Is it open to CCGs to create joint committees with majority or unanimity voting depending on how they wish to set those up?
Madam Deputy Speaker (Dame Dawn Primarolo)
Order. May I say to the Minister that I know he is trying to be helpful, but he will soon be seeking to answer this debate? We have only one more speaker to go, so to help the flow of the debate perhaps Members could finish their speeches and then he can respond.
Norman Lamb
I am grateful to all Members for their contributions to this debate. Regarding the shadow Minister’s contribution, I am pleased to hear that she is supportive, at least in principle, of this capacity to facilitate greater collaboration at a local level. As my right hon. Friend the Member for South Cambridgeshire (Mr Lansley) said, it is rather ironic that this is all about a reformed health system that has much better clinical and democratic legitimacy than the one we inherited from the Opposition. I notice that no one is out there waving banners demanding the return of the primary care trust. Ultimately, that body had no accountability to the local community—[Interruption.] No, it had no accountability. Its accountability was entirely upwards to the strategic health authority and to the national level.
Liz Kendall
That is completely over the top. Sometimes I have had great trouble getting any answers out of my CCG. Sometimes they have been good and sometimes they have been bad. I have also had great trouble getting anything out of the commissioning support unit. The Minister should not paint some super rosy picture of fantastic accountability and patient involvement, as there are still some real issues.
Norman Lamb
I fully understand that we should always be arguing the case for greater openness and for greater legitimacy and accountability. All I am saying is that the system that we inherited had no local legitimacy at all, and that this is a significant improvement.
The shadow Minister talked about alignment with health and wellbeing boards. I think that that will almost always be the case. In my county of Norfolk, there are several CCGs, but all are operating within a health and wellbeing area and a local health economy. There may be circumstances in which more than one health and wellbeing board area is being considered, and I think that that is the case within the Manchester area and the discussions that are going on there. But in most circumstances, the sort of collaboration that we are talking about will be consistent with the health and wellbeing board area.
The shadow Minister also asked how CCGs will be held to account for joint decisions. When they act in joint committee, they will be subject to the same duties as when they act on their own and the accountability they face will be exactly the same. It is very important to reiterate that point.
The hon. Lady also raised concerns about the issues that Healthwatch England has raised, and I stress that the Department, NHS England and Healthwatch England are working together to ensure that CCGs have the materials and resources they need to support their effective and accountable collaboration and that local healthwatch organisations and others are supported to hold the system effectively to account. Everything on our side is about facilitating accountability at a local level, not undermining it.
My hon. Friend the Member for Stafford (Jeremy Lefroy) raised concerns about the issues in his area. I think that it is fair to say that they are not directly related to the proposals under the order, in that his concerns are about issues under the current arrangements rather than any potential impact of the proposed change. I want to reassure him that nothing in the order in any way undermines effective accountability for changes. I think it would be dangerous for me to go down the route of responding to the points he raises about his local circumstances, and I suspect that you, Mr Deputy Speaker, would rule me out of order if I tried to do so.
Jeremy Lefroy
The point I wish to make is that in our case the group of CCGs that is seeking to put out to tender the commissioning of end-of-life and cancer services appears to be abrogating its responsibilities for commissioning. These are clinical commissioning groups, yet they seek to put out to tender the commissioning of vital services for our constituents for 10 years. One might be concerned that the groupings would seek to do more like that.
Norman Lamb
My hon. Friend expresses a concern about what is happening at present and he is absolutely right as a local Member to challenge, question and hold to account the clinical commissioning groups in his area, but I do not think that there is anything in the order that changes the arrangements about which he is concerned. Indeed, I think that streamlining the system so that there is more effective accountability and less opaque decision making is better for local people.
Concerns were raised that joint committees might not meet in public. Joint working does not need to mean that it will take place behind closed doors and exactly the same responsibilities will apply to CCGs when they work jointly as when they work on their own or through committees in common. Indeed, I understand that committees in common have already on occasion met in public and I would always encourage accountable organisations to operate in public wherever possible. That is the approach that I seek to advocate.
In response to concerns raised by my hon. Friend the Member for Stafford, let me make the point that the requirements for service change that apply to a CCG regarding any major proposal for change will still apply, including that for appropriate consultation. Joint committees might want to consult jointly to co-ordinate their communications to patients and the public where appropriate, but the duty remains on the clinical commissioning group and it must demonstrate that it is meeting it.
The hon. Member for Blackley and Broughton (Graham Stringer) again raised concerns about the process going on in Manchester and he and I debated the matter in the debate to which he referred. I stress that his concerns are about actions taken under the existing regime, with a committee in common, rather than under the proposals in the order.
The hon. Gentleman expressed worry about the appropriateness of the order under the Legislative and Regulatory Reform Act 2006, but both the Regulatory Reform Committee and the Delegated Powers and Regulatory Reform Committee judged that a satisfactory case had been made for the LRO and that the order met the tests under the 2006 Act, so his concerns are misplaced. Although he has legitimate and genuine concerns about the process in Manchester and whether it is right for local people, I suggest to him that accountability will be encouraged and improved if the new system is less opaque and more clearly set out in legislation than the existing one. All the things about which he worries are happening under the existing arrangements.
It is up to CCGs to set out terms of reference for any joint committee arrangement, such as the scope for decision taking, and arrangements for membership or voting. They may also determine situations in which a CCG would wish to withdraw from a joint committee arrangement. The hon. Gentleman was worried that one CCG might feel oppressed or bullied by others, but it could set the terms of reference so that it could withdraw in defined circumstances, so his concern is misplaced.
My right hon. Friend the Member for South Cambridgeshire spoke about important improvements in democratic accountability and clinical leadership in commissioning, and the benefits that that secures. He asked about collaboration on commissioning not only between CCGs, or between CCGs and NHS England, but, critically, with local authorities and public health bodies. Such collaboration is facilitated, and he and I share the view that we should try to promote a more permissive NHS health and care system within which local arrangements may be put in place to ensure that the resources available throughout the health and care system are used as efficiently as possible. We should encourage such joint commissioning, rather than putting blocks in its way.
My hon. Friend the Member for Bedford (Richard Fuller) rightly talked about the tension that exists between local decision making and clinical best practice. This approach is all about managing that tension, rather than trying to pretend that it does not exist. He made the vital point, with which I agree, that people want health decisions to be taken locally, and we should try to facilitate open discussion and debate about the difficult choices that we sometimes have to make, rather than taking power away from people, which just undermines confidence in the system.
My hon. Friend asked about unanimity, so I repeat that if a CCG wants to enter into a joint committee arrangement, and protect its position on behalf of its local community, it can insist that unanimity is the basis on which decisions are taken. That is entirely a matter for the participating CCGs.
My hon. Friend asked about the cost and burden of the existing arrangements. We all understand the possibility of legal challenge, and there can be complex arrangements that involve organisations going through hoops to ensure that they meet their legal duties, perhaps by going back to their CCGs so that a decision taken in a committee in common may be endorsed. The more complicated those arrangements, however, the greater the risk of legal challenge, and therefore the cost, so simplifying in law the basis by which CCGs and NHS England can come together to make joint decisions, should they want to, improves accountability, makes the system less opaque and reduces the risk of unnecessary costs. I totally agree with my hon. Friend that this is not about the burden of localism. Localism is a burden worth carrying; it is not to be avoided. The burden is bureaucratic complexity and the involvement of lawyers—I speak as an ex-lawyer. The more we can keep lawyers out of it, the better, and I am sure many hon. Members would agree.
My hon. Friend made the point that not all consequences may be known at the outset and that things may change, but CCGs can set the terms of reference to provide for that if they choose to. The measure is absolutely permissive; it does not impose anything on anyone.
My right hon. Friend—sorry, my hon. Friend the Member for Totnes (Dr Wollaston). I thought something might have happened as a result of her election to the Chair of the Select Committee, but it will happen in time, I am sure. I am delighted that she supports the measure. She made the perfectly legitimate point that we ought to be encouraging and facilitating working across boundaries, both of CCGs and of the different organisations involved in health and care, to get the best possible use of the resource available for any local area.
Finally, I repeat that we take on board the concerns of Healthwatch England. We intend to work with that body to ensure maximum accountability for the decisions taken as part of these joint committees.
Question put.
Obstructive Sleep Apnoea
Norman Lamb Excerpts(9 years, 8 months ago)
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Mr Dai Havard (in the Chair)
Order. I am going to have to stop you, because we have a procedure issue here. The Minister did not understand that you were going to make a contribution.
The Minister of State, Department of Health (Norman Lamb)
I am happy for the hon. Lady to make a contribution, but it needs to be brief.
The Minister of State, Department of Health (Norman Lamb)
It is a pleasure to serve under your chairmanship, Mr Havard. I congratulate the hon. Member for Bolton West (Julie Hilling) on securing the debate. One of the great benefits of Adjournment debates is that they force Ministers to focus on one condition among the array of things that we have to deal with, and this debate puts an important spotlight on OSA. I will take up with Professor Mike Morgan, the national clinical director for respiratory disease, the issues that the hon. Lady has raised. In accordance with the request from the hon. Member for Sheffield somewhere or other—
Norman Lamb
In accordance with the request of the hon. Member for Sheffield, Heeley (Meg Munn), I will write to the Health and Safety Executive. She made a good point, and I am happy to raise it directly with the HSE. Those are serious issues, and they deserve to be taken seriously.
