NHS: Hospital Beds

Baroness Finlay of Llandaff Excerpts

Thursday 6th December 2012 Lords Chamber

[Baroness Finlay of Llandaff]

Given the report’s figure that 6% of beds are occupied by patients who are readmitted within a week, costing almost £8 million per annum, what guidance is the department giving to clinical commissioning groups to ensure that support is available in the community so that patients discharged from hospital with multiple comorbidities and frailty do not tumble back into the admissions system?

[Earl Howe]

The noble Baroness has identified a very important issue. The causes of emergency readmissions are, of course, several. Some of them are not the fault of the provider but some are. Therefore, we have given an instruction to commissioners to build into the contracts that they have with those providing services that penalties may be applied to the provider should emergency readmissions occur which are the fault of the provider. I would be happy to write to the noble Baroness with further details.

Health: Obesity

Baroness Finlay of Llandaff Excerpts

Monday 12th November 2012 Lords Chamber

[Earl Howe]

My Lords, the role of Public Health England will undoubtedly stretch across government departments, because it should and will involve energising the efforts of not just the Department of Health and at not just national level. However, I agree that there is no single magic bullet to solve the problem of obesity. The call to action on obesity published last year set out a range of actions in which government and individuals, as well as local organisations, need to engage if we are to beat this threat to public health.

[Baroness Finlay of Llandaff]

Are the Government considering including in commissioning from health service employers a requirement to address obesity in their staff at all levels, given that the staff are often quite severely obese and act as a very poor role model for those patients whose obesity should be being addressed?

[Earl Howe]

My Lords, this is a very important point. Dame Carol Black and I chair a network within the responsibility deal in the Department of Health which draws together employers from a range of sectors to address health in the workplace. It is a tremendously important opportunity if we can engage employers to realise that it is in their direct interest to ensure that their employees enjoy good health and lead healthy lifestyles.

NHS: Death at Home

Baroness Finlay of Llandaff Excerpts

Thursday 8th November 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, for this timely debate, I draw on the information that I have from the Cicely Saunders research institute, of which I am an external international adviser, and my role in chairing the palliative care strategy board in Wales. The topic of licensing doctors to prescribe lethal drugs at lethal doses is complex, and I do not think that it falls within the title of this debate, but I would simply say that from many conversations that I have had with Dutch doctors many have said that they got it the wrong way round. In Holland, one in 38 of all deaths are by euthanasia, but they still have not established specialist palliative care.

I turn to patients’ desire to die at home. About two-thirds wish to be cared for at home and go on to die at home, followed by a preference for inpatient hospice care, which runs at about 29%. That is an important, large number of people who would like to access inpatient hospices when they feel that home care is not an option for them. The wishes tend to remain constant, but not always; the reversal in trends away from home deaths happened after 2004, when the end-of-life care was instigated, and the numbers have risen to over a quarter for those with cancer who are now at home, but hardly risen at all for those dying from other diseases, only going up from 16.7% in 2004 to 18% in 2010.

For those patients accessing hospice at home services, who provide high levels of hands-on care in patients’ homes, the results are dramatically different. Of those referred to hospice at home services in Wales, 92% of St David’s Foundation patients remain at home. In Pembrokeshire, 89% of Paul Sartori Foundation patients, 32% of whom have non-cancer diseases, remain at home. In Gwynedd, those referred to the domiciliary palliative care teams have achieved 45% home death rates overall in 2010-11. So things can be very different very easily.

The conversation around care and wishes happens early and is dynamic and ongoing as the patient’s condition changes. The conversations must address fears and what is likely to happen, what the family feel that they can cope with and what they feel they cannot—and also dispel illusions around what is not likely to happen.

It is worth noting that the Cochrane review of the literature showed that when palliative care services are available the chance of dying at home is doubled. The impact of patient-focused services aimed at supporting those at the end of life is key. The most important factors that enable home death in the UK are receiving home care and intensive home care, living with relatives, having extended family support, being married, being affluent, and being younger. Interestingly, functionally less able patients seem to be able to be at home more often, probably because home care services find it easier to fit to the needs of a bed-bound patient than an ambulant one.

Socioeconomic status is inversely related to home death rates, and lower rates are also seen in the Chinese, black African and Caribbean populations, probably for multiple cultural reasons. But for NHS policy, two other factors emerge that are crucial. First, when GP visits are more frequent, as rated at three or more visits during the terminal illness, home death rates are higher. So if a guiding principle of the NHS is to aspire to put patients at the heart of everything that it does, then continuity of primary care and the ability for home visiting of the terminally ill across seven days a week will need to be addressed, because disease respects neither the clock nor the calendar.

Secondly, there is a relationship between time that relatives can take off work and their ability to provide home care support. The Canadian compassionate care benefits system warrants looking at carefully in the context of our changing NHS as it may well prove to be the most cost-effective way to support the terminally ill at home. Relatives’ satisfaction with care is greater when home care is achieved; this seems important for children who find hospital or hospice visiting difficult, although I could find no specific study of the long-term effects of hospice at home on the bereaved child’s morbidity.

There are also sound financial reasons to help patients to remain home. The cost benefit is clear: the average length of care is almost 38 days, which in a hospital bed would cost over £16,000. In Wales, as in England, we have estimated hospice at home costs to be nearer one-third of hospice in-patient costs, even when some overnight care is provided.

