Health and Social Care Bill
Baroness Finlay of Llandaff Excerpts(12 years, 4 months ago)
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Lord Rea
My Lords, in supporting this amendment I declare an interest. Not only my former patients but I, as a patient, have received skilled help from clinical physiologists. The pacing unit at St Mary’s Hospital, which is run by clinical physiologists, has monitored my pacemaker since it was fitted four and a half years ago. My life has literally been in their hands while they periodically adjust my heartbeat to get the best setting.
The Registration Council for Clinical Physiologists, which has been described, has been trying to persuade the Department of Health to include the profession in the mandatory regulatory framework for health professionals for the best part of a decade. The Health Professions Council recommended in 2004 that clinical physiologists should be included in its regulatory regime, as well as other clinical scientists whose work involves a potential impact on patient safety. The then Secretary of State accepted this recommendation but still no action was taken and has since not been taken despite frequent reminders from me, among others. On my count, 30 parliamentary Questions have been tabled on this issue. It has also been raised in your Lordships' House in a debate on an order to do with the Health Professions Council. I hope that this amendment will serve to speed up the process by focusing the Government’s attention on an overdue step that we feel needs to be taken.
Baroness Finlay of Llandaff
My Lords, this group of amendments is very interesting as it reveals the enormous number of people involved in healthcare who literally hold the lives of others in their hands and are not subject to any statutory regulation but are voluntarily registered. I have an amendment in this group which seeks to establish,
“a statutory register of Physicians’ Assistants (Anaesthesia)”
and of other healthcare professionals. I will speak about that in a moment in relation to clinical perfusion scientists.
Physicians’ assistants in anaesthesia already have a voluntary register in place and they applied to the Health Professions Council for registration and had their application accepted. However, that all went on hold with the emergence of this Bill. The Royal College of Anaesthetists does not allow physicians’ assistants in anaesthesia to become associates as they are not registered with the General Medical Council, but it permits them to have affiliate membership. However, the college does not have a regulatory role as such; it is tied up with education and standards.
Physicians’ assistants in anaesthesia urgently need statutory regulation, given the range of invasive, and potentially life-threatening, procedures that they perform and the knowledge and autonomy of practice required in the roles that they carry out. These practitioners perform tasks that, in the UK, were previously carried out only by doctors. They cannot get indemnity insurance for their practice or apply for prescribing rights, even though they sometimes have to be able to respond in a matter of seconds, not minutes, if something goes catastrophically wrong with an anaesthetised patient while the anaesthetist is outside the theatre for whatever reason. They are on a voluntary register, which provides some reassurance for patients and employers, but that cannot realistically be seen as an alternative to statutory regulation. I think that in 2009 they were identified by the Department of Health as being urgently in need of registration. The Health Professions Council felt that these assistants fulfilled sufficient of its criteria to warrant the recommendation for statutory regulation being accepted.
Irrespective of whether Members of this House have undergone a procedure requiring anaesthesia, would they consent to being rendered unconscious by an individual who was neither bound by a stringent professional code of conduct nor properly registered to practise? After all, we would not get into an aeroplane if we did not know that both the pilot and the co-pilot were appropriately qualified to a very high degree, with ongoing continuing professional registration. We trust them just as we trust these physicians’ assistants, but if something goes wrong in theatre it does so with catastrophic rapidity. When I did my training in anaesthesia, on more than one occasion I saw these physicians’ assistants recognise problems arising before the trainee anaesthetists had done so. They carry enormous responsibility during complex procedures.
I have included other healthcare professionals in my amendment as I am well aware that the Government do not like to have enormous lists in a Bill. My amendment would therefore leave the door open to include clinical perfusion scientists—the other group involved in theatre—whose role is primarily to maintain a patient’s circulation during open-heart surgery, during a period of surgical repair when the heart has been stopped. They were recommended in 2003 for statutory regulation.
There have been two high-profile cases involving clinical perfusion scientists. The first fatality, in 1999, led the Southwark coroner to recommend the immediate statutory regulation of clinical perfusion scientists. The second fatality, in 2005, was attributed to inappropriate drug administration by a clinical perfusion scientist during an operation on a five-month-old baby at Bristol Royal Infirmary. That led to the publication of the Gritten report, which concluded that:
“The incident occurred because of latent weakness that lay dormant for years hidden by healthcare professionals compensating for inadequacies within national and local systems”.
The report recommended that action at national level should include,
“regulation and guidance on perfusion practice in cardiopulmonary bypass”.
More recently, there have been fatalities that have led to clinical perfusion scientists’ actions being questioned by coroners—the most recent of these incidents occurring in 2010 at Nottingham City Hospital.
I do not want to scare people from going in for surgery and I do not want to scare Members of this House who may be going in for surgery, but in the current climate people need to know that these very critical roles are being undertaken by people who are on a voluntary register but do not enjoy indemnity, as they would if they were on a statutory register and subject to the rigours of being statutorily regulated.
Baroness Pitkeathley
My Lords, I do not want to sound like a broken record in always resisting more statutory regulation or in disagreeing with colleagues with whom I normally agree, but I want to emphasise the application of light-touch regulation. We should use only the minimum regulatory force to achieve the desired result. Therefore, we should be considering extending regulation only where the risks to patient safety and public protection are such that other mechanisms such as those I previously mentioned—employer’s guidance, clinical governance, appropriate delegation and multidisciplinary teamworking—are unable to manage those risks.
When the Council for Healthcare Regulatory Excellence becomes the Professional Standards Authority for Health and Social Care, it will be accrediting voluntary registers as a more proportionate and targeted approach to developing high standards of care for people working in health and social care who are not statutorily regulated. I remind your Lordships that statutory regulation can be expensive and it is important that we explore and develop a range of options for maintaining and improving the quality of care delivered by people working in health and social care. It may be more proportionate, for instance, to promote greater co-operation and sharing of good practice. We seek to find the most efficient and common-sense solutions to the kind of problems that your Lordships have identified.
Lord Alderdice
It may seem a little unclear to the noble Lord, but it is not so unclear. Psychologists are qualified as psychologists, not as psychotherapists or as counsellors—they belong to a different professional body and have different qualifications and requirements. Psychologists themselves campaigned for many years for statutory regulation and finally got it through the Health Professions Council. Arts therapists and so on went through the HPC because many of them were occupational therapists, but try as I might—and I have been doing so for well over a decade—I cannot get successive Governments to address the question of psychotherapists and counsellors, despite the fact that they constitute a far larger number of people.
My dilemma with the current set of propositions is that, of the arguments adduced to try to persuade noble Lords that a quality-assured voluntary registration scheme is appropriate because the people referred to—the physiologists, the perfusion scientists and so on—are operating within the health service under supervision, are employed there and are smallish in number, none of them applies to this other group of people, for whom I have had precisely the same reply from the Minister. Therefore, I am keen to hear from the Government what the set of criteria is. Is it simply that this Government are not keen to pursue anything in the way of regulation except at the most modest level? If so, that is a legitimate argument but it needs to be made. If not, then I do not quite see the consistency of the current application.
Baroness Finlay of Llandaff
Perhaps I may add a small point. I do not know how many physicians in anaesthesia are employed in operating theatres in private hospitals, where an enormous amount of private surgery is done. One of the main reasons for people going to a private hospital is for surgery—particularly elective orthopaedic surgery. Therefore, although I cannot put any figures on this, I do not think that it is correct to assume that these people are necessarily operating only in the NHS and are subject to current NHS structures.