The case studies provided by the hon. Member for Bolton West clearly demonstrated the benefit of accessing treatment, and the impact that treatment can have on someone’s life. I agree with the hon. Member for somewhere near Liverpool—
Norman Lamb
I apologise; I agree with the hon. Member for West Lancashire (Rosie Cooper) that that is a no-brainer. As other hon. Members have said, we must raise awareness and understanding not only among the general public but among clinicians and general practitioners, because a problem with diagnosis may arise because a GP does not recognise the need for a referral. As the hon. Member for Strangford (Jim Shannon)—I think I have got his constituency right, at least—has said, we must work with the devolved Administrations and ensure that we raise awareness of the condition across the United Kingdom.
As the case studies demonstrate, OSA can have a huge impact on the quality of life of those who suffer from the condition and their families, which the example of Steve demonstrates so graphically. OSA can contribute to other long-term health conditions, such as high blood pressure, stroke, diabetes and, critically, mental health issues. The hon. Member for Bolton West made a point about Steve contemplating suicide, and we often forget about the close connection between many long-term conditions and the mental health issues that can go with them. People suffer depression because of an inability to escape their condition.
As we have heard, OSA can also lead to serious, even fatal, accidents. The statistic that there may be 40,000 preventable road traffic accidents is extraordinary. The issue is driver fatigue. Sleep apnoea sufferers are thought to be seven times more likely to cause crashes than drivers without the condition. The challenges posed by OSA should not be underestimated. In the UK it is thought that some 4% of middle-aged men and 2% of middle-aged women suffer from OSA, which in many cases requires lifetime treatment of the sort described by the hon. Lady. A further complication is that, as she describes, OSA is often left undiagnosed because people with the condition usually have no memory of some of the key symptoms, such as interrupted breathing during sleep, so they may be completely unaware that they have a problem unless a partner happens to raise it with them.
The NHS outcomes framework for 2014-15 sets out the Department’s priority areas for the NHS and includes reducing deaths from respiratory disease as a key indicator. Additionally, the mandate sets out the requirement for NHS England to improve outcomes in a range of areas, including preventing premature deaths from the biggest killers, which include respiratory illnesses, and supporting people with long-term physical conditions such as sleep apnoea. Incidentally, it will be interesting to see the economic impacts that the report will set out. I am happy to take that up with the national clinical director, too.
Our “Living Well for Longer” report, which was launched in April 2014, sets out what the health and care system will do to achieve the Government’s objective to be among the best in Europe at reducing levels of premature mortality. The report brings together in one place the national actions taken by the Department and the wider Government, NHS England and Public Health England on prevention, early diagnosis and treatment, focusing on the five big killers, including lung diseases, and showing how they will support local leadership and interventions.
Local clinical commissioning groups are responsible for assessing the needs of their local populations and for commissioning services to meet those needs. For patients with OSA, NHS England expects CCGs to take the NICE guidelines into account when deciding what services should be made available. NICE has recommended continuous positive airway pressure as a treatment option for adults with moderate or severe symptomatic OSA or hypopnoea syndrome, where certain clinical criteria are met. NHS commissioners are legally required by regulations to fund that treatment, where clinicians wish to use it.
Continuous positive airway pressure is currently the only technology recommended for OSA in NICE technology appraisal guidance. The hon. Lady mentioned a referral to NICE for a quality standard, and I am happy to write to NICE. She will understand that NICE is independent, and it is important to respect that independence, but I am happy to ask NICE where that issue is in the work stream of quality standards that are waiting to be addressed. That work will be completed by 2017, which is the long-stop date. I will check, and I am happy to write to her to confirm the position.
Although it is not always possible to prevent OSA, making certain lifestyle changes may reduce a person’s risk of developing it. Those changes include losing weight, limiting alcohol consumption and stopping smoking. The Government are acutely aware of the damage being done to the population’s health through smoking and harmful drinking, which is why we have set out clear ambitions for driving down the prevalence of smoking and reducing the incidence of alcohol-related disease in our tobacco control plan and our alcohol strategy respectively.
We have ensured that NHS health check, a key programme to address systematically the top seven causes of preventable mortality, includes identifying and helping people to take action to quit smoking, maintain a healthy body weight and reduce alcohol consumption. All those issues, of course, have an impact on a range of conditions, including vascular dementia and heart disease, but they are also relevant to sleep apnoea, and we ought to be doing more to address the issues that could prevent the condition.
Through the responsibility deal, we are actively working with business to take voluntary action on calorie reduction and food labelling to help people make healthier eating choices. That is already delivering change and making a real difference. The Change4life social marketing campaign is encouraging individuals to make simple changes, such as reducing their calorie consumption and being more active. One of the key challenges in tackling OSA, as several hon. Members have said, is raising awareness of the condition. It can be difficult for sufferers to detect OSA themselves, and it often goes undiagnosed as a result. In fact, it is estimated that in this country up to 3% of adults across all age groups have undiagnosed OSA, which is an extraordinary number. There are then the associated accidents.
Surveys carried out by the British Lung Foundation in 2011 and 2014 to measure awareness of OSA show that awareness of the condition has risen significantly, which we should applaud. Awareness has especially risen among men, who are most at risk, and in areas with a high risk of OSA. I pay tribute to the British Lung Foundation, which has worked collaboratively with the hon. Member for Bolton West, and the important work of its obstructive sleep apnoea project that aims to improve diagnosis and raise awareness of the condition. The project’s successes include the largest survey of OSA sufferers ever undertaken, a UK-wide mapping tool of sleep services and prevalence of known OSA risk factors and a media campaign that reached at least 48 million people.
It was a privilege for me to attend the recent opening of the Breathe Easy North Norfolk group. Breathe Easy groups have the potential to be incredibly powerful, and they are run by their members with help and support from the British Lung Foundation. Breathe Easy groups provide support and information to people living with a lung condition, as well as those who look after them.
Those are all examples of highly valuable initiatives led by the British Lung Foundation that have a huge impact on the lives of a great number of OSA sufferers in the UK. The effects of sleep apnoea are potentially devastating, and the condition affects thousands of people in this country, many of whom are not aware of the problem even when they are feeling its effects. It is vital that the NHS continues to work hard not only to reduce the number of premature deaths from all respiratory illnesses, including OSA, but to support people with long-term conditions better, regardless of where they live. I assure the hon. Lady that the Government will continue to work hard to improve outcomes for all those in society who have, or are at risk of, a long-term condition such as sleep apnoea.
I reiterate the point made by other hon. Members that the analysis of the economic case demonstrates that much better preventive work ultimately saves money, as well as having a massive impact on individual lives. I strongly feel that we need a shift of emphasis to focus much more on prevention.
Meg Munn
As there is a bit of time remaining, may I press the Minister on the Health and Safety Executive? We do not currently know how many accidents involve sleep apnoea, and we might need to consider not only more action on the health side but more action to ensure that employers are screening drivers who are particularly at risk.
Norman Lamb
I indicated earlier that I am happy to write to the Health and Safety Executive, and I will ensure that the Hansard report of this debate is referred to it so that the hon. Lady’s point can be taken up. I will also write to the national clinical director and NICE. I hope those actions will contribute to the objective, which we all share, of raising awareness and getting the system to be much better at intervening earlier to help people with conditions. Such intervention can have a massive impact on people’s lives and, with a bit of support and access to treatment, can completely transform the lives of those individuals.
Care Home Top-up Fees
Norman Lamb Excerpts(9 years, 9 months ago)
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The Minister of State, Department of Health (Norman Lamb)
I congratulate my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) on securing the debate. It would be wrong for the debate to be an exclusively Liberal Democrat affair, so I am delighted to see the hon. Member for Huddersfield (Mr Sheerman) in his place. This debate is, in some ways, a unique event.
My right hon. Friend raises an important issue. He provided two case studies, which almost smack of exploitation of vulnerable older people. The ratcheting up by a care home of the top-up fee for someone in the latter stages of their life who suffers from dementia is completely unacceptable exploitation of that individual, and it should be condemned.
Equally, the idea that it is suitable or appropriate to shove someone into a home far away from London but a long way from where she wants to be goes against the central principle of the Care Act 2014: the individual’s well-being. I know that my right hon. Friend is committed to upholding that principle. The issue that he raises is of real importance, and the findings of the local government ombudsman’s report from last year, to which he referred, are of real concern.
People should have a choice over the establishment in which they receive care and support. That establishment will, after all, become their home. Where the local authority is involved, it has a responsibility to ensure that the establishment meets the person’s needs without costing more than it needs to. However, another important principle, which we must respect, is that people or their loved ones should have the choice to use their own resources as they see fit. If by doing so they can improve their surroundings by having a bigger room or a better view, they should have that choice. I emphasise that that must be a positive choice on the individual’s part—something that they understand the costs and consequences of, never something that they feel pushed into.
Mr Sheerman
The right hon. Member for Sutton and Cheam (Paul Burstow) put his finger on it when he talked about secrecy. There are many excellent people in this field doing a fantastic job—my mother-in-law is in a care situation—but a certain percentage of people do not know what is going on. They need to know, and it should be in the public domain.
Norman Lamb
I agree with the hon. Gentleman. He will find that the Care Act has a much greater focus on transparency, and it strengthens the legal obligation by providing that personal budgets must reflect the cost to the local authority of meeting the adult’s needs. That is a legal requirement in the Care Act, whereas previously it had been guidance.
Paul Burstow
I understand, and I am grateful to my right hon. Friend. The guidance allows local authorities to consider whether to make an adjustment to a personal budget, but guidance should not give such discretion. If it is about care costs to meet eligible needs, an adjustment should be made.
Norman Lamb
I take that point. I do not want to pre-empt the outcome of the consultation, but I am happy to ensure that the Hansard report of this debate is counted as part of the consultation exercise. The comments of all right hon. and hon. Members will be included in that report.