This debate has looked at home death rates, perhaps because they are easy to measure, but we need to know where people want to live during their final illness and ensure that services are rapidly responsive to need. Above all, staff attitudes must focus on patient need. Attitude costs nothing but the right attitude is of infinite value. If patients do not feel safe and confident in care, they will not be able to stay at home.

We must also reassess some of the insistence of services to have a hospital bed in the home. Many people want to be in their own bed and could be moved quite easily on a sliding sheet. The evidence for the ubiquitous provision of a large invasive hospital bed warrants looking at. It is not patient focused and can effectively destroy a home atmosphere. How can a relative be easily cuddled on a large hospital bed in a small cramped living room? We as healthcare professionals have to be risk aware and not risk averse and prepared to take informed risk to meet patients’ needs. One area that we have instigated in Wales has been to put “just in case” boxes into patients’ homes so that, if symptoms become difficult, fluids can easily be set up and drugs given. Investigations at home should be easy.

I will say a very brief word on the Liverpool care pathway because of the preceding speeches. This important guidance is aimed to roll out the best of hospice care into other places of care. It is not a protocol. It is not rigid. It is important that people assess whether the person is irreversibly dying, whether it is an anticipated and expected death and, absolutely crucially, whether the family know and accept that the person is dying. Is regular review in place? Does the patient need fluids for comfort? Do they need their drugs altering? The planning of regular review is crucial. It is the regular review that detects the person who is not irreversibly dying when people think again. Happily, these patients have so-called come off the pathway. It is not a one-way street. However, if it is being badly implemented at a local level, it warrants investigation. This is crucial.

I quote from a patient’s husband about hospice at home. He said:

“The support we received from St David’s Hospice Care was incredible. Their nurse arrived and co-ordinated everything when my wife came out of hospital and another nurse came overnight: I was amazed at the care and support we as a family received. My wife died at home 16 days later surrounded by her family and a Hospice Care nurse”.

We can provide good care but we have to be flexible.

National Health Service (Clinical Commissioning Groups) Regulations 2012

Baroness Finlay of Llandaff Excerpts

Tuesday 16th October 2012 Lords Chamber

[Baroness Finlay of Llandaff]

The noble Lord, Lord Hunt of Kings Heath, has done us a major service by bringing forward a full debate on these regulations. We have discussed at length the problem of secondary care representation. Indeed, the fact that there will be secondary care representation and nurse representation on clinical commissioning groups is welcome. However, the principle of integration seems to be blown apart by the way in which these regulations are written. The Royal College of General Practitioners and the Royal College of Physicians—I declare an interest as a fellow of both—and the Royal College of Paediatrics and Child Health produced a document entitled Teams without Walls about involving generalists and specialists to ensure a better, more seamless journey for patients.

In an area—and we are trying to have more localism and more local involvement in decision-making—the very clinicians on half of this pathway are now excluded from involvement in the planning and decision-making for those services yet they are the clinicians who have an in-depth knowledge and experience of the health economy, integrated working and, indeed, of the deficits in standards. That is where I wish to focus my remarks for a moment. The Francis inquiry has not yet reported but I understand that the Government have given a commitment to implement the findings when they come out. I do not understand why the Government have not left this matter completely open at the moment. If the Francis inquiry considers that there is not enough integration between secondary and primary care in decision-making, planning of services and so on, then allowing a secondary care clinician from the local area to be on the clinical commissioning group would provide the flexibility that Teams without Walls refers to.

The clinical governance of an area and its problems will be known to the local secondary care services, and they will know it across the board. There has been concern about conflicts of interest, yet a medical director in a trust represents a range of different specialties, and that has not been a problem. Clinicians have learnt how to do it. The Royal College of Physicians has produced guidance. It will produce guidance on a competitive appointment process whereby the best person for the job gets the job, and it has produced a clinical commissioning hub as a support for secondary care in its involvement in clinical commissioning groups. You could say that the basic rule of physics pertains—two negatives make a positive. It is difficult to understand why the conflict of interest that the GPs will experience, where they may be providing part of secondary care services themselves, does not matter in this, and yet it is completely prohibited to have a secondary care person who might understand how that interface between primary care and secondary care will work better at a local level. That person is excluded. It seems to work particularly against rural areas.

The last point I should like to make—apart from reminding the Government that the absolute reverse principle has been in place with the local education and training boards, where local people are involved in the very processes of commissioning the education—is about the people who will come forward. We already know that, to date, there is underrepresentation of secondary care. A clinician who is going to apply to be on a board and leave their clinical service, travel long distances and be involved elsewhere is not going to be the clinician who is completely dedicated to their local NHS service. The clinician who is dedicated to their local service and driving up care for patients is going to be the very person who will be most motivated to work with the clinical commissioning group to improve the services and the seamlessness across the piece. Excluding local clinicians seems unnecessarily to be closing down flexibility.

[Baroness Jolly]

My Lords, this is a debate about conflicts of interest and getting the right person for the job. During the passage of the Bill, my noble friend Lady Barker led the call for conflicts to be declared where a board member has connections with a provider, where GPs can provide secondary services from their practices and where there are connections with commissioning support organisations. This was deemed right and proper, and was incorporated into the Bill.

It is important that the right people sit on clinical commissioning group boards and there are clear guidelines about competence, as well as protocols about conflicts of interest. This piece of secondary legislation puts restrictions on a clinical commissioning group in the choice of its members, irrespective of their competence, in two areas. One restricts councillors from being on the board and the other restricts the clinicians to those who work for providers from whom the clinical commissioning group does not commission services.