In the new world where we will have a broad range of providers, it will become even more important to know that there is a minimum standard and that all the people at each step of the way will be answerable. The patient may well choose to go to an organisation where these people are employed but the patient will not know that. No one gives him a list and says, “Of all these people looking after you, these will be statutorily registered but these may or may not be on a voluntary register”. If we are thinking about patients taking informed decisions regarding their future, I suggest that the coroners’ reports that we have had to date should already be sounding alarm bells.
Baroness Northover
I have already mentioned to the noble Baroness—she is probably totally familiar with this—that the Department of Health does not have evidence of there being a risk in this regard. Clearly, as I mentioned on the earlier group, these issues will always be kept under review. If the concerns that she has flagged up and if the association, which is particularly encouraging the regulation of clinical physiologists—that is fine; it is all part of professionalisation—flags up particular concerns that emerge from other evidence, then of course the department will take that very seriously. However, things need to be proportionate.
Baroness Finlay of Llandaff
I have listened very carefully to what has been said about the assistants relating to anaesthesia, but I also used the more catch-all phrase about the clinical perfusion scientists. I would be grateful if, after this debate, the noble Baroness would write to me and explain why coroner recommendations in relation to clinical perfusion scientists are not considered to be enough of a risk to take action. If one is trying to assess this on a risk spectrum, it would be helpful to understand why a coroner's decision to recommend that this small, contained group of clinical perfusion scientists should be regulated does not constitute enough of a risk to go down that route to regulate them and to have them on a statutory register.
Baroness Northover
I am very happy to take away what the noble Baroness has said and to discuss the situation further with her.
We expect the assured voluntary registration to be up and running by 2012. Therefore, afterwards that would need to be assessed to see whether anything further is required, as noble Lords have figured might be the case. We are hoping to see how it all works.
The noble Lord, Lord Walton, flagged up various groups which were regulated and he could not quite see why others were not. Given that I used to bump into the noble Lord, Lord Walton, in the Wellcome Library for the History and Understanding of Medicine, I think he will fully understand that the way in which regulation has grown up has not necessarily been logical or consistent. Therefore, I flag up the 2005 Hampton review on regulation which says that it should be proportionate to the risks that it seeks to mitigate and various other provisions. That is what we are seeking to do. Of course, we shall keep under review what we are doing to see whether it is adequate. In the mean time, I hope that the noble Baroness will be willing to withdraw the amendment.
Health and Social Care Bill
Baroness Finlay of Llandaff Excerpts(12 years, 5 months ago)
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Lord Marks of Henley-on-Thames
I, too, support this suite of amendments. I shall speak only briefly, not in favour of a reinvigorated Earl Howe but in support of Amendments 234 and 234A, which are to the same effect and concern the termination of the appointment of directors of public health.
The Bill provides for joint appointment of the directors of public health, by the local authority and the Secretary of State, and it is right that it does so. I entirely agree with the noble Lord, Lord Patel, that it is therefore essential that the Secretary of State should also have a crucial vetoing part to play in the termination of such an appointment. It is not only that it is logical and sensible that he should do so. It is also that it is more important upon termination that the Secretary of State has that power of intervention. It is important because the director of public health has to have a sense of independence and security. As my noble friend Lady Cumberlege and the noble Lord, Lord Warner, have pointed out, there is considerable potential for disagreement between the local authority and the director of public health. It is therefore crucial that, in the event of friction, the director of public health can act with confidence to disagree.
This is exactly the kind of decision in which it is the Secretary of State, having ultimate responsibility for the health service, who should have that role. The Secretary of State’s role is therefore the best guarantee of the independence and the freedom of action that directors of public health ought to have.
Baroness Finlay of Llandaff
My Lords, my name is to Amendment 339. The other amendments have been spoken to most eloquently, having been introduced fully by my noble friend Lord Patel. One additional point, and the reason for having these directors of public health on a register, is that the person appointed may be fit to do the job today but they need to be fit to do the job tomorrow as well. By having them on a register, issues of revalidation, continuing professional development and so on would be maintained, and a level playing field would be maintained in an upward direction.
We have heard today about infection, but the greatest threat to public health may well come not from infection but from issues such as cyberterrorism around our major utilities and the havoc that that could cause. These directors of public health will have an enormous amount on their shoulders, and they need to be linked into the national and international disaster planning groups. Some of those aspects of their work will be ill understood by those in local authorities, who may feel that such things are remote and unlikely to happen. In the event of a disaster, those skills will have to be drawn on immediately, and the directors of public health have to be prepared and able to take the leadership role.
I urge the Government to consider carefully any good reason why not to register directors of public health. I cannot see any reason not to register these people who are trained specialists. You have to have a really good reason not to, in the face of all the evidence that they should be registered.
Lord Beecham
My Lords, there is clearly a broad and deep consensus in the House that the general direction of the Government’s proposals for public health is on the right lines. We welcome in particular the restoration to local government of many public health functions.
There are still some areas of potential difficulty, though, which may well account for the recently published survey of the Faculty of Public Health, which showed great concern among 1,000 members of the profession who responded to a survey. Some 71 per cent of them disagreed that the new system would create a safer and more effective response to emergencies, and we will be looking at the situation regarding emergencies in a subsequent group. Eighty-one per cent disagreed with the proposition that the proposals would reduce inequalities in access to health; 83 per cent disagreed that the new structures would reduce bureaucracy; and 79 per cent feared that they would lead to fragmentation. I do not necessarily concur with those views—I think they are too pessimistic—but they disclose a degree of concern that some of the amendments that we are now discussing would allay.
Underpinning some of those concerns is the issue that is not part of the Bill: funding. We cannot ignore the real concerns about that—they have been voiced before and no doubt they will be again as we continue to debate the Bill—but in particular there is concern that, whereas the department apparently estimates the cost of public health services at £4 billion, which presumably is to be used as the basis for ring-fencing the grant that would go to local government, the BMA’s estimate is £5 billion. If that is right, it is a significant difference that would impact on local authorities. Of course, we are awaiting next year’s revenue support grant settlement. In addition, there are concerns about how the health premium would operate and how it might disadvantage areas that suffer from significant social and economic disadvantage. They would find it harder to improve the health of their communities than other, better placed authorities and might, therefore, lose out. In looking at the Bill, particularly the provisions that relate to public health, these concerns must be borne in mind.
Having said that, it is clear that many of the amendments that have been spoken to this afternoon address very serious issues. While I do not necessarily accept the entire burden of the criticisms made by the members of the Faculty of Public Health, I am sure Ministers in this House would not describe those with such concerns in the terms that Simon Burns used in another place when he described critics of the Bill as “zombies”. They are not zombies; they are dedicated public health professionals whose concerns have to be addressed. I am sure that the noble Earl and the noble Baroness would not descend to language of that kind.
The amendments that have been moved and spoken to by the noble Lord, Lord Patel, and supported by Members across the Committee, deal in particular with the position of directors within local government. They begin with the question of how they should be appointed in the first place. On appointments, Clause 27 refers to an authority,
“acting jointly with the Secretary of State”.
This is a slightly curious formulation. I suppose it should not be detached from the later provisions about Public Health England. In the words of Mr Burstow, the Minister of State for Health, Public Health England is deemed to be the Secretary of State. For the purposes of this clause, it may be that that is what is envisaged: Public Health England, as the Secretary of State, would be involved jointly in the appointment.