Although we all agree that, in an ideal world, local authorities would be able to fund a person’s chosen accommodation, that is simply not possible in every circumstance. We are in a tough financial situation, and local authorities need to take great care in how they spend their resources to ensure that they can meet the care and support needs of the whole population that they serve. There are clear rules in place on the operation of top-up fees, which we are strengthening to achieve greater clarity and force under the Care Act. It is important that everyone is aware of those rules, as my right hon. Friend said.
We are aware of concerns about top-ups, particularly the concerns raised in the research by the charity Independent Age. That is why in March 2014 the Department wrote to all local authorities in England to remind them of their responsibilities under existing regulations and guidance, let alone the rules coming in through the Care Act. We reminded them that the existing guidance is clear that a top-up fee should be sought from a local authority-supported person only where they have chosen to go into more expensive accommodations and a third party or, in limited circumstances, the person themselves, is willing and able to pay the additional cost.
The person should not be asked to pay a top-up fee where it is necessary to arrange care in a more expensive home to meet their assessed eligible needs, nor should a top-up fee be sought where accommodation is not available at the local authority’s expected rate due to a failure of commissioning. In such cases, the local authority must meet the full cost of care and should not seek to make a top-up arrangement.
Where a local authority arranges care it is responsible for the full cost of that care, including any top-up fee to the provider. That ensures that, if a top-up fee is not paid for any reason, the person can continue to receive care and support in their accommodation while a decision is made about their future care. A care home, therefore, should never ask a local authority-supported resident for a top-up fee without the involvement of the local authority, but it appears that that sometimes happens.
The local authority is responsible for the full cost of care, including the top-up, so it should not arrange more expensive care unless it is satisfied that the person paying the top-up has the resources to keep paying the fee. Local authorities should regularly review the position to ensure that a person will continue to be able to make those payments—that is another point raised by my right hon. Friend. It is in a local authority’s interest to do that, as it will be liable to pay the full costs if the person is unable to pay the top-up.
We are maintaining people’s right to choice in the accommodation where they receive care under the Care Act. As part of that we will give people more rights to top up their own fees from 2016. We would have liked to have been able do that from next year, but we need to ensure that extending the right to self top-up is sustainable and that those receiving care are not adversely affected. We are working with stakeholders to resolve those issues.
Currently, as I am sure my right hon. Friend knows, the circumstances in which people can top up their own fees are restricted. People can top up during the 12-week period only when their main or only home is disregarded, or when they have a deferred payment agreement—in effect, where they have a property to sell that can meet the cost of the top-up fee. People should be able to decide how to spend their own money, and they should be able to pay more for care if they wish. Under the Care Act we will enable people to self top-up using other assets, not just property, from April 2016 at the same time as we implement the cap on care costs that, for the first time ever, will protect people from the risk of catastrophic care costs—protection that my right hon. Friend fought for before I took over this role.
We are also strengthening the regulations and guidance on top-up fees, which will apply from April 2015. That will make the position on top-up fees even clearer and provide additional protection to cared-for people and their families. We will make further changes in April 2016 to give people greater scope to self top-up. The draft regulations and guidance currently out for consultation set out that the local authority must ensure that the person paying the top-up is willing and able to meet the cost for the likely duration of the arrangement. The local authority must also ensure that the person enters into a written agreement, thereby ensuring that all involved are fully aware of their responsibilities and any consequences should the arrangement break down. Again, my right hon. Friend referred to the written agreement in his speech. The local authority must review top-up arrangements from time to time.
Paul Burstow
“From time to time” are classic words that can be wriggled out of—they mean nothing. It is important that the guidance is clear that “from time to time” means at least annually.
Norman Lamb
I note my right hon. Friend’s point, but I will complete my comment.
The local authority must set out in writing details of how the arrangements will be reviewed, what may trigger a review and when any party can request a review. Although the regulations and guidance do not set a specific review period—my right hon. Friend’s point is now in the consultation responses, as I indicated—we expect top-up arrangements to be reviewed at the same time as the local authority reviews the financial assessment of what the person can afford to pay for their care. That normally happens at least annually, around the time when changes are made to the charging regulations.
Additionally, the local authority must make clear in writing the consequences should the top-up arrangement break down. That may result in the resident’s having to move to alternative, less expensive accommodation, where such accommodation is suitable to meet their needs. As with any change of circumstance, the local authority must undertake a new needs assessment before considering that course of action, including an assessment of health needs and having regard to the person’s well-being, which is the central principle of the Care Act. Local authorities should already be monitoring all top-up arrangements for the people they support because they are ultimately responsible for the full cost of accommodation. Local authorities should also discourage arrangements for top-up payments to be paid directly to a provider.
The new regulations and guidance under the Care Act are being consulted on at the moment, and I encourage all right hon. and hon. Members to contribute to that consultation alongside their contributions today. The consultation closes on 15 August, and we will consider all the responses that we receive. We are aware that, although our approach has been welcomed as a big improvement, there is always a desire to do more. We are continuing to engage with stakeholders and will await the close of the consultation before making any decisions on further changes.
The intention of the Care Act is to enable self top-ups in other circumstances, which is entirely right, but also to ensure that top-ups are not inappropriately used and to strengthen the rules on top-ups.
Paul Burstow
In the past 12 months I have been leading work with Demos on the future of residential care, and we will publish our report in September. Will the Minister meet me and colleagues from that commission in the autumn to discuss our recommendations?
Norman Lamb
That sounds like an interesting session in principle. I would like to attend that meeting if possible, but I cannot guarantee it at the moment because of the nightmare that is my diary.
I hope my comments have been helpful. The points that have been raised today are an incredibly important part of the consultation process.
Healthier Together Programme (Greater Manchester)
Norman Lamb Excerpts(9 years, 9 months ago)
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The Minister of State, Department of Health (Norman Lamb)
It is a pleasure to serve under your chairmanship, Mrs Riordan. I congratulate the hon. Member for Blackley and Broughton (Graham Stringer) on securing the debate. The opportunity to debate important issues at the start of a process is welcome. I also thank my hon. Friend the Member for Bury North (Mr Nuttall) and the hon. Members for Wythenshawe and Sale East (Mike Kane), for Stalybridge and Hyde (Jonathan Reynolds), for Stretford and Urmston (Kate Green) and the shadow Minister—[Interruption.] I thank my hon. Friend the Member for Harrogate and Knaresborough (Andrew Jones) for ensuring that I also thank the hon. Member for Wigan (Lisa Nandy) for her important interventions.
The impression that I got from all hon. Members is that there is a recognition that things need to change and of the importance of developing an integrated system of out-of-hospital support and strong primary care. Some hon. Members also recognised the importance of specialisms in specific cases, but concerns centred on the nature of the consultation. The shadow Minister was extremely fair in describing the process’s objective as a good one and the hon. Member for Wythenshawe and Sale East said that the aim is right, so there is something of real value to achieve here if it is possible. I completely understand, however, why hon. Members feel the need to speak up for and express concerns on behalf of their communities.
Norman Lamb
I will give way in a moment, but I was about to comment on the intervention of the hon. Lady, whom I rudely left out of my list earlier, in which she mentioned the lack of democratic legitimacy. The reforms have strengthened legitimacy. Until the reforms, there was no local democratic accountability for the NHS, but every area now has a health and wellbeing board. Interestingly, Lord Peter Smith, who I think is from the hon. Lady’s own community, said:
“We accept the case for change made in this consultation document…Remember it is not buildings that deliver good health care, it is the dedicated NHS staff who make it possible.”
To pick up on the point made by the hon. Member for Stalybridge and Hyde, Lord Smith, a local Labour leader, also talked about the move being towards greater integration:
“We are clear that this improvement in integration and in GP services needs to be up and running before the changes to the hospital services are introduced”—
clear support there for the objective.
Lisa Nandy
The Minister is right. Like the leader of my council, I accept the case for greater integration. I wanted to make one point, because the Minister seems to be suggesting that the concerns centre only on the consultation. I have a real concern, which I am not sure has been expressed clearly so far, about how the consultation sets up hospitals as either specialist or local.
My hospital specialises already, and it is rightly fighting to retain that because good outcomes are delivered. That does not mean that my hospital can, or should, do everything. Indeed, many of my constituents travel, for example, to the Christie for cancer care, as the hon. Member for Bury North (Mr Nuttall) said. There is, however, a real issue about some hospitals being specialist and some being local, but with nothing in between.
Norman Lamb
I take that concern on board, and the hon. Lady should respond to the consultation. It is really important for hon. Members to do that.
Incidentally, I should say something on behalf of my hon. Friend the Member for Cheadle (Mark Hunter), because he is a Whip and so is unable to speak in the debate, although he has attended it all. He has expressed particular concerns about the potential implications for the University Hospital of South Manchester and Stepping Hill, and about options 4.1 and 4.2. It is important that I place that on the record.
Norman Lamb
Will the hon. Lady let me make another point that is on the tip of my tongue? I will then be happy to give way.
The hon. Member for Stalybridge and Hyde expressed the concern that, in his assertion, we are moving away from integrated care. Precisely the opposite is the case. Indeed, the hon. Member for Copeland (Jonathan Reynolds), the shadow Minister, expressed clearly some of the fantastic potential gains that could be achieved in the Greater Manchester area if the objectives were achieved. When I announced the pioneer programme to demonstrate the exemplars of integrated care, Greater Manchester was one of the applicants to get on to the shortlist and was close to securing pioneer status, so my every impression is that exciting work is going on in Manchester to change local health and care services in a way that all of us could probably sign up to.
Julie Hilling
I thank the Minister for giving way. The bit that I do not understand is that local authorities, leaders such as Lord Smith and others, have been saying, “Yes, we need to sort out the integrated care”, but the consultation has been putting front and centre the need to change the status of hospitals. What everyone in the conurbation is saying is, “Let’s look at the integrated care and then see what comes out of that”, rather than putting changing hospitals up front, which is what exercises the whole community.