Time restricts me from addressing both issues so my noble friend Lady Williams will address the area of clinicians. In nearly 10 years as a member of an NHS trust board, I have sat with members of all political parties and none, some of whom were councillors. Where we had conflicts, they were declared. In that time, everyone left their party allegiances at the door. They were clear that they were there to look after the interests of the NHS in their patch, and had the skills and competences required for that role. It has been like this all over the country for years. It is worth mentioning that the work of Torbay Care Trust, which has been referred to frequently, depended on both NHS non-executive directors and councillors being on the board and working together.

Clinical commissioning groups want the right person for the role. They advertise, interview and appoint. It might be that the right person is a councillor, or not. This SI restricts their choice. Councillors know the community and, furthermore, particularly in the beginning, could have given useful guidance on the workings of the council because that is an area where GPs have generally not ventured—unless of course they are a councillor and a GP. This legislation has an unintended consequence for both doctors and indeed a nurse appointed as one of the two clinicians. The LGA wrote to the then Secretary of State as soon as the SI was published. The letter was signed by Councillor David Rogers, who is chair of the LGA Community Wellbeing Board and the only councillor member of the NHS Future Forum. He wrote:

“We do not accept the case for barring councillors from the governing body who hold professional roles within the NHS, as the reason for the appointment would be their professional experience within the health service—such as the GP … The Government, if it does not listen, is in danger of creating an unintended consequence of both discouraging experienced health service personnel from getting involved in their clinical commissioning group and from discouraging them from getting involved with their local authority”.

Councillor Rogers adds:

“I know that you are fully aware that all councils have standing orders that address conflicts of interest. We expect all public bodies, including clinical commissioning groups, to have equivalent rules regarding membership of their governing bodies but the proposed statutory instrument is far too wide-reaching and disproportionate. It will not only affect GP councillors serving on the governing bodies of clinical commissioning groups but any health professional group that a clinical commissioning group decides it wants represented on the governing body”.

I also received an email from a councillor GP who had been told that he had to make his mind up. Did he want to sit on the clinical commissioning group or did he want to remain a councillor? This level of restriction was not mentioned during the passage of the Bill. He asks:

“What are the justifications for this action which makes clinical commissioning groups the most politically restricted Public Body within the UK ? Where is the evidence”—

we spent a lot of time during the passage of the Bill trying to ensure that things were evidence-based—

“that this is in the public interest? Will GPs be banned from holding political office as Councillors on the basis that they could influence Health and Well Being Boards?”.

I should like the Minister, in summing up, to reassure the House that this was indeed an unintended consequence, and that when the implementation of the Bill is reviewed in 2014, clinical commissioning group governance will indeed be part of that review. Also, for those councillors who would have wished to become engaged in the commissioning of services, will he indicate how the clinical commissioning group might still involve them, so that their skills and competences are not lost?

Drugs: Prescribed Drug Addiction

Baroness Finlay of Llandaff Excerpts

Thursday 12th July 2012 Lords Chamber

[Baroness Finlay of Llandaff]

Will the Government ensure that the recommendations from the Royal College of General Practitioners for increased training in psychiatry is implemented in workforce planning after the new Act is in place? The inappropriate initiation of prescriptions is a major problem for those becoming dependent when alternative therapies, such as cognitive behavioural therapy, or simply better social support, would have avoided the inappropriate prescription of a drug on which physical dependence then develops.

[Earl Howe]

The noble Baroness is absolutely right, and I am very pleased that both the Royal College of General Practitioners and the Royal College of Psychiatrists have been keen participants in the round table group on addiction to medicines convened by my colleague Anne Milton. The actions agreed by the group have included greater recognition of the risk and the treatment of dependence on prescription drugs within the core competencies of psychiatrists and the further development of training and guidance on this issue for GPs and other healthcare practitioners.

NHS: Liverpool Care Pathway

Baroness Finlay of Llandaff Excerpts

Wednesday 20th June 2012 Lords Chamber

[Earl Howe]

My Lords, we will continue to do so. The Liverpool care pathway has sometimes been accused of being a way of withholding treatment, including hydration and nutrition. That is not the case. It is used to prevent dying patients from having the distress of receiving treatment or tests that are not beneficial and that may in fact cause harm rather than good. The noble Lord was right that the recent national care of the dying audit of hospitals, run by Marie Curie in collaboration with the Royal College of Physicians, notes that in 94% of documented cases discussions explaining the use of the LCP were held with relatives or carers. That audit process gives clinicians an opportunity to feed in their views about how well, or not so well, the pathway is working in practice.

[Baroness Finlay of Llandaff]

My Lords, given that the Government have recognised that the Liverpool care pathway has been designed to bring the best of hospice care into other care settings, such as hospitals, nursing homes and patients’ own homes, and that it is a tool—and a tool is often only as good as the person using it—will the Government ensure that Health Education England includes in its remit comprehensive education around the appropriate care of dying patients?

[Earl Howe]

Yes, my Lords. To ensure that it is used properly, the Liverpool care pathway emphasises the importance of staff receiving appropriate training and support in its use as well as accessing relevant end of life training and education programmes. A range of activity has been undertaken to support staff education and training and end of life care by the national end of life care programme and others. That includes the development of an extensive package of e-learning, which is free to access for health and social care staff.