I am not convinced that it is necessary for an appointment to be made jointly but I concur with the view of the noble Lord, Lord Patel, that a procedure is needed for the approval of the Secretary of State of such appointments, and for the approval of any dismissal. I may be risking my status as an honorary vice- president of the Local Government Association when I dissent from its views on these matters. It takes the view that a director of public health should be treated in exactly the same way as any other chief officer of an authority. Respectfully, I disagree profoundly with that; they are not in an analogous position. Their position is much more analogous to that of a head of paid service, the chief finance officer or the monitoring officer, who have separate roles because they are not simply departmental officers; they have a wider responsibility, which impinges on the roles of other officers and other departments. A director of adult services or a planning officer does not have the same relationship with his colleagues. He is on level terms, as it were, and would not necessarily be expected to take the kind of stance that a director of public health might have to take in relation to failures of other parts of the authority. It is therefore essential that the position and independence of the director are protected. Therefore, I strongly support amendments to that effect.
What I am not clear about is how the appointment should be couched in terms of responsibility. Certainly, I agree with Amendment 229, which suggests that the director should be able to report directly to the local authority. However, to say that the director should be responsible to the chief executive is too narrow a definition. Not all authorities may choose to have chief executives. Fortunately, under the Localism Act, we have been spared the notion that the position of chief executive could be combined with that of the leader of a council or an elected mayor. Councils are not required to have a chief executive; they are required to have a head of paid service. The appropriate mechanism is that promoted by Amendment 229. That should be the line of accountability and the directors should certainly be part of the authority’s management team. They should have the status of a chief officer and the ability, if necessary, to report to the council. They ought also to be qualified.
The Opposition endorse entirely the proposals for a statutory registration system along the lines to which noble Lords have referred, not a voluntary system which I think is envisaged by the Bill. The statutory system should have external quality control, particularly of non-medical public health professionals. This would certainly strengthen the position and maintain the quality of the service. The noble Lord, Lord Warner, referred to comparable status with NHS professionals and made a significant point in that respect. This could, of course, place directors on a higher salary level than other officers within a local authority. That might create some difficulties and might also be something of a new burden. I think that that is the phrase we use in local government. Therefore, it perhaps ought to be reflected in the way that grant is distributed. Perhaps the Minister will undertake to have a look at this. Perhaps some portion of the salary should be specifically contributed to by the department in making its allocations. This would facilitate an acceptance of a differential within local government. However, Amendment 259 talks about making terms and conditions,
“no less favourable than those of persons in equivalent employment in the National Health Service”.
I am bound to say that I am not entirely clear how to define that equivalence. That may need to be explored further. No doubt the Minister will want to look at that aspect.
I think that the noble Baroness, Lady Finlay, referred to what might be described as public health emergency situations. One of the difficulties to which we will have to return in the next group of amendments is the absence of a fully fledged regional structure under the new system. As I say, we will no doubt return to this. However, there is concern about resilience and about how matters that transcend local authority boundaries—and public health problems do transcend local authority boundaries in many instances—will be managed and how these can be addressed, in particular under the proposals around the Health Protection Agency and the current local pattern of provision. I agree strongly with the noble Lord, Lord Walton, about the desirability of the director of public health being a member of the commissioning groups and, indeed, of the national Commissioning Board. We have discussed this before. The noble Earl, Lord Howe, indicated that the boards should be relatively small. However, there seemed to be a possibility of ensuring that if a director was not a member of the board, one could at least be appointed as an adviser to the board and, presumably, if it is the national Commissioning Board, also to the clinical commissioning group at local level. That would certainly be helpful.
However, there remains the issue of the position of directors in relation to district councils. As other noble Lords have pointed out, the responsibilities relating to public health are not confined to principal authorities at county, metropolitan district or London borough levels. There are housing issues and other significant issues around food safety and the rest which are district council responsibilities. It is not clear how directors of public health would operate in two-tier areas where district councils have those responsibilities. A mechanism might have to be developed to ensure that directors are able, for example, to report directly to those authorities where the exercise of the district council responsibilities may not be sufficiently addressed to public health issues. I am not inviting the Minister to give a definite indication at this moment but I would hope that this matter can be taken away and looked at further.
It is clear that there is considerable consensus around the House on the direction of government policy and the need to make improvements along the lines of these amendments. The noble Lord, Lord Warner, invited the Minister to turn over a new leaf and asked for a different type of Earl Howe. For my part, I would be quite happy to settle for the noble Earl, Lord Howe, that we know and love from previous incarnations. I just hope that he is given scope by the Secretary of State to respond positively to this positive debate and to the positive suggestions that have emerged.
Baroness Finlay of Llandaff
My Lords, I have one amendment in this group and have added my name in opposition to Clause 31 standing part of the Bill. At face value, these are very different but they are grouped because of the radical changes that are occurring.
In relation to Clause 31, I want to address where clinical commissioning groups are different from PCTs and what might be lost in the process, and that is why I have put my name to opposing the clause. These organisations appear to be emerging with a hybrid responsibility. On 2 November, in response to a question about whether clinical commissioning groups are just like PCTs and asked for a yes or no answer, the Minister replied:
“In terms of population responsibility, the responsibilities are very similar. CCGs are responsible for patients on the registered lists of their constituent practices as well as having specific area-based responsibilities … linked to their unique geographic coverage”.
Of course, the difficulty here is that clinical commissioning group areas are indeterminate and their responsibilities are not comprehensive, whereas at the moment PCTs, however much they appear to be failing, as they are in some areas, have in statute a range of clear responsibilities.
Clinical commissioning groups will not be formed on the basis of responsibility for all residents within a contiguous geographical area. As was pointed out on 2 November, it will be possible,
“for individuals within that area to be registered with a GP practice which is a member of a different CCG. It would therefore be the responsibility of that other CCG”.—[Official Report, 2/11/11; cols. 1270-71.]
We have debated the problem for people with difficult conditions. I know that the clinical commissioning groups’ responsibilities will be for emergency care for people within their area; that seems to be one of their limits, but they do not go much further than that. David Nicholson confirmed the Government’s position when he spoke on the “Today” programme on 31 October. He said:
“We will publish information about general practices so you will be able to see what your general practice provides, as compared with other GPs in the area and nationally… If you’ve got a long-term condition, you might want to think in future about different GPs and whether they are providing a full range of services for particular people with long-term conditions”.
Of course it would be fantastic if patients could move between one general practitioner and another, but I fear that the financial restraints on all of the system will mean that that ideal will just not be met.
Health and Social Care Bill
Baroness Finlay of Llandaff Excerpts(12 years, 5 months ago)
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Baroness Finlay of Llandaff
My Lords, I in no way want to detract from the debate that has already taken place, and I am grateful to the Committee for allowing me to speak now on my opposition to Clause 51. I appreciate it, although I realise that it is in many ways unrelated to the very important debate that we have just had. Clause 51 relates to medical examiners, to the changes in the coronial system introduced through the Coroners and Justice Act, and to the change of placement for these medical examiners, given that PCTs will no longer exist.
Medical coroners are being phased out, in part due to concerns about their difficulty in handling complex cases in court. However, legal coroners have difficulty in making crucial, and sometimes far more common and more far-reaching, decisions on whether to open an inquest and whether to question medical reports. The recent BBC Radio 4 “File on 4” programme on the variation in the adequacy of inquiries in NHS inquests criticised several coroners, none of whom was a medical coroner.