Norman Lamb
I note the hon. Lady’s point, but I come back to Lord Smith’s statement:
“We accept the case for change made in this consultation document”.
It cannot be clearer than that.
Norman Lamb
Let me finish the point. I am acutely aware that it is critical to develop those out-of-hospital services to which the hon. Member for Wigan referred. That is the whole essence of integrated care, of which Manchester is seeking to be an exemplar. I applaud Manchester for doing that, because that is a big shift towards the greater focus on preventing ill health, rather than on repairing the damage once it is done.
Norman Lamb
I am conscious that I need to make progress in my response to the debate, but I will give way to the hon. Gentleman.
Jonathan Reynolds
I am extremely grateful to the Minister for addressing my point directly. It is pleasing to see that he is well briefed. He is right about some of the exciting conversations about integration going on in Greater Manchester. I anticipate that he knows something about the proposals. If they develop into specific plans, is it his desire and belief that the Government would not seek to apply the competition law to which the NHS is now subject and allow them to proceed?
Norman Lamb
I have made the case very clearly that the whole purpose of the pioneer programme is to use the pioneers—although we are not simply focused on them—to identify the barriers to integration and to remove them. That is the whole point. There are concerns about all sorts of things that could block integrated care, such as information sharing across different providers and competition.
I should stress, incidentally, that in the section 75 regulations is a specific recognition that integrated care is an ambition that should be achieved, so commissioning can be for the whole integrated care pathway. There should be no problem in securing our ambition. Where barriers are found, they need to be addressed and removed.
I am conscious that the hon. Member for Stretford and Urmston asked to intervene—
Norman Lamb
The hon. Lady has moved on, so let me make some progress.
It is important to recognise that we are discussing proposals that originated with local clinicians. Dr Chris Brookes, who is not a politician or a bureaucrat, who too often get condemned, but an accident and emergency consultant and a medical director of Healthier Together, says—
Norman Lamb
May I make this point? I am sure that the hon. Lady will be interested to hear it. Dr Brookes said:
“Currently, there are too many variations in the quality of treatment, whether its emergency surgery or getting to see a GP when you need to. Not one of our hospitals in Greater Manchester meet all the national quality and safety standards.”
I am sure that all hon. Members present are concerned about that. He goes on to say something which, if we think about it, is shocking:
“At present your chance of being operated on by a consultant surgeon in an emergency at the weekend is much less than midweek. Your chance of recovering well from surgery carried out by a consultant is greatly improved.
But it’s not just about hospitals. It’s about access to a GP, and better community-based services—more services provided locally or at home and joining up the care provided by local authorities.”
That is a clinician making the case for integration.
Before I turn to the Healthier Together changes, it is probably best to make a few points about service changes in the NHS generally and Government policy towards them. The Government are clear that the design of health services, including front-line services and A and E, is a matter for the local NHS and, critically, the health and wellbeing boards, which have democratic accountability. Our reforms put doctors in charge of the care that people receive and how it is delivered to best serve their populations.
The NHS has a responsibility to ensure that people have access to the best and safest health care possible, which means that it must plan ahead and look at how best to secure safe and sustainable NHS health care provision—not only to meet today’s needs, but to plan ahead for next 10 or 20 years.
Kate Green
In Trafford, my understanding is that neither the local authority nor the CCG supports the proposals before us. Will the Minister explain the role of the health and wellbeing boards in the final decision on the plans?
Norman Lamb
I understand that the health and wellbeing boards are keeping a watching brief throughout. They will have a decisive voice at the end of the consultation process in declaring whether they support the outcome. They bring together the local authority and the NHS, so they are pretty central to the whole process—and rightly so. The local NHS is constantly seeking to modernise delivery of care and facilities to improve patient outcomes, to develop services closer to home and, most importantly, to save lives.
The hon. Member for Stalybridge and Hyde focused on specialisation, and expressed scepticism about the case for it. Let me give him a case. It is from during the Labour Government and should be applauded—the lessons from it should be learned here. Stroke care in London, centralised into eight hyper-acute stroke units, now provides 24/7 acute stroke care to patients, regardless of where they live across the city.
Transport links are not that great across much of London—[Interruption.] Hon. Members should listen to Members from London complaining about transport links. Stroke mortality is now 20% lower in London than in the rest of the UK and survivors with lower levels of long-term disability are experiencing better quality of life. Hundreds of lives have been saved as a result of the specialisation undertaken predominantly under the previous Government.
Jonathan Reynolds
I was very fair in my speech and said that I absolutely accept the case for specialisation. I actually made the most positive case of any made by an Opposition Member today as to why that might be important for my borough, so the Minister has perhaps misunderstood that. But I have to say that comparing the transport situation in Greater London with that of Greater Manchester or any other northern city will, I am afraid, have our constituents in uproar: it is simply not the same picture by any means.
Norman Lamb
I acknowledge that, just as in London, there are real bottlenecks in Manchester. I have a son who was at university in Manchester—and found it to be a very fine city—so I understand the transport challenges there completely. The point remains that specialisations can save lives. We all have to recognise that.
All service changes should be led by clinicians and be based on a clear, robust clinical case for change that delivers better outcomes for patients.
Norman Lamb
I really cannot. I have been pretty generous in giving way many times, so I will make a bit more progress.
It is therefore for NHS commissioners and providers to work together with local authorities, patients and the public in bringing forward proposals that will improve the quality and sustainability of local health care services. Government policy has been to emphasise local autonomy and flexibility in how NHS organisations plan and deliver service changes, subject to meeting legal requirements, staying within the spirit of Department of Health guidance and ensuring schemes can demonstrate robust evidence against four tests. Those are that there is support from GP commissioners; there is a focus on improving patient outcomes; that schemes consider patient choice; and that they are based on sound clinical evidence.
I recognise that change is often difficult to achieve because the consequences of not getting it right could be so profound—hon. Members have been absolutely right to raise their concerns. It is therefore right that the NHS does not rush into change without fully understanding all the potential consequences, sometimes including unintended consequences. Change can be difficult to explain to patients who have had quite reasonable anxieties exacerbated by speculation—in many cases, in the media—about whether this or that service might close. Services are sometimes described as closing when in fact they are simply being provided in a neighbouring facility or changing for the better in response to advances in treatment.
For example, my hon. Friend the Member for Macclesfield (David Rutley) referred to the possibility of hospitals closing, but I am not aware of any proposal to close hospitals. When we communicate to patients and the public, it is important that we are clear on what this issue is and is not about, so as not to raise anxieties. From my perspective, we have to be careful to avoid ramping up anxieties inappropriately by playing on fears. We see that too often; unfortunately, it stifles genuine debate and discussion about what health services will need to change in order to do better in future. But I applaud all hon. Members for speaking in this debate very reasonably and about legitimate concerns.
The right hon. Member for Leigh (Andy Burnham) has agreed that the NHS needs to have the freedom to change the way services are provided. He said:
“If local hospitals are to grow into integrated providers of whole-person care, then it will make sense to continue to separate general care from specialist care”—
the point made by the hon. Member for Wigan a moment ago—
“and continue to centralise the latter. So hospitals will need to change and we shouldn’t fear that.”
Perhaps the hon. Lady will take the point better from her party’s health spokesperson than from a Minister, but the right hon. Member for Leigh was making the case for the specialisation of services.
Lisa Nandy
I thank the Minister for being so generous in giving way. He seems to be setting up straw men that he then batters down. As far as I can work out, there is no disagreement from me or any Member on either the Government or Opposition Benches about the need for specialisation, integrated health care and locally delivered services. That is not what we are talking about. We are talking about a process that lacks democracy, that has been top down and centrally driven and that the public have lost confidence in.
Norman Lamb
To be fair, when I indicated earlier that the issue is about process, the hon. Lady came back at me—as is her right—to say that it is not just about process but about the model of separating specialisms from general hospitals. I therefore quoted what the shadow Secretary of State for Health had said in that regard.
I turn to the specific case raised by the hon. Member for Blackley and Broughton in this debate. Healthier Together was launched by the NHS in Manchester in February 2012 and is part of the Greater Manchester programme for health and social care reform, which seeks to improve outcomes for all Greater Manchester residents. The scheme is substantial, involving 12 CCGs and 12 hospital sites across Greater Manchester. As the consultation sets out, the case for change aims to improve access to integrated care and primary care, community-based care and in-hospital care services, including urgent and emergency care, acute medicine, general surgery and children’s and women’s services.
The House should appreciate that although those are the services being looked at, there are interdependencies with the core in-hospital services, including anaesthetics, critical care, neonatal services and clinical support such as diagnostic services. Changes in one area might have consequential effects elsewhere, as hon. Members have pointed out, and those effects have to be fully understood.
I should also repeat that the proposed changes are not a top-down restructuring. They are led by local clinicians who know the needs of their patients better than anyone. They believe that the clinical case for change—
Norman Lamb
I am conscious that I have only three minutes left. I have tried to be generous.
Local clinicians estimate that across Greater Manchester around 1,500 lives could be saved over five years as a result of implementing the proposed changes; that is not my assessment, but that of local clinicians. That would be an impressive improvement in health care, touching and affecting the lives of thousands of ordinary people—not only the individuals concerned, but their families and friends. It is because of the area’s current performance: if all trusts in Greater Manchester achieved the lowest mortality rates in the country, the CCGs believe that the number of deaths in Manchester could reduce by some 300 per year, equating to saving 1,500 lives over five years. That is an objective that we should all sign up to.