Older People: Health and Social Care

Baroness Finlay of Llandaff Excerpts

Monday 18th June 2012 Lords Chamber

Asked By

[Baroness Finlay of Llandaff]

To ask Her Majesty’s Government how they plan to implement the recommendations in the report Delivering Dignity.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the Government welcome the report from the dignity in care commission and will consider carefully all the recommendations addressed to government. We will respond to the commission in detail in due course. Many of the solutions to the issues in the report lie with the local NHS, social care providers and other key stakeholders. The Government will encourage the sharing of best practice by bringing people together and putting in place the right system incentives to enable providers to increase the quality of their services to older people.

[Baroness Finlay of Llandaff]

Following the report, Delivering Dignity, which was published today, will the Government instruct Monitor and the Care Quality Commission to require all authorised providers to seek, monitor and act on feedback from patients and their families, and will the Nursing and Care Quality Forum be widened to look at all aspects of care home staffing, root out poor care and ensure that action is taken so that respect of the individual is an “always” event in the delivery of care?

[Earl Howe]

My Lords, the NHS outcomes framework contains two domains that are highly relevant to this area. The NHS Commissioning Board will be in prime position to monitor those areas of the domains that relate to the patient experience. However, I have no doubt that the CQC will continue to do its work in maintaining essential standards of quality and safety. The Nursing and Care Quality Forum is an independent group and it is therefore for the forum itself to consider how to take forward the issues raised in the recommendation, but I understand that its chair, Sally Brearley, was already planning to consider care homes as part of the next phase of the forum’s work. She has already approached a number of individuals to strengthen the forum’s membership and add further expertise in that area.

Social Care: Legislation

Baroness Finlay of Llandaff Excerpts

Monday 11th June 2012 Lords Chamber

[Earl Howe]

My Lords, this is the first reform of social care law in more than 60 years. It is a unique opportunity to get the legal framework right. That is why we have deliberately taken time to engage fully with those who have experience and expertise in care and support. Many people in the sector have called explicitly for scrutiny on a draft Bill, so publishing a Bill in this way demonstrates our commitment to working in partnership. We remain absolutely committed to introducing legislation at the earliest opportunity in this Parliament to establish a sustainable legal framework for adult social care. The draft Bill will be the critical next step in delivering the reform agenda.

[Baroness Finlay of Llandaff]

Will the Government reassure us that in considering adult social care they will also take into account the transitional needs of children with very complex needs as they grow older and transition to adult care, because many of them are in the last phase of their illness and will die in early adulthood?

[Earl Howe]

The noble Baroness raises the key issue of transition, which will be covered in the forthcoming White Paper.

Health: Pancreatic Cancer

Baroness Finlay of Llandaff Excerpts

Monday 23rd April 2012 Grand Committee

[Baroness Finlay of Llandaff]

My Lords, I am grateful to the Committee for allowing me to speak in the gap. In this important debate, there has been much focus on research. However, results will take years to come through. Work on early diagnosis and necessary training will also take time. There are patients now with an advanced form of the disease, and there are patients whose disease will recur even when they have gone through treatments that put it in abeyance. Under the new contracting process, how will we ensure that patients with pancreatic cancer have access to anaesthetic intervention services for nerve blocks such as celiac blocks? How will we ensure that clinical nurse specialists work seven rather than five days a week, and that they work as part of multi-professional teams? Without expert medical back-up, the complexity of pancreatic cancer symptoms is difficult to deal with. How will we ensure anticipatory prescribing to reduce the complications of pancreatic cancer such as thromboembolism that sometimes kill patients before the cancer itself? Patients should also have access at all times of the day and night to drugs for pain relief and to combat vomiting.

Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Monday 19th March 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I very much welcome the fact that these amendments have the Minister’s name on them. He has already made some concessions in relation to indemnity for these providers where they provide services for and on behalf of the NHS for patients. It seems completely right that some of the difficulties that they have faced in being able to provide flexible patient and family-focused services should be considered and looked at separately. As has already been said, in end-of-life care the charitable sector has completely revolutionised what is available to patients. I know that Marie Curie has done that. They even admitted a dog so that a patient would come in, and allowed that dog to be formally adopted, which enabled the patient to die peacefully because the dog was the only person that the man really loved in life. That flexibility makes all the difference. You would not find that provision or ability to meet an individual patient’s needs in many other parts of the sector.

This group of amendments is really important and to be welcomed. This morning, I was with Help the Hospices, which expressed concern on behalf of some very small organisations as to how they would cope in the new world in being able to continue providing the services that they want to. This group of amendments will provide them with a great deal of assurance.

[Earl Howe]

My Lords, I am pleased to conclude what has been a very good and constructive debate. I am extremely grateful to the noble Lord, Lord Patel of Bradford, for raising these important issues, both now and in Committee. As he stated, since his original Amendment 46 was introduced in Committee, we have worked together on this alternative amendment. While this has to some extent been a joint venture, all credit for the inspiration behind it must go to the noble Lord—along with the noble Lord, Lord Noon, whose strong commitment to the charitable sector is well known.