Every jurisdiction needs medical input to support a legal coroner, but the introduction of medical examiners per se is not without its problems and is not straightforward. Local authorities have made it clear that they do not want to take over this role. They are concerned that it will be more expensive at a time when they have no capacity to increase investment. They are also concerned about how this burden will be funded and that the need to raise the money directly will be viewed as a death tax by their local population, which will be politically unacceptable. The cremation certificate fee of £147, which is paid directly to the clinician signing the form but is currently taken from relatives as part of the undertaker’s fee, raises about £40 million per annum across the country. That is only for cremations, which make up 70 per cent of all funerals.
There is a need for transparency over the fees, and that is to be welcomed. However, there are real concerns about how local authorities will decide to raise this money and what they will do about debt recovery if people are unable to pay, and about the various models of medical examiner that will be put forward and how the fees to support them overall should be collected. There is also uncertainty about whether there will be a national medical examiner. There is a need for a national medical examiner to ensure the quality and competence of examiners, who are likely to be retired GPs who have to be trained in coronial law and in the importance of judging decisions according to the requirement to ascertain causation and not to breach a duty of care. There will also be a need to ensure that an examiner is available within 24 to 36 hours so that families can proceed with rapid burial arrangements and not delay them. The current coronial officer capacity is already very stretched, and there is concern that examiners would have a conflict of interest if they were recruited from local general practices or trusts.
There is also real concern over the pilots of the new death certificate processes, which are showing delays in the role of the new medical examiners of up to four or five days, with mortuaries being stretched, undertakers being concerned that funerals are not happening as quickly as they should be, and a general backlog.
I hope that in response to my questioning of Clause 51, the Government will recognise that there is a need for the Department of Health to get together with the Ministry of Justice as the new chief coroner is appointed to make sure that a group looks at this issue in detail before proceeding further with the rollout. The system should be examined in the light of the chief coroner, in the light of what the local authorities find acceptable, in the light of how the costings are worked out, and in the light of the pilots, which are raising, rather than allaying, concerns. As I said, I am grateful to the Committee for allowing me to speak, as a matter of convenience, on Clause 51 at this point.
Baroness Jolly
My Lords, I wish to add something on Clause 51 stand part. I am sorry that it is not where we expected it, but that is absolutely fine. We are in a place of unintended consequences, because without a PCT there is no home for this particular service. Also, post-Shipman, there is a need for sharpening up clinical governance on death certificates. Therefore, there is no disagreement with any of that, but the unintended consequence is that local authorities have a serious problem in that, as I understand it, funeral directors no longer wish to be a part of the mix, so local authorities are being tasked with implementing a system in which something will have to be collected—somewhere in the order of £150 per certificate to cover the costs. The call for the system to be set up came in 2009; the previous Labour Government asked us to look at regularising the system of certification of deaths not only for cremations but for burials. It was to be revenue-neutral, which poses another problem for the local authorities.
The timing of this for somebody who is bereaved is really difficult. If you lose somebody, you can neither bury them nor have them cremated without the death certificate. Being charged something in the region of £150 could be really awkward, difficult or maybe even impossible. If they paid into an insurance plan, it will not have paid out; after a few days, probate is just not in the right place at all. I would like the Minister to consider two things. First, the cost is anticipated to be somewhere between £40 million and £60 million. I cannot think of anything else on which the taxpayer actually pays for the collection of government data. I would like the Government to consider whether it is appropriate to pass on these fees when certificates for births, marriages and deaths are currently less than £20. Secondly, failing that, would my noble friend commit to working with the Department for Communities and Local Government and the Ministry of Justice to devise a sensitive system that does not call for a sizable payment up front on collection of the death certificate? They should pay attention to the pilot data alluded to by the noble Baroness, Lady Finlay; the pilots are not running absolutely smoothly.
Health and Social Care Bill
Baroness Finlay of Llandaff Excerpts(12 years, 5 months ago)
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Baroness Finlay of Llandaff
My Lords, I have some amendments in this group to which I would like to speak. The first is Amendment 62A, a probing amendment which seeks a government response. This amendment would require the Secretary of State to report annually on the steps taken in relation to the duties listed in the Bill. Currently we have the Chief Medical Officer’s annual report, which is excellent and provides an enormous amount of information particularly on matters relating to public health. However, given this Bill and the dramatic changes we will see in the delivery of healthcare across England, it seems important that we should have regular annual reporting that can be tracked from year to year against a specific set of headings. Over the years this would create comparators that could be used to see whether the quality and health improvements on which the Bill is focused are being achieved.
Similarly, I have amendments about undertaking an audit of healthcare providers’ processes and outcomes in terms of how they improve public health and implement the public health advice they receive. Amendment 71A, another probing amendment, suggests changing the wording of the provision so that there is an obligation to consider diagnosis and treatment rather than diagnosis or treatment, as the Bill currently provides. I tabled this amendment because I was somewhat horrified to see that the Bill provides a requirement to consider treatment but not to ensure that the diagnosis guiding the treatment is correct. Treatment for the wrong condition will result in morbidity and mortality related to the treatment plus progression of the underlying condition. I wonder whether that might not be a drafting issue which the Government might be inclined to look at again.
I have taken further advice on my Amendment 69A and have decided not to press it. I can therefore spare the Minister the trouble of trying to respond to it.
However, perhaps I may give a little evidence in support of this pressure to require reporting and audit at every level. There is high-powered and strong evidence from public health itself. Public health is a competency set, not a separate discipline. All public health practice needs epidemiology, biostatistics and a commitment to organisations and community understanding, with a focus on prevention and the implementation of evidence into practice. Evidence is not just a matter of, “Yes, there is evidence”, or, “No, there is not”. There is a hierarchy of scientific evidence in relation to public health.
It is important to understand that there are five criteria in relation to the reporting requirements that I am asking for. First, there may be evidence of no benefit. Secondly, there may be no evidence of benefit. Thirdly, there may be uncertain evidence of benefit. Fourthly, there may be evidence of efficacy. Fifthly, there may be evidence of both efficacy and effectiveness, which means that these interventions would incontrovertibly improve efficacy and seem feasible for large-scale implementation based on effectiveness trials. So that is very high-level evidence, and the others are hierarchies right down to the first I listed, which was a reason for decommissioning and stopping the use of an intervention.
Perhaps I may give some examples of where that hierarchy has influenced clinical practice and the reason why public health cannot be divorced from clinical practice. Even though this has been put on local authorities and will have a strong influence, I hope it will not become divorced from clinical practice. It needs to be linked to commissioning by GPs for the following reasons. First, it has been demonstrated that general practitioners and clinicians can save money if they provide advice on health in the consultation as well as dealing with the presenting complaint. Secondly, involving clinicians in detecting alcohol problems as part of a routine consultation has been shown to save money and lives. Thirdly, in nurse-led clinics there is evidence of cost-effective secondary prevention when they are used for targeted areas such as coronary heart disease. They can be extremely effective. Fourthly, drug treatment is a public health issue and there needs to be close working in the clinical setting to make sure that the use of drugs in conjunction with the appropriate use of pharmacy advice can maximise health benefit. Fifthly, primary care itself is more effective where public health is involved in the way that primary care is delivered. A very powerful trial conducted in the USA has shown that to be the case. Last but not least, high-tech interventions that at first sight might seem expensive, when properly evaluated in public health terms, have been shown to save lives and money, so they become an investment for savings.
Those are just some of the examples of why we need public health right at the heart of the changes, but we also need the monitoring that public health can bring to ensure that things that should happen are happening.