I am sure hon. Members will agree that it is not an unrealistic aim for hospitals in Greater Manchester to want to be the very best in the country. I am also sure all hon. Members want the very best for their constituents. Greater Manchester has some of the best hospitals in the country. However, not all patients experience the best care all of the time. In particular, the consultation sets out evidence that suggests that for the sickest patients who need emergency general surgery, the risk of dying at some Greater Manchester hospitals might be twice that at the best hospitals. That is simply not acceptable.
There is a shortage of the most experienced doctors in services such as A and E and general surgery, leaving some hospitals without enough staff. Only a third of Greater Manchester hospitals can ensure a consultant surgeon operates on the sickest patients every time; similarly, only a third can ensure a consultant is present in A and E 16 hours a day, seven days a week.
Healthier Together aims to ensure that all patients receive reliable and effective care every time. The programme is endorsed by the independent National Clinical Advisory Team, which offered strong support for the programme’s ambition, vision and scope, as well as its impressive public and clinician engagement. The NCAT felt that the programme’s approach was an exemplar of how the NHS should try to improve safety, value and sustainability.
I have not had time to say everything that I wanted to. I am conscious that hon. Members raised specific issues that I should respond to and am happy to write to all Members who have taken part in the debate. I hope my remarks have been of some help.
Oral Answers to Questions
Norman Lamb Excerpts(9 years, 10 months ago)
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Sir Tony Baldry (Banbury) (Con)
6. What steps his Department is taking to support carers.
The Minister of State, Department of Health (Norman Lamb)
Under the Care Act 2014, rights for carers that are equal to those for whom they care will be enshrined in law for the first time. That includes support to meet their needs. My Department has also separately provided £400 million for the NHS to enable carers to take breaks from their caring responsibilities.
Sir Tony Baldry
As a condition of the better care fund, areas are being asked to choose local indicators, which will accompany national measures, to show progress towards the integration of health and social care. How many areas have chosen carer-reported quality of life as their local indicator, and how can more areas be encouraged to make carers a priority in their delivery of services through the better care fund?
Norman Lamb
My right hon. Friend is absolutely right to focus on the importance of better care fund plans, including the interests of carers. The planning guidance that was issued in December made it clear that the plans should include the well-being of carers. Updated guidance will be issued very soon, and will reinforce the central importance of carers’ being part of the plans. We do not yet have a final picture, but we are keen to ensure that all plans include the interests of carers.
Barbara Keeley (Worsley and Eccles South) (Lab)
Last week I raised with the Prime Minister the case of a 62-year-old man who is caring for his wife, who has Alzheimer’s. When he sought an urgent GP appointment for her, he was told that it would take five weeks for her to see her GP and two weeks to see any GP, or he could take her to Salford Royal hospital’s A and E department. Does the care Minister think that that is acceptable, and will he now back the creation of a duty for NHS bodies to identify carers, so that they and the people for whom they are caring are given the support and the priority that they deserve?
Norman Lamb
No. I do not think that that level of wait is acceptable, which is exactly why we are promoting the better care fund. We want to bring together disparate parts of the system so that care is shaped around the needs of patients, and that has been widely supported throughout the system. I should also mention that the hon. Lady’s party colleague Baroness Pitkeathley was incredibly positive about the Care Act, saying that it was the biggest advance in her 30 years of working in the interests of carers. I wish that at some point the hon. Lady would just acknowledge all the good things that the Government have done in carers’ interests.
Mr Tom Clarke (Coatbridge, Chryston and Bellshill) (Lab)
8. What the new deadline will be for moving people with a learning disability out of assessment and treatment units and into community provision.
The Minister of State, Department of Health (Norman Lamb)
We are working with NHS England to set out clear expectations for progress and improved rates of discharge. This includes NHS England producing an action plan to measure progress against. The Winterbourne View joint improvement programme is working with local areas to identify issues and to support them to make progress.
Mr Clarke
Given the severe lack of funding in this area and the need for development of housing and proper support within the community to avoid the recurrence of, for example, what happened in Winterbourne, will the Minister explain how he is addressing this problem and who he is working with?
Norman Lamb
I applaud the right hon. Gentleman’s work on this, and it is very important that we make it very clear to the public that all of us share the ambition to get people out of institutional care when they do not need to be there. Actually, it is not about the lack of resources. The scandal is that, as a system, we are spending a fortune on institutional care when people could very often be much better cared for in their own communities. The good thing is that Simon Stevens, the new chief executive of NHS England, has shown a personal interest in this. I have discussed it many times with him. We have asked NHS England to produce an action plan by the end of August, demonstrating exactly how it will speed up the progress of getting people out of institutional care.
Mrs Anne McGuire (Stirling) (Lab)
20. Promises come cheap, but results take sustained action. The fact is that a promise was made to the families of those with learning disabilities to move them out of assessment and treatment units by June 2014. What exactly is the situation now? The latest figures revealed that only 35% of that promise had been fulfilled.
Norman Lamb
The truth is that progress is far too slow. This has been a scandal that has dragged on for many years. It is not a new problem, and helping people who are capable of living independent lives with support in the community to get out of institutional care is long overdue. Changing the culture is complex and difficult, but we are absolutely determined to sustain the pressure to ensure that change is achieved.
Grahame M. Morris (Easington) (Lab)
22. I thank the Minister for those replies, but I understand that Sir Stephen Budd has been asked to lead a working group on these issues, reporting to NHS England. Will the Minister say a little more about the purpose of this group and its significance, in the light of the failure to meet the June deadline?
Norman Lamb
That is absolutely right, but Sir Simon Stevens took the view that it was essential to get the voluntary sector much more involved in the whole process. There are brilliant organisations such as Mencap and the Challenging Behaviour Foundation which are absolutely committed to achieving change, and the more we can work with them to achieve that change, the more likely we are to be successful.
Liz Kendall (Leicester West) (Lab)
After the appalling scandal at Winterbourne View, the Minister promised to stop people with learning disabilities being sent to assessment and treatment units for long periods. He has spectacularly failed: 2,600 people are still in ATUs, including 150 children; more people are now going into these units than are coming out; and half are still on anti-psychotic drugs or subject to physical restraint. Change will only happen with real leadership, but in answer to a parliamentary question, the Minister said he had not even met one of his colleagues at the Department for Communities and Local Government. He must now set a clear, non-negotiable deadline to end this practice in two years’ time and to secure public commitments from the Health Secretary, the Communities and Local Government Secretary and NHS England’s chief executive to make sure it happens.
Norman Lamb
I caution against sanctimony, because this scandal continued under the last Labour Government, who did nothing to get people out of institutional care. At least this Government are absolutely committed to changing that. What we discovered is that changing the culture is a lot more difficult than I had hoped, but we are absolutely determined to achieve the change, which is so necessary.
Mr Robert Buckland (South Swindon) (Con)
9. What assessment he has made of progress towards achieving parity of esteem for mental health.
The Minister of State, Department of Health (Norman Lamb)
Our mandate to NHS England requires measurable progress in achieving parity of esteem by March 2015. Parity will involve extending and ensuring better access to talking therapies, in particular for children, young people and those out of work. Progress towards better access to these services has been good.
Mr Buckland
I thank my hon. Friend for that answer. What further measures will be taken to improve access to specialist perinatal mental health services to deal with problems such as post-natal depression, and will we see measurable objectives on that in the NHS mandate?
Norman Lamb
We had a very good round table discussion about this with leaders from around the country last week. What emerged is that fantastic progress is being made in many places, but it is not uniform. There needs to be a concerted effort to ensure that mothers get access to the same specialist treatment wherever they live across the country, and we are determined to achieve that.
Mrs Madeleine Moon (Bridgend) (Lab)
21. The all-party group on suicide prevention has been looking at the money going into suicide prevention as a result of the Government’s suicide prevention plan. It is acknowledged by most local authorities that there is more money for mental health, but suicide has been rolled into mental health and there is a distinct lack of support for those who are suicidal but do not have a diagnosable mental health problem. What does the Minister intend to do about that?
Norman Lamb
The hon. Lady raises an important point, which she and I have discussed before: the fact that very many people who end up taking up their own lives have had no contact at all with statutory services. I would be happy to discuss further with her what additional steps we can take to ensure that those people get the support they need.
Dr Sarah Wollaston (Totnes) (Con)
I am delighted to see all the members of the Front-Bench team in their places this morning—or this afternoon, I should say. The principle of parity of esteem should also apply to consent to treatment. Does the Minister agree that the offer of talking therapies and other therapies must always be based on the principle of informed consent? Has he held any discussions with his colleagues in other Departments?
Norman Lamb
I completely agree with my hon. Friend. It seems to me to be inherent in the nature of therapy that people go into it willingly. The idea that we could frogmarch them into therapy against their will simply would not work. We could end up with a dangerous and costly tick-box exercise that achieved nothing, so there is no plan to introduce compulsion to access therapy.
Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)
I listened carefully to what the Minister said in answer to the Chair of the Health Committee, the hon. Member for Totnes (Dr Wollaston), but will he confirm that there is no truth to reports that the Government are considering plans that would mean that people with mental illness would have their benefits stopped if they refused treatment? Rather than people refusing treatment, are not the increasing shortage of beds and ever longer treatment delays under this Government the real reasons why people are not receiving the help that they desperately need?
Norman Lamb
I can confirm, as I already have done, that there is no truth in the rumour. Indeed, in August we anticipate publishing the start of trial programmes to bring together IAPT—improving access to psychological therapies—with Jobcentre Plus. The idea of ensuring that people who are out of work and have mental health problems get access to psychological therapies is incredibly important, and I am very excited about the pilots that we will launch in August.