I can add little more to what the noble Lord has said, but it might be helpful to clarify a small number of points. First, I reassure the House that the Government are committed to a fair playing field for all providers of NHS services. We are particularly keen for voluntary sector organisations and social enterprises of all types and sizes to be involved. These providers are often among the most innovative and can offer highly personalised and bespoke services that meet the needs of local people. We understand that it is not just charities but the full range of voluntary sector providers—mutuals, co-operatives and social enterprises—that noble Lords are keen to see delivering NHS services. The new amendment enables a fair, transparent and impartial consideration of the issues, addressing all providers and possible means of responding to their concerns. I can confirm that the full intention is to look at how existing barriers can be removed, not to create new obstacles.

Secondly, as noble Lords are aware, a variety of barriers affect different providers. This includes not only payment of taxation but also access to and the cost of capital, the difficulty of securing appropriate insurance and indemnity, and the difficulty of bidding due to the scale or scope of contracts. The amendment therefore relates to a review of the full range of issues that affect the ability of providers or potential providers to deliver services for the NHS. I am sure noble Lords will agree that the potential is truly enormous.

We are clear that this is an important issue, which is why we want the report to be statutory and therefore accountable to Parliament and produced within 12 months of Royal Assent. Equally, it is crucial that the duty for the Secretary of State to keep these matters under review is in the Bill.

I can also assure noble Lords that the preparation of the report will involve full engagement with providers from all sectors, commissioners, and other stakeholders, such as Members of this House, to ensure that the full range of issues are considered and each of the concerns addressed. In particular, it will ensure that concerns around treatment for VAT of supplies of healthcare services or associated goods to the NHS by charities, including hospices, are considered. In response to the specific question of the noble Lord, I can confirm we would not see this review as in any way being slanted towards giving private sector firms a ‘leg up’.

This review will look at the barriers to achieving a fair playing field, and recommend actions to be taken to address them. We are already well aware that a number of the most deep-seated barriers affect voluntary sector providers, not those from the private sector. While I would not want to prejudge the result of the review, I fully expect that it will put forward a number of actions which could be taken to remove such barriers, thereby better enabling third sector providers to compete fairly with other providers of NHS services. I hope this reassures the noble Lord that, while I think we should look across all providers, it is our view that barriers facing voluntary sector providers are greater than those facing the private sector and we expect the review to focus accordingly on those.

I turn to the separate but related issue raised by my noble friend Lord Newby. We have also listened to the matters raised in other debates during this Bill and during the passage of the Public Services (Social Value) Bill, about the need to take social value into consideration in public sector procurement more generally. The Government agree that a wide-angle lens on the extended social, economic and environmental benefits when conducting procurement exercises can only be helpful. Today I am going further and put on the public record that the Secretary of State for Health is committing that the requirements in the public services Bill will be fully applied in relation to commissioning of NHS services through the procurement guidance that the board will produce on this. These were issues that were raised very compellingly by the noble Lord, Lord Mawson, and I pay tribute to him for his powerful and consistent advocacy on this theme.

I hope very much that your Lordships will find the amendment of the noble Lord, Lord Patel of Bradford, agreeable and I will be happy to support it.

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Moved by

[Baroness Finlay of Llandaff]

8: Clause 26, page 39, line 24, at end insert—
“( ) the provision of integrated urgent and emergency care at all times.”

[Baroness Finlay of Llandaff]

I am grateful to the Minister for meeting me with the President and Vice President of the College of Emergency Medicine and for listening so attentively to the concerns raised. This amendment comes from those discussions and aims to resolve the potential lacuna around the commissioning and the provision of unscheduled urgent and emergency care at all times of day and night.

Emergency medicine departments—commonly known as A&E—see 15 million patients a year, of whom about a quarter are children. About 7.5 million patients arriving in A&E are not ambulant. Typically one-third of these on a stretcher need to be admitted, most frequently into an acute medical bed. The extent of seriously ill and injured attendees is illustrated by the fact that one in 50 will need high levels of care. A quarter of all intensive care admissions come through A&E and seriously ill patients go straight to coronary care and high dependency units from the resuscitation room in the emergency department.

The full spectrum of integrated services has to involve acute medicine, acute surgery and orthopaedics, paediatrics, obstetrics and gynaecology and is crucially underpinned by critical care and anaesthesia.

These very seriously ill patients need integrated services along the whole care pathway; care cannot be broken up. The full spectrum of back-up services with radiology and laboratory services needs to be there 24/7. The best outcomes—and we were talking just now about patient outcomes—for trauma and stroke victims are absolutely reliant on immediate cross-sectional imaging, ideally co-located in the emergency department.

There is a need for closer integration and improvement of the services needed to care for emergency department patients. For example, those with mental health problems, both acute suicidal ideation and acute psychosis, and those with drug and alcohol problems, need a comprehensive integrated psychiatry service, as they are a very vulnerable group. Improving primary care, both out of hours and alongside emergency departments, is essential if departments are to deliver the best care and not be overwhelmed. This will require close collaboration, integration and accurately informed commissioning.

Emergency departments are the 24/7 final safety net for all other services in the healthcare system and they are the last open-access point of call. Escalation of a problem, failure in community care and inadequate out-of-hours primary care support all result in urgent presentation out of hours. Such patients often arrive at night, are unstable clinically and cannot be sent home again, as they are alone or unable to monitor the condition reliably. These 7 per cent to 8 per cent of attendees need to be observed for up to 24 hours in a clinical decision unit, where there is twice daily consultant input, either until they are stable enough to be sent home, or until deterioration indicates admission and ongoing management.

Emergency departments are busy places, providing 24/7 care, looking after patients with wide-ranging needs from resuscitation to reassurance, and interacting with many specialties to ensure the best care. The seriously ill initially need the close interaction of typically three to four specialties; any fragmentation threatens the quality of care.