Baroness Finlay of Llandaff
I am grateful for the reassurance that the noble Baroness does not see any way of uncoupling diagnosis from treatment. I am not terribly comfortable with the furniture analogy. Pieces of furniture are not as complex and integrated as human bodies.
Baroness Northover
I have a feeling that carpenters might disagree. Nevertheless, I take on board what the noble Baroness says, and I hope that I have reassured her.
Where was I? I think that I have covered the points spelled out by various noble Lords on research and evidence. Research and evidence would rightly run right the way through these arrangements, and I would have expected noble Lords to flag this up. It is absolutely crucial that evidence underpins the work that is done. I heard what was said about nudging, and so on. The Select Committee itself said that it welcomed the exploration of new ways of doing things, provided that they do not dislodge other ways of assessing things. It is extremely important that, in all these areas, you assess what the impact of something is. I hope that noble Lords will be reassured. We will come on to this in a minute.
“( ) providing services for the prevention and treatment of harmful drinking and alcohol dependence.”
Baroness Finlay of Llandaff
My Lords, I hope the Committee will agree that it would be more convenient to discuss the spirit of this amendment when we come to the later group of amendments that focus on issues around alcohol—the group beginning with Amendment 71 —and that the other amendment in this group, Amendment 74B, warrants a short debate in its own right. I beg to move.
Baroness Northover
I can see the temptation. The list in the Bill is indicative. These lists are always subject to much debate about what goes in and what stays out. I fully understand why the noble Baroness wishes to add her list. However, we would resist adding to the list in the Bill, which is, as she knows, indicative. We appreciate people's contributions to what needs to be covered in these areas. I point out to her that the list—no doubt we will spend many hours debating the regulations—includes all sorts of things, such as mental health services and dental public health services. I will not read out the whole list. If noble Lords think that something is on it that should not be there, or that other things that are not on it should be, I am sure that we will consider those points as we debate the regulations.
I noted a response to the noble Baroness, Lady Hollins, but I think that I may be referring to a previous debate. She is absolutely right to emphasise that we have to make sure that everything we do is patient-centred. All the changes must focus on that. It is a challenge for everybody. Perhaps people have tried to do it before. No doubt we will have problems trying to do it ourselves, now and in the future, but that has to be the focus. Therefore, we have to remember the diversity of the patients that we are talking about. I am sorry; that answer belonged in an earlier debate.
I know that we will return later to debate alcohol. I hope that noble Lords will not press the amendments in this group.
Baroness Finlay of Llandaff
My Lords, I hope that the Government will be able to give some assurance that environmental health will be recognised in the new public health services that will be established. I became acutely aware of the importance and contribution of environmental health when I chaired the House of Lords Science and Technology Select Committee inquiry into allergy. Environmental health officers were most helpful on issues around climate change, air quality, diesel particles and the hyperallergenic effect of high levels of diesel in making pollen more allergenic.
When I chaired the inquiry into carbon monoxide poisoning, I had a great deal of help from the Chartered Institute of Environmental Health on gas safety and gas regulation. It brought its engineering and architectural expertise to inform that inquiry. It is important to be aware that although these professionals are called environmental health officers, they come from a broad range of backgrounds and bring in engineering, architecture and what you might broadly call environmental physics to inform the health debate. They are complementary to but not duplicated by the provisions in standard public health medicine.
Lord Greaves
I echo everything that the noble Baroness, Lady Finlay, has just said. The noble Lord, Lord Rooker, has raised some extremely important issues and hit some serious problems at the heart of the Bill. I am not sure that his solution is the right one, but it needs discussion. I am sorry that the noble Baroness, Lady Gould, in not in her place because she made the important point that the meaning of the phrase “public health” has evolved over the years. The core Public Health Act 1936 was about the role of local authorities in relation to public health and what we now call environmental health.
In the 1974 local government reorganisation, public health functions were split. Half went to the health service, the other half remained with local government, and the phrases “environmental health” and “environmental health officers” were largely invented at that time to distinguish the new environmental health service from what had previously been public health. Of course, in two-tier authorities environmental health is a function of the lower-tier authority.
The noble Lord, Lord Rooker, made a very important point. We have some amendments coming up, probably in a few hours’ time, when we will discuss this, so I will not say a great deal more about that now except to make the basic point that it is very important indeed that environmental health functions, which already rest with unitary authorities but in county and district areas will rest with district authorities, are properly integrated with the rest of the public health function.
As the noble Baroness, Lady Finlay, said, the things that environmental health officers and departments do are astonishingly varied. If a problem is clearly a public health or environmental health problem, they will find the expertise, go out and get expert advice if it does not exist within that authority, and tackle it. It is a very important function indeed. However, at the national level, environmental health, as defined in the Local Government Act 1974, rests with the Department for Communities and Local Government, not with the Department of Health. It probably ought to rest with the DCLG because it is very clearly a local government function, but again, at the national level, the Government need to take action to integrate it into the new, very important public health functions of the Secretary of State.
Baroness Finlay of Llandaff
My Lords, I am grateful to the House for being so accommodating in moving the amendments slightly so that we can discuss alcohol now. The reason for this group of amendments is because of the ever increasing problem and toll on our society from alcohol misuse. These amendments are designed to ensure that alcohol misuse is a national priority for the Secretary of State and a priority for local authorities and clinical commissioning groups. Amendments 328, 329 and 331 ensure that local organisations have levers in their responsibility to promote integration; and that health and well-being boards and health and well-being strategies take into account alcohol misuse and are devised with appropriate expertise in alcohol misuse.
Turning to the individual amendments, we passed over Amendment 66 briefly for convenience, but it links to Amendment 71, which changes the duty on the Secretary of State from “may” to “must” because of the danger to health that alcohol poses. Alcohol is a major and growing public health concern. Alcohol misuse affects 4 per cent of the population and more than 10 million people drink above the recommended limits. The prevalence of liver disease, to which alcohol is the major contributor, is growing and is set to overtake stroke and coronary heart disease as a cause of death in the next 10 to 15 years. This is set out in the Department of Health’s document on developing a national liver strategy, published last year.
Last year, more than 1 million hospital admissions were due to alcohol misuse. This represents a doubling in the number of admissions over eight years and the rise is becoming exponential. The estimated cost of alcohol-related harm to the NHS in England is £2.7 billion based on 2006-07 prices. However, the overall cost to the nation from all aspects of alcohol abuse is £20 billion. The Exchequer gets back only £13 billion from tax on alcohol, so there is a £7 billion gap. We just cannot leave that unaddressed. Amendment 72 would insert a new subsection to state that one of the steps that local authorities and the Secretary of State might take to improve public health is,
“providing services for the prevention and treatment of harmful drinking and alcohol dependence”.
In Clause 9, local authorities will take new responsibilities for public health. As PCTs and strategic health authorities are abolished and their responsibilities are transferred to clinical commissioning groups and the Commissioning Board, there is a need to make sure that nothing falls through any gaps. Local authorities’ new public health responsibilities will be supported through their ring-fenced budget of £4 billion, which we have already heard about. However, at present they are unaware of how much funding they will actually receive, and there is a real danger that, with a squeeze on local government’s finance, the budget may be used to fill other gaps within the increasing number of responsibilities that local authorities will be taking over.
The Bill does not specifically state that local authorities will have responsibility for alcohol services, but those of us who have put our names to these amendments are keen to see that in the Bill. It has to become a statutory responsibility, given that the problem is evergrowing. The Department of Health’s consultation on commissioning and funding routes for public health stated that the commissioning of treatment, harm reduction and prevention services for alcohol and drugs will be the responsibility of these local authorities.