Kerry McCarthy (Bristol East) (Lab)
10. What assessment he has made of the effects of trends in food prices on public health.
Jesse Norman (Hereford and South Herefordshire) (Con)
13. What steps he is taking to improve care for people affected by stroke.
The Minister of State, Department of Health (Norman Lamb)
Mortality from stroke has fallen by over 40% in recent years. Awareness of stroke symptoms is being raised through the Act FAST campaign. The strategic clinical networks are sharing best practice in stroke care by, for example, working with commissioners and providers to improve stroke rehabilitation services.
Jesse Norman
I thank the Minister for that reply. Effective stroke care is extremely difficult to deliver in my county of Herefordshire, because patients are often scattered and inaccessible and the necessary treatment is highly time-critical. What are the Government’s plans to protect and enhance stroke care in rural communities, especially at Hereford hospital?
Norman Lamb
My hon. Friend raises an incredibly important point. I have the same experience in my county of Norfolk. Clinical commissioning groups are responsible for commissioning stroke care. The Herefordshire CCG is working with Wye Valley NHS Trust to improve the quality of stroke services and is seeking to establish a sustainable, hyper-acute service in the county, and it is clearly necessary that that is achieved.
Helen Jones (Warrington North) (Lab)
Emotional and psychological support after stroke can be just as important as physical care, yet many patients do not get the care they need even though research shows that investment in this area can not only benefit patients but save the NHS money in the long run. What steps will the Minister take to ensure that all stroke survivors get the right emotional and psychological support after stroke?
Norman Lamb
The hon. Lady is absolutely right. The cardiovascular disease outcomes strategy, which was published last year, acknowledges the importance of access to psychological therapies. Indeed, there is some really innovative work going on. A psychiatrist called Andre Tylee in London is doing work with heart patients, bringing in psychological therapies and improving their physical as well as their mental health outcomes, and the hon. Lady is absolutely right to make the case for that.
Paul Burstow (Sutton and Cheam) (LD)
14. What the timetable is for publication of a successor to the current national dementia strategy.
Paul Burstow (Sutton and Cheam) (LD)
T9. Given that last year, more than 7,500 people with a mental health crisis found themselves in police cells rather than anywhere appropriate such as a hospital, given that 263 of those people were children and young people, and given that they stayed for 10 and a half hours in a police cell, is it not time that we took the evidence of street triage, which we know works, and rolled it out across the country?
The Minister of State, Department of Health (Norman Lamb)
The fascinating thing is that street triage is spreading across the country because forces and mental health trusts see the enormous value of it. The really exciting news is the significant reduction in the number of people who end up in police cells. That is in part due to the standards that we set through the crisis care concordat for the first time for mental health crisis care.
Meg Munn (Sheffield, Heeley) (Lab/Co-op)
I welcome the Secretary of State’s commitment to getting rid of as much bureaucracy as possible, so will he look into what is happening with NHS England in south Yorkshire that is delaying approval for a much-needed GP surgery in my constituency? Given that it is in partnership with the local authority, the delay risks us losing the surgery altogether.
Mrs Emma Lewell-Buck (South Shields) (Lab)
Annually 30,000 applications for funeral payments are rejected, leaving families committed to expensive funerals that they cannot afford. People who are approaching end of life are not advised, as part of their palliative care, about planning for funeral costs or their eligibility for support. What is the Secretary of State going to do to remedy this?
Norman Lamb
The hon. Lady raises an important issue and I am very happy to discuss her concerns further with her.
Iain Stewart (Milton Keynes South) (Con)
The Secretary of State will be aware of the campaign run by the Milton Keynes Citizen, my hon. Friend the Member for Milton Keynes North (Mark Lancaster) and myself for an expanded A and E department at Milton Keynes hospital. What assurances can he give me that A and E services at the hospital will be able to meet the needs of an expanding population?
Norman Lamb
No, that is entirely unacceptable. What we see in some of the best parts of the country such as Torbay, one of the integrated care pioneers, is that they are completely integrating mental health with primary care, delivering better results for patients. The sort of attitude that my hon. Friend describes has to end.
Chris Bryant (Rhondda) (Lab)
There is lots of evidence to show that chronic traumatic encephalopathy is now a major cause of depression, dementia and in many cases suicide, but the World cup showed that many sporting bodies are still not taking concussion seriously enough. Will the Minister, perhaps with colleagues in other Departments, bring in all the sporting bodies, the doctors and the teachers so that we can take concussion in sport seriously?
Residential Home Closures
Norman Lamb Excerpts(9 years, 10 months ago)
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The Minister of State, Department of Health (Norman Lamb)
I thank the hon. Member for Luton South (Gavin Shuker) for securing this debate and for speaking in a reasonable tone about issues of enormous concern to some of his constituents. I very much noted the fact that they have told him that they have experienced good care. They regard the care home as their home. In a way, that demonstrates the conflict that sometimes arises, in that there is a general trend towards more people wanting to live in their own communities with support, as the hon. Gentleman rightly said. He described his sense that he would want to remain in his own home were he to be disabled, but at the same time there are those who regard a care home as their home and they have no desire to change that. It is right to recognise that that conflict exists, and it creates a dilemma.
The hon. Gentleman suggested that, in a way, Scope was closing the home because of Government policy. Government policy, as enshrined in the Care Act 2014, is to put people in charge—to focus on well-being, which is the central theme of the Care Act. As far as possible, it should be the individual who determines where they want to be. I have spoken to Richard Hawkes, the chief executive of Scope. Scope is very clear that this is its decision: it wants to do it and is doing so for what it regards as a good purpose. However, the Government’s focus is simply on the individual—on ensuring that, as far as possible, we enable people to make the decision that is right for them, recognising, however, the conflict that can arise.
Care homes often look after some very frail people, but also individuals with quite complex needs. It is understandable and reasonable that, should there be a possibility of a care home closing, residents and their families will be extremely concerned about the future, particularly with the upheaval of having to move. It will inevitably be an unsettling and potentially stressful time. The decision to close a care home voluntarily is taken by the owner or operator—either the local council, where that remains the case, or, if it is an independent home, the proprietor, whether the home is in the private or the voluntary sector. Of the approximately 17,000 care and nursing homes in England these days, over 90% are in the independent sector—that has been the case for many years—and are owned and operated by private companies or charitable and voluntary sector organisations such as Scope.
Homes may close for a variety of reasons, including lack of financial viability and/or insufficient demand for places, retirement of the owners, the sale of premises for alternative use and even the de-registration of unsuitable or unsafe services as a result of the Care Quality Commission’s intervention. In the case of Scope, the organisation is looking to redesign the services it provides to support people. It is important that people who need care and support are accommodated in appropriate settings that are based, critically, on their choice as far as possible. It is clearly not desirable if someone has to move from a care home where they are settled and happy and where their needs are being met.
Local authorities have a responsibility, through good commissioning strategies, to ensure a healthy local care home sector. Through the Care Act 2014, which will come into force next April, we are giving local authorities a core duty to promote their local care market, with a particular focus on ensuring diversity, quality and sustainability. Importantly, they should ensure that sufficient high-quality services are available to meet the needs of individuals in their local area. However, although local authorities should make all reasonable efforts to ensure that good care homes remain viable and stay open, there will be situations where homes have to close or where the proprietors choose to close them. We have to face this. What is most important is that any decision to close a home should be handled sensitively and appropriately. It is essential that person-centred care planning identifies the best possible alternative for each individual. Adequate time should be allowed for the process, so that residents and their relatives can be properly involved and be given plenty of time to make decisions and arrangements in a way that minimises stress.
I must emphasise that, should a home have to close, local authorities have a statutory duty to arrange suitable alternative accommodation for those residents who are assessed as being in need of residential care, so it should never be the case that someone who needs residential care will not be provided with it. I fully appreciate, however, that that does not reassure someone who regards a particular building and set of care workers as their home and their home environment.
I am aware that some providers of residential care for disabled people—including the charity for disabled people, Scope—are reviewing their residential services and are consulting users of services and their families. I appreciate, as I have said, that this can be an extraordinarily worrying time and a stressful situation both for the people in those homes and for their families. Parents of adult disabled people are often themselves quite elderly, which can cause additional stress. The hon. Gentleman touched on that when he talked about his constituent. I would encourage the residents and their families fully to engage with the consultation process and ensure that their views are taken into account.
Scope has given an assurance to the Department of Health that it is committed to ensuring that all users of its services who may be affected are properly consulted and supported. It has promised to provide any individual who needs it with advocacy so that every resident of its homes can understand what the proposals mean for them and can make it clear what they want for the future. Richard Hawkes told me that Scope has even provided care workers to come down to Parliament to support people who were lobbying their MPs against the closures. It says that it has tried to be as reasonable as possible. This process will not, Scope says, be rushed or hurried. It has informed the Department that the consultation will take place over a period of three years.
Scope runs many other care homes that will remain open. There is a particular focus on the larger care homes, but there are also many smaller care homes that it intends to keep open—eight of them, as I think the hon. Gentleman mentioned. Scope appreciates that many residents are happy in its homes, but has to face the fact that there is a lessening demand for large, traditional residential care services.
Richard Hawkes, as chief executive, made the point to me that more people are taking on personal budgets—a concept substantially and rightly developed under the previous Government and one that is continued by this Government and now legislated for in the Care Act 2014. The concept was designed to put the individual in charge, so that they can determine how the money available for their care is spent to meet their particular priorities. As people take on personal budgets, according to Richard Hawkes, they are increasingly voting with their feet and choosing not to go into larger care homes, which often have long corridors, shared bathrooms and so forth. They are increasingly choosing to remain in supported living if possible with a package of care built around their individual needs. Scope is reviewing its services now, so that decisions can be made and, if need be, homes closed in a controlled, planned manner before vacancy levels make them unviable.