Commissioning of services in emergency care is optimised by direct and close working between those specialists responsible for delivery and the local commissioners. Given the size and complexity of urgent and emergency care, this should mandate such a specialist on the local commissioning board.

The challenge to us with this Bill is to ensure that commissioning processes recognise that patient choice in emergency care is inappropriate, as every patient needs access to a quality service that is fully integrated with pre-hospital services such as out-of-hours primary care and ambulance services, and with all the back-up and specialist services that patients are moved to for ongoing management.

The national Commissioning Board must work very closely with the College of Emergency Medicine to ensure that commissioning guidance drives up the standards of weaker departments, that the integration of services is included in the commissioning and that the urgent and emergency service for a population has the full skill set to deal with the full range of undifferentiated clinical problems that arrive at the only open access point of care. It is key to local commissioning that specialists in urgent and emergency care are directly involved. Without that, we will replicate Mid Staffordshire, but it may not be evident until unnecessarily large numbers of lives are lost. I beg to move.

[Baroness Hollins]

My Lords, given the concerns among the medical profession which are still evident, I ask the noble Earl for reassurance that, for those services where commissioning is appropriate, competition will always be on the basis of quality, not price, and that providers will not be able to cherry-pick lucrative parts of the care pathway to the detriment of vulnerable patients, such as people with learning disability or severe mental illness—people that I am particularly concerned about as a psychiatrist. The health and well-being of these patients depends on the effective delivery and co-ordination of complex care pathways.

According to the Guardian, NHS Devon and Devon County Council have shortlisted bids to provide front-line services for children across the county, including some of the most sensitive care for highly vulnerable children and families, such as child protection, treatment for mentally ill children and adolescents, therapy and respite care for those with disabilities, health visiting, palliative nursing for dying children, and so on. On the shortlist for the £130 million three-year NHS contract are two private profit-making companies as well as the Devon Partnership NHS Trust, which has been bidding along with Barnardo’s and other local charities.

The contract will apparently be awarded, according to the criteria, to the most economically advantageous bid, which appears to be possible under current commissioning arrangements. I seek reassurance from the Minister that the new safeguards in the Bill also prevent such commissioning decisions risking the perceived risks raised by my noble friend with respect to the commissioning of integrated care pathways in emergency care. I am referring not just to the emergency care part of the pathway but to the whole care pathway, which inevitably requires stable working relationships across organisational boundaries.

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[Earl Howe]

I reassure my noble friend that there will be no shortage of advice available to CCGs once they are up and running, not only from the NHS Commissioning Board centrally—she will know that a programme of work is in hand on the part of NICE to produce quality standards that will underpin the commissioning guidance—but also from the clinical senates, which will fall under the wing of the board. We envisage that those senates will be a resource on which clinical commissioning groups can draw, not least in the area of less common conditions. We are very conscious that the quality of commissioning needs to be improved in many areas, and this is our answer to that. My noble friend has put her finger on an issue that is of central importance if the new duty to improve quality is to become a reality across the system.

Noble Lords will wish to note that the interpretation section of the NHS Act 2006 states that illness includes any disorder or disability of the mind,

“and any injury or disability requiring medical or dental treatment or nursing”.

We are absolutely clear that this covers cases relating both to physical and mental health requiring urgent and emergency care. This definition will apply to the duty to obtain advice in the new Section 14W. I hope I have been able to reassure the noble Baroness that CCGs will absolutely be expected to ensure that they obtain appropriate advice in order effectively to commission emergency and urgent care services; that they will be held to account for doing so; and that the current duty is deliberately drafted to ensure that it covers the full spectrum of services which CCGs will be expected to commission, including emergency and urgent care services. On this basis, I hope that she feels content to withdraw her amendment. I would, however, like to take this opportunity to thank the noble Baroness for our recent conversations on this topic, along with the College of Emergency Medicine.

My right honourable friend the Secretary of State and I both recently met with the college and found these meetings useful in exploring how we can ensure that we make the most of the opportunities presented by the new system in relation to improving the quality of emergency care. We look forward to constructive discussions with the college and with the noble Baroness as we move on to implementing the new arrangements.

[Baroness Finlay of Llandaff]

I am most grateful to the Minister for that full reply and for his recognition of the contribution that the new College of Emergency Medicine is making to the urgent care of people who are often in extremis. It is literally the life-saving service for many people every day across the country. I am also grateful for his assurance that the performance assessment of commissioners will include how they seek advice from the appropriate people who really know what they are doing, and that integration is assured. The importance of 24/7 recognition has also been brought out in his answer. I am sure that the College of Emergency Medicine will be delighted with the assurances that he has given, as will A&E consultants up and down the country. I am most grateful to him and beg leave to withdraw the amendment.

Amendment 8 withdrawn.

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[Lord Patel of Bradford]

My Lords, I am obviously very happy to add my name to the amendments tabled by the Minister in respect of Section 117 of the Mental Health Act, pertaining to after-care services. I was grateful to the noble Earl and to the noble Baroness, Lady Northover, for not opposing my amendment on this issue. It somewhat caught me off-guard, but I was pleased with that. I was particularly pleased that we have continued to work together to add these technical adjustments today. To remind noble Lords: Section 117 requires primary care trusts and local authority social services to work jointly in providing vital after-care services. These types of services can vary a great deal, including visits from the community psychiatric nurse, attending a day-care centre, administering medication, providing counselling and advice, and most importantly supporting accommodation within the community.