The public health outcomes framework includes outcomes on the rate of hospital admissions per 100,000 for alcohol-related harm, and the NHS outcomes framework includes a measure of the mortality rate among the under-75 age group from liver disease, based on a set of conditions where alcohol contributes to 50 to 60 per cent of liver disease overall in the country.
The voluntary sector providers of alcohol services risk a disinvestment in their services if they are not given sufficient priority. They find that their services are already often marginalised and stigmatised because they are dealing with a marginalised and stigmatised group. Some alcohol services that are currently funded by the National Treatment Agency for Substance Misuse will be integrated into Public Health England, and the future of its funding is unclear.
Alcohol services have tended to be a Cinderella in public health, with smoking and illegal drug misuse tending to be prioritised over alcohol. I completely welcome the emphasis on smoking cessation and tackling illegal drug misuse but I regret that alcohol has slipped past and the problem has escalated in the process.
To put this into perspective, on average £136 is spent on dependent drinkers, compared with more than £1,300 on dependent drug users. Yet we know that the social toll on the health, particularly of children in families where there is a problem drinker, can be as great as the toll where drug abuse is going on. The cost of smoking has been estimated to be £2.7 billion a year, which is the same as the cost to the NHS of alcohol. The problem is no smaller than smoking.
The wording in Amendment 202 is designed to ensure that clinical commissioning groups have a duty to make reducing alcohol-related harm a priority. General practitioners have a crucial role to play in identifying, assessing and referring people with alcohol use disorders. General practitioners have tended to under-identify alcohol misuse and, unfortunately, GPs identify only about one in 67 males and one in 82 females who are hazardous and harmful drinkers. Detection in general practice is currently woefully inadequate. Less than one-third of GPs use an alcohol-screening questionnaire.
The Government have indicated that 15 per cent of QOF funding will be assigned to public health and primary prevention indicators from 2013. All the proposed public health indicators are focused on smoking, and the indicator for screening for alcohol misuse has to date been rejected. There is strong evidence that brief intervention and advice in primary care can lead to one in eight people reducing their drinking to sensible levels, so it becomes a very cost-effective and clinically effective intervention. That has been demonstrated in 22 randomised control trials, so there is a very high level of evidence for this clinical intervention.
Amendments 238 and 239 are designed to ensure that the joint health and well-being strategies takes into account the drinking levels in the local population and, in preparing those strategies, that the people who have experience in alcohol services are involved. The joint strategic needs assessment must include an examination of levels of hazardous, harmful and dependent alcohol use in the population and must widen the scope of the local authority with its partner clinical commissioning groups in preparing the health and well-being strategy to include alcohol service representatives.
These joint needs assessments will be very important in underpinning the overall direction taken with funding and commissioning services. That is why Amendment 331 requires health and well-being boards to include expertise in alcohol and drug services in the preparation of reports and strategies on the health and well-being boards. It is worth noting that the criminal injury compensation from alcohol-related injury alone is substantial and is a cost that we are handing on to the next generation. There is also a cost to the private sector from alcohol abuse, which comes completely outside any health costs, such as when premises are damaged, sometimes very severely and set on fire in alcohol-fuelled criminal activity.
Overall, integration is essential. If we are going to spend £400 million per annum on dealing with alcohol-fuelled injury that results in hospital admissions and violent woundings, one must remember that that is only the cost of those that have been recorded by the police. The actual cost just from injuries and woundings is possibly twice that. With an overall cost of £21 billion to the public purse from alcohol abuse, I suggest that this cannot be ignored in the Bill. I beg to move.
The Archbishop of York
As the Minister resumes her seat, I would ask: if the matter is so serious, what is the problem with changing the word from “may” to “must”? What difficulty does that bring? Seeing the seriousness of the matter, why do the Government continue to say, “We will watch this”, “We will do this”, or “There will be a review of this”? This is a very simple amendment. I would have thought that they could, for once, admit and accept that the amendment be inserted, instead of postponing for some future thing. What is the real problem? I have not heard an answer to why “may” must remain and “must” must not be inserted.
Baroness Finlay of Llandaff
I am extremely grateful to the most reverend Primate for that very eloquent and sensible interjection at this stage. I know that, in responding, the Minister has tried to be reassuring, but I note that she said that the scale of the problem is such that it would be astonishing if it was not addressed.
The Minister also said that it would not be a panacea to put it into the Bill, and there I disagree because it is not a panacea putting things in legislation. We have to protect the children growing up in this country who are abused through alcohol-related harm. They are bereaved by the deaths of their parents through alcohol. They are becoming the next victims of excessive misuse of alcohol. To do that, we have to put things into the Bill. We have seatbelt legislation, which has dramatically decreased the number of children who die in road accidents. We have legislation about smoking in public places, which has dramatically decreased smoking. In Wales, we are actively looking at smoking in confined places and at legislation on domestic abuse, precisely because of the alcohol-fuelled domestic abuse problem that is escalating, as my noble friend Lord Wigley said earlier.
I am most grateful to all noble Lords who have contributed to the debate. The call for something in relation to general practitioners has been overwhelming from several noble Lords. I remind the House that secondary care is being evermore squeezed—squeezed until the pips squeak—and is taking a hit for the failure of alcohol-misuse control in our communities. That is where massive expenditure is incurred. It all seems to come together and it seems as though that is the final sump. The financial hit alone deprives other patients with other conditions from being looked after properly.
I shall not divide the Committee on this today, but I say to the Government that the failure of the Ministry of Justice to bring in pilots to control excessive drinking and drunkenness in our city centres, through allowing sentencing schemes for magistrates, has strengthened my resolve. Unless we get something in the Bill, all the strategies and persuasion in the world will not turn around this ever-increasing toll—the graph goes up and up. At this stage, I shall withdraw the amendment but I shall certainly return to it on Report. I hope that the Minister and the Bill team will engage in some constructive discussions as it would be much better for everyone to reach a compromise on this rather than to have to divide the House.
Lord Clement-Jones
I, too, support the amendments of the noble Lord, Lord Ramsbotham. He clearly has a great deal of support in the Committee for the amendments, on which he spoke so eloquently, as did the noble Baroness, Lady Wilkins.
I come at this as a former chairman, and now the president, of Ambitious about Autism, the autism education charity, and also as a very strong supporter of I CAN, the communications charity for children. I also strongly believe that speech, language and communications needs should be regarded as a public health issue. As both the noble Lord, Lord Ramsbotham, and the noble Baroness, Lady Wilkins, highlighted, speech, language and communication needs are the most common disability experienced by children or adults, and it is now being recognised that communication is indeed the single most significant factor in determining a child’s life chances. Because our economy has become increasingly dependent on communication-based employment, the fitness of a person in this century will be defined ever more in terms of his or her ability to communicate effectively. The economic impact on society of people whose communication disability renders them unemployable is significant and is growing year on year. As a society, we need to recognise this issue and find ways to improve the communication skills of children and adults.
As has been pointed out by the noble Lord, Lord Ramsbotham, a number of primary care trusts and local authorities in England have indeed already recognised the importance of boosting early language and communication development. They have aligned the work of speech and language therapists with the Healthy Child Programme and Sure Start children’s centres to create a powerful public health approach based on primary prevention.