Richard Hawkes also told me about an experience that Scope has been through in Southampton. It proposed to close a care home, leading to the same totally legitimate anxieties and concerns. It went through the process and all the individuals in the home have been relocated in circumstances that suit those individuals, with their having a central say in where they are going to go. He tells me—I base my comments just on what he says—that all now appear to be happier with their new circumstances and are finding a new sense of freedom that they did not experience in the past. Although these changes to circumstances can be traumatic and difficult, the end-result, as demonstrated in the experience of Southampton, can sometimes be a good one for the individuals involved. I realise, though, that elderly parents in particular will sometimes find that quite hard to recognise.
It is worth taking a moment to look at the history of this issue. Many traditional, large residential care homes are quite old now. A number of Scope’s homes date back to the 1970s. They were developed in—and designed to suit the needs and demands of—a different era. By modern standards, they lack privacy, and they do not allow residents the degree of freedom, choice and control that we rightly expect and demand nowadays. As a result, many Scope homes are under-occupied. The increasing availability of new models and types of care, support and accommodation means that traditional large care homes are no longer the default or only option when it comes to providing care and support for people with disabilities.
Innovations and developments in supported living, and the various types of housing with care that are available these days, offer disabled people far more choice than they ever had in the past, and control over their lives. I am sure that, ultimately, we should all welcome that. Scope has informed us that, owing to the newer options that have become available, local authorities do not automatically make routine new placements in residential care, and it expects the number of empty places in its older homes to continue to rise. In the long term, it can only be a good thing that people have so many more choices when it comes to the care that is available to them, but, as I have said, I entirely appreciate that, as with any change, the process is not without its short-term challenges.
The Government want to give people more control over their health and social care services, and, therefore, over their lives. That is the central ambition of the Care Act. Personalisation means building support around individuals and providing more choice, control and flexibility in the way in which they receive care and support, regardless of the setting in which they receive it. There is no central policy, incidentally, that says care homes are bad: absolutely not. It is a question of what is right for the individual involved.
The Care Act provides a new legislative focus on personalisation, increasing opportunities for greater choice, control and independence, so that people can choose the services that are best suited to meet their care and support needs. The Act provides that adults who are eligible for care and support must receive services that meet their individual needs. It also requires that they must be involved in care planning. Some, of course, will need and benefit from residential care. There will always be an important job for care homes to do. However, for others a different model of care may now be more appropriate to their needs, and, most importantly, to their aspirations and desire to lead the sort of independent life that all the rest of us take for granted.
We are committed to ensuring that people who wish and are able to live in their communities are given the support that they need in order to do so. Everyone, especially younger adults—including those with a learning disability—should have the opportunity to make informed choices about where and with whom they live, and to have greater choice and control over their lives and support to help them to lead a fulfilling life of their own.
Question put and agreed to.
Gosport War Memorial Hospital (Deaths)
Norman Lamb Excerpts(9 years, 10 months ago)
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The Minister of State, Department of Health (Norman Lamb)
Following the publication of the Baker report in August 2013 into higher than expected death rates of elderly patients at Gosport War Memorial hospital between 1988 and 2000, families have continued to raise concerns about the initial care of their relatives and the subsequent investigations into their deaths. In order to try and address their concerns, and having given consideration to a number of alternative options, I am setting up an independent panel to review the documentary evidence held across a range of organisations.
I have asked Bishop James Jones to chair the panel. Having successfully steered the Hillsborough panel, he brings a wealth of expertise and experience to this work. He has begun to work with affected families, and will continue to do so over the coming weeks and months to ensure that the views of those most affected by these deaths are taken into account. I have also asked Christine Gifford, a recognised expert in the field of access to information, to work alongside him and the various organisations to ensure maximum possible disclosure of the documentary evidence to the panel.
I will further announce the details of the other panel members and agreed terms of reference in the autumn.
Learning Disabilities (Care in the Community)
Norman Lamb Excerpts(9 years, 10 months ago)
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The Minister of State, Department of Health (Norman Lamb)
I congratulate the right hon. Member for Coatbridge, Chryston and Bellshill (Mr Clarke) on securing the debate and thank him for doing so. I do not think I disagree with a single word he said in his speech today. The right hon. Member for Oxford East (Mr Smith) also talked about the scandalous case of Connor Sparrowhawk. I have met his mother and what happened there should shock us all. There was acknowledged negligence in the care and these things simply cannot go by without a proper and effective response to stop repeats of this sort of thing ever happening again.
One thing that the right hon. Member for Coatbridge, Chryston and Bellshill focused on was the families, to whom I pay enormous tribute for their campaigning. What is most shocking when one talks to them is the sense that they are not listened to—that they raise their concerns with public bodies and get no effective response. They are ignored and that should shock us all.
The right hon. Gentleman also said that it is an ongoing scandal and a scandalous misuse of public money, and I completely agree with him. This has now gone on for very many years. It is an unacceptable remnant of the previous system of institutional care that has to come to an end. The thing that has depressed me in this job, more than any other aspect of it, is the extent to which it is so difficult to change the culture that allows this sort of thing to carry on. There is the sense that those commissioning care seem, it appears, to be willing to carry on with business as usual, when we know that the outcomes for those individuals are not acceptable, and that very many of these individuals are able to live a better life in supported living in their communities. The imperative to achieve change is as strong as ever, and for as long as I am in this job, I will do everything I can to try to change things.
Because of my total frustration about the way in which commissioning has happened, I chose to go out to visit one 17-year-old girl a couple of weeks ago in an assessment and treatment centre to see it for myself, and to see the barriers that that family are up against and the problems that they have had engaging with the commissioners of care, which, in that case, is NHS England. Indeed, with regard to the case of Josh that the right hon. Gentleman mentioned, I have invited the clinical commissioning group to come into my office on, I think, 22 July, together with NHS England and with the family, so that we can get to the bottom of what has gone wrong and try to achieve a solution. I am prepared to intervene in this way if necessary, to force change to a situation that I regard as completely unacceptable.
I am very pleased to have the opportunity to focus on the needs of people who, as the right hon. Gentleman said, are among the most vulnerable in our society. Many of us share the concern that people with learning disabilities and their families are still getting an unacceptable raw deal from the health and care system, from other public services, and from society in general. People with learning disabilities have exactly the same rights as anyone else, yet they continue to experience discrimination, abuse and a basic lack of respect for their fundamental rights. That should shock us all.
Margot James (Stourbridge) (Con)
I am most encouraged by my hon. Friend’s remarks, and I congratulate the right hon. Member for Coatbridge, Chryston and Bellshill (Mr Clarke) on securing this important debate. Has my hon. Friend come across the organisation based just outside my constituency, Changing Our Lives? It was founded by Jayne Leeson, who was awarded the MBE for her services in this area. It is doing such innovative work that demonstrates clearly the potential of people currently in residential care with learning disabilities, who can live a most fulfilling life outside, in the community, through supported living.
Norman Lamb
I am very grateful to my hon. Friend for that intervention. I would be interested to hear further information about the organisation to which she refers. It is clear that sometimes a leap of faith is required to give a person the chance of a better life outside, and the system is horribly risk averse. We know that the main cause of decisions to keep people in assessment and treatment centres is the clinical judgment that the person needs to stay there, so that needs to be challenged. I want to give people the right to a second opinion and I am in discussions with Simon Stevens, the chief executive of NHS England, to give people that right, because we have to find ways of giving a voice to people who hitherto have felt that they are ignored and not listened to and that nothing ever changes.
I pay tribute to the two organisations mentioned by the right hon. Member for Coatbridge, Chryston and Bellshill: Mencap and the Challenging Behaviour Foundation, which have continued to make the case on behalf of people with learning disabilities.
Winterbourne View and the appalling abuse of people there reminded us that there is still a massively long way to go to ensure that people are safe and get the right support—the support that they need. The Government’s review following the Winterbourne View case looked at the systemic issues facing people with learning disabilities and their families. At the end of the review, we published the concordat—the right hon. Gentleman referred to that—bringing together all the national organisations to commit to change. In a way, the most distressing thing is that I felt that organisations committing to the concordat and the change set out in it were doing that with a seriousness of intent that they would deliver on. The lack of change that there has been since then is really shocking, given that they committed to achieving that change. Eighteen months on, we all need to remind ourselves that progress so far has not been nearly good enough and that we all need to continue to work in partnership to deliver on the commitments solemnly made at the start of all this.
I have said recently, and the information that we have shows, that far too many people with learning disabilities are still stuck in hospitals, often hundreds of miles from home and in many cases for years, with serious questions about whether they are getting the right care and support.
I have also met Mike Richards, the chief inspector of hospitals, and Paul Lelliott, the deputy chief inspector for mental health, to ensure that the Care Quality Commission challenges organisations. If someone is living in an assessment and treatment centre, which is there for assessment and treatment, not for long-term living, surely it is not delivering the right model of care. That needs to be challenged by the Care Quality Commission and not simply accepted and tolerated.
Collectively, we need to be honest and say that the system has so far completely failed to deliver on the commitment made in the concordat significantly to reduce the number of people with learning disabilities who are in effect living in hospitals—for whom hospital is their home.
Jim Shannon
I want to say just one thing. Is the Minister saying that this Government are committed to partnership relationships with housing groups and those who are committed to facilitating supported living for people outside these homes? I think that, if he is, he will find that many outside bodies are prepared to take him up on that.
Norman Lamb
I very much agree and I am grateful to the hon. Gentleman for that intervention. Providers of supported living care need to be much more central to the task of changing this culture. Indeed, I have asked for a meeting to be arranged that will bring in some of those providers, with Simon Stevens and the chief nursing officer, Jane Cummings, who I am pleased is now in charge of this programme, to demonstrate how they can play a part in effecting change.
I also want to acknowledge the work that has been done from the concordat and what has been achieved by NHS England and other delivery partners.