Section 117 provides crucial protection for vulnerable people because it ensures that their local primary care trusts and local authority provider supply that after-care package in an appropriate way, including sorting out the funding on an agreed basis. This means that these essential services cannot be taken away until both the PCT and local authority, in consultation with the patient and their carers or the voluntary sector—the people who are supporting some of these patients—are satisfied that the patient no longer needs their services. The original concern that the noble Lord, Lord Adebowale, and I had was that Section 117 after-care was being unnecessarily diluted, as a joint duty to provide after-care was being changed. To all intents and purposes, Section 117 would have been treated as a duty under Section 3 of the NHS Act, and that would potentially have opened up the possibility of charging.

The noble Earl has laid out the protections set out in additional amendments and they are to be welcomed. They go beyond my original concerns and address a number of important issues. I will not list those listed by the noble Earl, but I was happy about the part of Section 117 arrangements that fall under the remit of the Care Quality Commission, ensuring that the regulator and monitor of services should look across patient pathways. I am particularly pleased about the amendment that ensures that Section 117 services are eligible for direct payments. This is a positive step, because it means that people detained under the Mental Health Act can take more control of the services that they receive after their release.

This is not only the right thing to do, as it will empower people who have been affected by being detained, but it is also likely to help to avoid readmissions by ensuring that people are more satisfied and engaged with services. We still have a long way to go to improve services for people detained under the Mental Health Act; in particular the experiences and outcomes when they return to the communities where they live. However, these amendments are a definite move in the right direction and I must congratulate the Minister for having the foresight and good grace to bring these amendments before the House. I wholeheartedly support them.

[Baroness Finlay of Llandaff]

My Lords, in this group of amendments there are two that relate to Wales. On behalf of the NHS in Wales, I am most grateful for the clarification. Could the Minister confirm that the Public Services Ombudsman would deal with complaints by any provider who is providing services for and on behalf of the NHS, irrespective of whether that is an NHS provider or a non-NHS provider? It would be helpful to have that clarification.

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[Lord Cotter]

My Lords, I thank the noble Baroness, Lady Emerton, for introducing this amendment, which I hope the Minister will agree gives an opportunity for a very important issue to be aired. Many noble Lords have aired it in the past; indeed, I raised it on the very first day of the Bill. It is an area that remains of concern, and I have been pleased to hear from the Ministers that they are well aware of this. I recollect at the beginning of the Bill speaking to a nurse who, with an air of concern in her voice, said that when she asked assistants to carry out work the responsibility remained with her if that work was not carried out correctly. I welcome this opportunity for the Minister I hope to give a very strong response to indicate the Bill will cover this issue. As the noble Lord, Lord Patel, said, we are talking about 450,000 healthcare assistants: many people of varying abilities and knowledge.

I will say no more except to thank the noble Baroness for her amendment and, in anticipation, to thank the Minister for his response, which I hope will be robust and clear as to what we are going to do to address this concern.

[Baroness Finlay of Llandaff]

My noble friend Lady Emerton, in tabling this amendment, has come up with something very sophisticated and really rather clever. By requiring education, she will ensure that the next group has its standards driven up. People enter into a caring group and learn from others around them; the problem is that at the moment they are learning bad practice as well as, hopefully, learning good practice.

Making sure that these are assured training programmes is eminently sensible. Modern educational techniques using e-learning, DVDs and other ways of training mean that you do not have to take people away from the job and put them in college. They could be given provisional registration while they worked through some of these training programmes. Modern ways of teaching also allow you to train those with very low literacy skills. It is worth remembering that some of the very high-standard care assistants in the system providing care in people’s homes often have low levels of literacy, so they need to be taught using modern techniques. This will allow that to happen. As for tracking their attendance, with electronic records it becomes quite easy to monitor what they turned up for and how they performed and to assess them in the tasks that need to be undertaken.

This amendment seems to meet all the criticisms that the Government laid at the door of previous amendments. I hope that it will get a better reception than its predecessors.

[Baroness Cumberlege]

As a fellow of the Royal College of Nursing and the Royal College of Midwives, I very much regret that I have been unable to take part in the previous debates initiated by the noble Baroness, Lady Emerton. I regret that for many reasons, not least because I had the privilege of introducing the noble Baroness into your Lordships’ House, and what a good thing that was. The noble Baroness is a truly remarkable person. I am not at all surprised that she has crafted this very clever amendment, as the noble Baroness, Lady Finlay, said. I know that the noble Baroness, Lady Emerton, recognises that statutory regulation will not always prevent abuse. Indeed, the chief executive of the Council for Healthcare Regulatory Excellence told your Lordships at a seminar that the regulator is never in the room when abuse occurs.

I understand that the noble Baroness is calling not for regulation but for a voluntary register assured by the CHRE. People will get admittance to the register provided they have attended an assured training programme. The training programme is to be mandatory for all new healthcare support workers from 1 April 2013. I understand that that is where the Government have something of a problem because of the numbers and costs involved, as the noble Lord, Lord Patel, said.

However, is it not right that good employers should pay the registration fee and have some element of discrimination in deciding who they recruit to a job? The question asked by the noble Lord, Lord MacKenzie, was very apt. My noble friend’s answer to it will be very interesting. If individual support workers have to pay the registration fee themselves, it could be seen as a tax on work for people mostly on the minimum wage, and there is an issue about that. It will probably increase the cost of employment, and this is a market in which retail, part-time working and motherhood compete, so we have to be careful.