However, in contrast, many commissioners—this was also mentioned by the noble Baroness, Lady Wilkins—as reported by Sir Ian Kennedy last year in Getting it Right for Children and Young People, have a limited understanding of children with speech, language and communication needs. Many of these local areas are still not doing enough to address these needs, and it is clear that the economic and social benefits of early intervention and prevention of speech, language and communication needs must be much better promoted. That is why the approach indicated by these amendments is so important and why I support them.
Baroness Finlay of Llandaff
I have added my name to one of the amendments in this group but support many of the others. The key issue is that children often need accurate diagnosis but do not get it. It is the way in which you detect learning difficulties of all sorts—sensory impairment and motor impairment. The need for a range of services integrated to support children is critical because as they grow up, unless their needs are addressed early they become greater; they do not decrease.
I shall illustrate that. A little girl, whom I shall call Emily, is eight. She was born prematurely but by the time she is eight, having had a stormy neo-natal period, she has epilepsy, cerebral palsy and swallowing difficulties. She is wheelchair-dependent, partially sighted and has communication difficulties. For her ordinary care, like other children, she needs her GP, district nurse and health visitor. For her hydrocephalus she needs paediatric neurosurgery. For her complex epilepsy she needs paediatric neurology. She needs physiotherapy because of the cerebral palsy and cramps. She needs speech and language therapy to help her learn to swallow efficiently and occupational therapists who help her to manipulate her communication device through which she communicates with her family who love her dearly and want to do the best for her.
That is one example and we have hundreds of children in our country who need integrated co-ordinated care. Perhaps Emily was lucky because she got the interventions that she needed and they were brought together. But, we also have a lot of children, as referred to in this debate, who are being missed on the way through because they do not have such clear-cut presentations. That is why, unless we use this as an opportunity to really change the way that we look after our children in health and social care in the broader context, we will be failing them.
Baroness Thornton
My Lords, this is a very important debate and the first opportunity we have had to look at the proposals affecting children. The Government’s plan is that public health services for children under the age of five, including health visiting and the family-nurse partnership, will initially be commissioned by the NHS Commissioning Board. To facilitate its plans to increase the health visiting workforce by 4,200 over a four-year period from 2011, the intention is that eventually this responsibility will pass to local authorities, which from the outset commissioned services for children between the ages of five and 19, including the Healthy Child Programme for school-age children. Maternity care meanwhile will now be undertaken by CCGs, although it was originally intended that this would be undertaken by the NHS Commissioning Board. The board will still be responsible for specialist neonatal services.
In the very helpful public health report recently published by the House of Commons Health Committee, Councillor Rogers of the LGG told the committee that the initial split of commissioning children’s public health services,
“doesn’t make sense. There is obviously a serious risk of a gap developing around the age of five, and it doesn’t make sense for school nursing to be in one place and health visiting to be in another”.
The Government’s response to the Health Select Committee was that,
“we believe that the commitment to raise the number of health visitors by 2015 is best achieved through NHS commissioning and thus will retain our existing proposal that the NHS Commission Board should lead commissioning in this area in the short-term”.
Violence Against Women
Baroness Finlay of Llandaff Excerpts(13 years, 4 months ago)
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Baroness Finlay of Llandaff
My Lords, I am grateful to the House for allowing me to speak briefly in the gap in this important and powerful debate initiated by the noble Baroness, Lady Gould. I want to focus on healthcare and a concern as to whether the NHS reforms might inadvertently promote, rather than decrease, abuse blindness in healthcare. We know that one in four pregnant women is abused, that in just under a third of these cases abuse starts in pregnancy and in just over a third of those being abused, abuse worsens in pregnancy. We must recognise child abuse in the womb in policy, because the outcomes for these infants are worse, including an adverse effect on brain development, as the noble Baroness, Lady Walmsley described, an increase in risk of death in the first year of life, and underperformance throughout the rest of child development.
A study of midwives recently published showed that three-quarters in hospital practice and almost a half in the community had no training in domestic violence, and many had no child protection training. Even when trained, the training effect wears off, so abuse awareness needs to be part of clinical service contracts, with a requirement to ask the question and act on the response, and follow the Welsh example. In that study, although 12 per cent of community midwives encountered definite child abuse, only 2 per cent reported it, leaving a 10 per cent gap between identifying and acting on abuse.
Double vision requires simultaneously looking at the woman who is being abused and the child. The GP is in a unique position to ask about abuse; such questions are overwhelmingly acceptable to women, particularly those frightened of instigating any action themselves. Children in those households are 30 per cent to 60 per cent more likely to be abused, with poor performance and aggressive and disruptive behaviour.
Will the quality outcome framework that has changed general practice behaviour be looked at? Have the Government considered using QOF as a way of encouraging GPs prospectively and sensitively to ask about abuse and to signpost support? It has to be tackled at every opportunity.
Health: Cancer
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To call attention to measures to improve the quality and quantity of life of people with cancer; and to move for papers.
Baroness Finlay of Llandaff
My Lords, I am delighted to have secured this debate at this time. We are facing a huge upheaval in the way the NHS functions. The good news is that cancer deaths are falling. Cancer control is key as cancer becomes a chronic disease. However, cancer still kills more than 150,000 people a year—a quarter of all deaths in this country. It cuts many off in their prime; 23 per cent of those who die are aged 18 to 64. They often leave behind young children, who carry the details of their parents’ death emblazoned on their memory. Unlike many others in Europe we have excellent registration data that allow us to progress year by year and monitor that, but the EUROCARE study data suggest that we lag behind Scandinavian countries, which are the best in Europe, probably because of delayed diagnosis.
We must improve time survived as well as quality of life for patients, so let us look at the cancer journey, the problems on the way and the issues that the planned NHS reorganisation throws up. Smoking is the biggest single risk factor for cancer. A third of all cancers, and nine out of 10 lung cancers, are attributable to smoking. Cancer prevention through tobacco control strategies is already having an impact; the peer pressure to smoke is less. Tobacco control is cost-effective and a public health success. There is evidence that even once one type of lung cancer has occurred, stopping smoking slightly improves survival time. Can the Government assure me that the planned regulations to ban point-of-sale displays will come into force soon?
I turn to early diagnosis through screening. The breast screening programmes are improving their information to patients to provide a more balanced view on early detection. Bowel screening through faecal occult blood has been rolled out to those aged 60 to 75, but adding flexible sigmoidoscopy at 55 years of age should detect many more early cancers. It is being assessed through pilots already, but in the new NHS how will new screening programmes be advanced, commissioned and progressed? What will happen about the increasing calls for PSA tests for prostate cancer and the problems of interpreting results? How will biopsies be commissioned? As other early diagnostic tests emerge, such as viral testing for cervical cancer, how will they be rolled out nationally?
The biggest challenge we face overall is that of delayed diagnosis. Patients are seeing cancer specialists too late in their disease. The target of diagnostic testing within a week has been abandoned. Patients wait terrified, believing that every day's delay lessens their chance of survival, so if we are to have a patient-focused NHS why has that one-week wait been dropped? In the new NHS, whose responsibility will it be to ensure early diagnosis? Public health should encourage patients to come forward to the GP, who is in turn responsible for diagnostic testing. If the delays worsen, who will be held to account? Currently, GPs act as gatekeepers, sometimes holding the gate too tightly closed. I know only too well that having the right “index of suspicion” is not easy, but who will ensure that GPs examine and investigate, and if in doubt proactively bring patients back in two weeks for review, rather than become overzealous gatekeepers at a time of pressure to limit referrals?