It is appropriate for us to start by looking at the people who were in Winterbourne View before it closed. I am pleased to report that NHS England’s Improving Lives team, who include senior clinicians, social care staff, third sector partners and family members of people with learning disabilities, have now reviewed the care of all but one of the 47 people who were in Winterbourne View, and the care of the one remaining individual will be reviewed by the end of this week. Those reviews have resulted in some people moving out of hospital into circumstances that are more appropriate for them as individuals.
The Government have provided funding so that the people who were in Winterbourne View can have additional trauma assessments where the need has been identified and they have consented to those assessments. We are providing additional funding to support families through a telephone helpline, regular telephone counselling and family support days. The funding will also support other people with learning disabilities—including the 17-year-old girl whom I visited a fortnight ago—who have experienced institutional abuse, and help their families.
Involving people with learning disabilities and their families is key to ensuring that the work that we are doing means that they have a better experience and better outcomes. We have provided funding to organisations to allow people with learning disabilities and their families to share their views with us, so that we can listen to them and respond to the concerns that they raise.
We have also made progress on other Winterbourne View concordat commitments. For example, guidance has been developed on commissioning advocacy for people with learning disabilities so that, again, they get a voice and they get access to information, advice and support when necessary. It is vital that local commissioners ensure that people have proper access to high-quality advocacy where they need it.
Mr Tom Clarke
I am very grateful for the Minister’s tone and I know that he feels deeply bound to respond to the problems that we are discussing. I welcome the fact that he mentions advocacy. Will he assure us that his Department will do everything possible to insist that advocacy remains at the heart of all our discussions?
Norman Lamb
I very much will do that. I have specifically talked to Simon Stevens about that. I am conscious that time is tight, so let me just mention one or two specific things. First, there is now movement on people getting plans for leaving institutional care. NHS England expects that clinical commissioning groups and its area teams will discharge or transfer 35% or 892 of the 2,615 people currently in in-patient settings within the next 12 months. That is 385 within three months, 266 within six months and 241 within 12 months. That is what they have come up with in terms of going through individual plans. We now have to ensure that it happens, and there is no guarantee in my mind that it will happen, so we have to hold the system to account.
I have mentioned that we have to unlock barriers wherever they exist. For me, one of the barriers is this. When someone transfers from the responsibility of NHS England to the local authority, the responsibility for the funding transfers to the local authority. That creates a disincentive for the local authority to take responsibility for that person, so the money has to flow with the individual. We have to ease the transition and not make money a barrier to an appropriate transfer to supported living in the community.
I have also mentioned that we have to address the question of the clinical judgments. That is not to say that in individual cases a clinician will not be making their best judgment about an individual’s need to stay in a particular setting, but surely the family need access to a second opinion to be able to challenge that judgment. I am conscious—I say no more than this—that the clinicians who are making the judgment are often employed by the organisation that is receiving payment for providing the bed to the individual. Whether it is in the state sector, the independent sector or the voluntary sector does not matter. The right to a second opinion is essential.
In the moments left to me, let me say that I remain totally committed to getting the culture change that we are all after. What has happened so far is not acceptable.
Code of Practice: Mental Health Act 1983
Norman Lamb Excerpts(9 years, 10 months ago)
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The Minister of State, Department of Health (Norman Lamb)
We have today launched a consultation on proposed changes to the Code of Practice: Mental Health Act 1983. Following this consultation, we will lay before Parliament a revised code by the end of 2014. It is intended that this will become effective from 1 April 2015.
Since the code was last published in 2008, there have been substantial changes and updates in legislation, policy, case law, and professional practice. A revised code needs to reflect and embed developments since 2008 in areas including the use of restrictive interventions; use of police powers to detain people in places of safety; and the use of community treatment orders.
In publishing “Transforming care: A national response to Winterbourne View Hospital” and “Closing the Gap: Priorities for Essential Change in Mental Health” we committed to improving mental health services. “Closing the Gap” sets out 25 priority actions to improve the provision of mental health care, promote recovery and the experience of patients, their families and carers. “Transforming Care” also committed the Department of Health to review and consult on a revised code to address the need to improve the quality of care received by patients detained under the Mental Health Act 1983.
The code is an important lever for delivering these changes. Health care and social care professionals consult the code routinely to inform their practice, safeguard patients’ rights and ensure compliance with the law. The code is also used by patients who are detained or otherwise subject to the Act, and their families, carers and advocates.
We are committed to ensuring that high-quality care is always provided for patients detained and treated under the Act. Care should always promote recovery, be of the shortest duration, be the least restrictive option, keep the patient and other people safe, and ensure value for money for the taxpayer.
The consultation sets out proposed changes to the code but does not include any changes to either primary or secondary legislation. The draft code includes new chapters on: the care programme approach; equality, human rights and parity of esteem; mental capacity and deprivation of liberty; and victims.
The revised code will apply to the use of the Act in England.
Copies of “Stronger Code: Better Care—Consultation on proposed changes to the Code of Practice: Mental Health Act 1983” and “Mental Health Act 1983: Draft Code of Practice for Consultation” have been placed in the Library. Copies of the consultation documents are available to hon. Members from the Vote Office and to noble Lords from the Printed Paper Office.
Liverpool Care Pathway
Norman Lamb Excerpts(9 years, 10 months ago)
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The Minister of State, Department of Health (Norman Lamb)
The Leadership Alliance for the Care of Dying People has today published details of the approach to secure high-quality, personalised care for everyone in the last few days and hours of life in England.
Today’s publication by the alliance of 21 organisations follows the report by the independent review that I commissioned to consider the Liverpool care pathway (LCP). The review panel made 44 recommendations, including that the LCP should be phased out over the succeeding six to 12 months. As I announced on 15 July 2013, the Government accepted that recommendation. I said that the Government would consider fully the recommendations of the review and work with the organisations to which the panel addressed its recommendations, other stakeholders and charities to inform a full system-wide response to the review’s recommendations. That response, which includes details of the new approach, is published today.
The work that has been done goes beyond responding to each of the recommendations. The leadership alliance has developed five priorities for care of the dying person. These set out, for dying people, their families, health and care staff and others, what should happen when someone is thought to be close to dying.
The priorities for care provide that:
the possibility that a person may die within the next days and hours should be recognised and communicated clearly, decisions about care made in accordance with the person’s needs and wishes, and these decisions reviewed and revised regularly; sensitive communication should take place between staff and the person who is dying and those people who are important to the dying person;
the dying person, and those identified as important to them, should be involved in decisions about treatment and care;
the people important to the dying person should be listened to and their needs respected; and
care should be compassionate and reflect a care plan for the individual dying person.
The response includes further details of the priorities, as well as a statement of the duties and responsibilities of health and care staff to deliver the priorities, and implementation guidance for service providers and commissioners. The 21 organisations have also published a collective statement, as well as individual statements, of the key actions they will take to implement the priorities. These include that the National Institute for Health and Care Excellence (NICE) will be developing new clinical guidelines on the care of the dying adult and end-of-life care for children. These guidelines will inform the development of a quality standard for end-of-life care for children and an update of NICE’S quality standard on end-of-life care for adults. From October 2014, Care Quality Commission (CQC) inspections will incorporate the priorities as part of inspection of end of life care.
Taking account of the fact that one of the panel’s recommendations was in two parts, the organisations have accepted 28 of its recommendations in full and 12 in principle or in part. There are three that have not been accepted at this stage or that are still being considered. Two recommendations have not been accepted. NHS England and Health Education England will not promote the use of prognostic tools in relation to dying. The approach in the priorities for care does not, unlike the LCP, rely on a diagnosis of dying. The priorities apply
“when it is thought that a person may die within the next few days and hours”
and will support good care irrespective of whether someone is actually dying.
Rather than issue guidance to nurses on caring for people at the end of life, the Nursing and Midwifery Council will instead incorporate the principles behind the priorities into the revised NMC code: standards of conduct, performance and ethics, a draft version of which is currently out for consultation. It has also published its standards for competence as a separate stand-alone document.
The review panel found evidence of both good and poor care given to people in the last few days and hours of life. Use of the LCP was not found to be synonymous with poor care. The panel said that whilst in some circumstances, the LCP had supported the delivery of good care, it was not always applied properly. Where it was used as a generic protocol, the LCP ran the risk of becoming process-driven.
As I made clear in my statement of 15 July 2013, everyone who uses health and care services has the right to be treated with respect, dignity and compassion by staff with the skills and time to care for them properly, and any variation in standards of care is not acceptable. The priorities for care make it clear that where someone is thought to be in the last few days and hours of life, there must be sensitive communication, involvement in decision making and consideration of the needs of those who matter most to the dying person.
Key national organisations in the health and care system have committed to a co-ordinated programme of actions to take forward the priorities for care. This includes providing relevant education and training, as well as regulatory and inspection action. There is no excuse for individual organisations and health and care staff to deliver anything less than high-quality care for people in the last few days and hours of life, as set out in the five priorities.
The Government will continue to take a close interest in this area and intend to publish a report, around July 2015, two years on from the review panel’s report, assessing how national organisations have implemented the commitments they have set out today. The independent review panel chaired by Baroness Neuberger will continue to have a role, providing independent advice to Ministers about implementation of the commitments in the system-wide response. Their views will inform the report that the Government intend to publish.
I am grateful to members of the panel for agreeing to continue in this role, as well as for their wider commitment to ensuring high quality, compassionate care for everyone in the last few days and hours of life.
One chance to get it right, which incorporates the system-wide response to the report of the independent panel on the LCP, has been placed in the Library, along with the commitment statements made by national organisations. Copies are available to hon. Members from the Vote Office and to noble Lords from the Printed Paper Office.