In the GP consortium, what sanctions will there be against primary care if diagnostic delays continue or worsen? Will there be greater powers to counter clinical underperformance? It is not enough to say that a patient can change GP; for the patient subject to delay that is too late. People with suspected or proven cancer want to see a specialist. They will travel to an expert in a centre of excellence with good outcomes, whose team personalises treatment with good information to meet a patient’s individual needs.
Specialist oncology services peer review—the CQuINS report—shows that, despite many recent improvements, 5 per cent of teams are underperforming and some patients are not being referred readily enough to specialist centres. The report shows the impact of national benchmarking, quality assurance and specialist centres. It highlights the adverse patient outcomes when complex surgery is undertaken outside a specialist centre, when there are gaps in the core multidisciplinary team membership, when data use is suboptimal and when communication across organisational boundaries is poor.
The Government have stressed the need for good outcome measures in mortality, morbidity and patients’ reported experience of care. The National Cancer Action Team report illustrates the importance of collaboration, but when each hospital is a foundation trust how will cross-referral be assured? Decision aids are being developed to help patients access information about treatments when various options are available. These are particularly important in conditions such as bowel cancer, where laparoscopic surgery for an early tumour may be the best choice. However, if the hospital does not offer that option, who will be responsible for ensuring that the patient is referred, and what sanctions will be in place if a trust hangs on to patients inappropriately? What will stop competing trusts dabbling in oncological surgery or chemotherapy, especially if the Patient Safety Agency monitoring is cut back? How will the CQC's responsibilities link with Monitor and who will determine whether a local service should continue? What if the GP consortium, the CQC and Monitor's conclusions suggest different decisions?
There is always a balance between locality and centres of excellence, but real choices need to minimise risk. Commissioning along disease pathways will require secondary and tertiary care to be at the table with primary care in planning a whole service to optimise outcomes across the population. Individual needs vary. Cancer management is not an off-the-shelf package. It is complex, involving close collaboration between many experts from different fields to personalise care for patients. Patients cannot possibly know the ins and outs of each option. Choice per se can be a red herring. The choice that is important to patients is the choice of appropriate treatment, with people working together, driven by clinical quality assurance not financial gain. The previous Government instigated quality standards development by the National Institute for Health and Clinical Excellence. Can the Minster assure us that this work will continue to inform the national outcomes framework?
When it comes to non-surgical cancer treatment, radiotherapy and chemotherapy are the mainstays. Where will the levers for building capacity lie? Radiotherapy will have to be centrally commissioned, given the need for major capital investment. Techniques such as intensity-modulated and image-guided radiotherapy reduce toxicity by ensuring accurate targeting of the tumour at every dose. CyberKnife, which was featured in the news yesterday, and results from the prostate radiotherapy trial in my own centre in Cardiff, have shown remarkable results. Other super-targeted techniques are developing apace. We know if radiotherapy is poorly targeted; there is a 20 per cent deficit in two-year survival. How will the commissioning board ensure that the ongoing functioning of a modernised unit is not starved of funds locally by a consortium?
As chemotherapy also becomes more targeted, new genetic tests indicate who is likely to respond. For example, colon cancer patients with the K-ras mutation have a much higher chance of responding to Cetuximab, which costs about £1,000 per dose. The test costs £140. It is really good value for money. In 4 per cent of non-small cell lung cancers, the presence of a specific fusion protein indicates likely drug response, allowing far better patient selection and avoiding inappropriate chemotherapy for those who will get only side effects without a response. Quality control and economies of scale suggest that it is better to invest in a few laboratories to do all such tests nationally. Will these be centrally commissioned or left to the randomisation of market forces?
There is evidence that patients treated in research-active cancer centres have better outcomes overall, whether or not they are in a clinical trial. The National Cancer Research Network has increased patients entering trials from 4 per cent to 18 per cent over the past decade. The investment is reaping rewards for everyone going through these services, so will research-active units be commissioned as accredited centres nationally? Major advances occur, often sporadically, in a research-rich environment. The human genome project revealed that the B-Raf mutation is a key trigger in melanoma, with a B-Raf inhibitor showing a short-lived but dramatic effect in 60 per cent of patients with the mutation.
The cancer drugs fund was welcomed, but now that it has been handed out to local SHA decisions a postcode lottery has emerged. Avastin for bowel cancer is funded in Newcastle for first-line therapy, in London only for second-line therapy, and in Wales and Scotland not at all—in line with NICE’s recommendation. Rather than abandon NICE’s decisions, with its rigorous processes, would it be useful to discuss variable parameters around their QUALYs assessment mathematics, or will litigation eventually set a precedent before NICE’s role is reconsidered and reinstated?
Palliative care has a role during active treatment, not just at the end of life. Recent research published in the New England Journal of Medicine showed that early palliative medicine interventions in patients with lung cancer improves the quality of life and mood of patients, including lower depression scores. This was a proper randomised controlled trial, analysed on an intention-to-treat basis, so the data are very robust. The surprising finding was that those who had prospective palliative care lived longer, with an average of three months’ extra life of better quality, than those in oncology who were referred only as the clinician saw fit. Given the impact that my discipline—I declare an interest—of specialist palliative care services has across the UK, will the Government ensure that such services are commissioned at a local level in line with national guidance, with stated minimum levels of specialist palliative care staff everywhere, recognising the enormous contribution of charitably funded hospice inpatient, daycare and home services?
For the 150,000 people who will die of cancer this year, whose preferred place of care is often home, seven-day services are essential. However good the cancer care, it is a disaster if it falls apart over a weekend. All the good is undone. I suggest that England should follow Wales's example of seven-day working by dedicated palliative care teams, with consultant advice available 24/7 everywhere. I declare my interest here, too. It is proving very effective at low cost. If the local supermarket is open seven days a week, why is our NHS fully operational for only 30 per cent of the time? Seven-day working would be a more efficient use of valuable resources in primary, secondary and tertiary care.
We face a huge upheaval in GP commissioning that raises more questions than it answers. I was privileged to be part of the original Calman-Hine committee that recommended cancer centres and units, with national standards. Cancer services have come a long way since then. Multidisciplinary teams and tumour site-specific groups are firmly embedded across the UK's NHS services. There is real anxiety that market forces may fragment this progress. Services from screening through primary care to secondary and tertiary care must be planned and integrated. The cancer journey will be a far better pathway if there is integrated planning. Patients will live longer and better. Independent living allows them to return to economic activity. If young patients die early, it is their children who carry the scars and burden of bereavement for the rest of their lives.
Delivering high-quality care depends on co-operation between professionals. The idea of any willing provider, and competing hospitals, is anathema to the collaborative model of delivering stable, high-quality healthcare. We cannot promote fragmentation if patient outcomes in cancer are to continue to improve, as they have done so dramatically over the past 10 years. I beg to move.
Baroness Finlay of Llandaff
My Lords, I thank the Minister for his reply and all noble Lords who have spoken in this outstanding debate. I particularly thank the noble Lord, Lord Howard of Lympne, for having decided for his maiden speech to contribute to this debate. He raised the tone even higher than that set by everyone else in this House.
There are some very clear messages here. People want the choice to be treated well at all times and, to cite the title of the book by the late Lady Beecham, to be moving forward with their cancer and living with it. Integration, not fragmentation, must be the way that the changes take us in the new world that we face. Outcomes can and must improve. Prevention must continue. We must not lose sight of tobacco control.
I finish simply. There has been a call for information from around the House. In the words of the late Vicky Clement-Jones, whom I had the privilege to know, knowledge is the antidote to fear. This debate has demonstrated that.