On Report, the noble Lords, Lord Turnberg and Lord MacKenzie of Culkein, referred to the history of state enrolled nurses. Unlike registered nurses, they were said to be used and abused. I remember that because I served with the noble Baroness, Lady Emerton, on the United Kingdom Central Council for Nursing, Midwifery and Health Visiting where, over time, we phased out state enrolled nurses. They have been replaced to some extent by healthcare support workers, and we are facing almost the same issues again.

In the previous debate, my noble friend Lord Newton and the noble Lord, Lord Hunt of Kings Heath, were very kind to mention my role in nurse prescribing. I am delighted to see the noble Baroness, Lady Jay, in her place. I remember the day when we rejoiced in the fact that nurse prescribing had gone another step on the way. It took me 26 years to get that to happen—a very long time indeed—and we are not quite there yet. It seemed to me that nurse prescribing was extremely obvious. In the light of today’s debate on risk and risk registers, it probably would have been seen as a very high risk, but it has not proved to be so—but we are not there yet. I am very much hoping that, with the help of my noble friend Lord Henley and the Home Office, the last piece of this jigsaw will be put into place.

We started very small with nurse prescribing. We started with Bolton. The whole of Bolton took on nurse prescribing. In some parts of the country, the fight was enormous. GPs saw prescribing as their territory, and they did not want nurses to step into it. We managed to achieve it, and one of my real worries is that if we have support workers who, as the noble Baroness told us in the previous debate, are administering some very serious drugs, the work that I have done will be diminished because people will then think that nurse prescribing can be done by anybody with sufficient training, and that is dangerous. It is wrong for patients, and it is wrong for support workers who have perhaps been told that they have to administer these drugs.

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[Lord Dubs]

My Lords, I shall speak very briefly as the House wants to move to a vote. I support this amendment and would like to pay a tribute to my noble friend Lady Thornton for the work that she and her team have put into this. Without the backing of a government department, they have performed heroically and very effectively.

I want to give only one personal reminiscence. The National Health Service started on 5 July 1948. I was a child in hospital on that today; I was quite ill in Stockport Royal Infirmary. The consultant and his team came; in those days one either had to stand to attention or lie to attention when the consultant came with the matron and the team of junior doctors. Momentarily, he stopped at the foot of my bed and I said, “Are we going to celebrate? Are we having a party?”. He asked, “What are you talking about”? I was the only child in the ward, so it was cheeky of me but I said, “Well, the hospital is ours today—isn’t it wonderful?”. He walked on without saying anything, but it was a momentous day and I never thought that, 64 years later, I would be here at Westminster and lamenting what has happened to our beloved National Health Service. Let me conclude by quoting Nye Bevan, who said,

“The NHS will last as long as there are folk … with the faith to fight for it”.

[Baroness Finlay of Llandaff]

My Lords, it is with a very heavy heart that I feel I must stand up and record that many of the voices outside, who are very scared about this Bill and what it means, are people who are of no particular political persuasion. Yet they are worried about the problem of lack of financial transparency, about the number of private healthcare companies incorporated in offshore jurisdictions—which they see may evade taxes of various types—and about the commissioning process. They are also concerned that the use of public money in the healthcare system will slowly be obscured like a great iceberg wrapped in fog. They will work to deliver whatever is needed for the patients in front of them. The vast majority of them stand to gain nothing by this Bill passing, but to gain nothing either if it does not pass. They want to improve the standards for their patients, and indeed they argue for change.

The noble Earl has worked tirelessly and has confidence across the whole House. Everybody, however much they have been concerned about this Bill, owes him an enormous debt of gratitude for the way that he has listened to every single one of us, at all times of the day and night, and weekends and so on. But we should not let this Bill pass without recognising the enormous concerns there are outside this House among those who will be delivering healthcare, now and into the future, in whatever form it takes.

[Lord Greaves]

My Lords, this has been an extraordinary parliamentary process. When this Bill was introduced, I said at Second Reading that it was a bad Bill. It was a bad Bill when it came here; there has been a growing tide of opposition to it and concern throughout the process while it was in the Commons and the Lords. There was the pause in the Commons and the Future Forum, which resulted in a large number of changes, and at that time Nick Clegg said that no Bill is better than a bad Bill. What we all individually have to do now—I speak very much for myself and not my party—is to assess whether it has now moved over from being a bad Bill to perhaps being, as Nick Clegg said last week, a much better Bill.

There is no doubt at all that on a spectrum of bad to good, it has shifted very considerably. It shifted in the Commons; it shifted far more here in the House of Lords. I believe that the process in your Lordships’ House has been the House of Lords at its best. This House can be proud of the work that it has done throughout the gruelling Committee stage, then during Report and again today. I regret that I could not take a detailed part in much of that, because I was then spending time as a patient of the NHS, but I have been watching it all and I believe that the work this House has done has been absolutely superb.

If I can make a party political point here for a moment, the work that our team has done on the Bill, led by my noble friend Lady Jolly with all my other noble friends who have taken part, has contributed well. I refer not only to the Liberal Democrats but to Cross Benchers and everybody around the House. Tribute has been paid to the Minister. I pay particular tribute as a Liberal Democrat to our person on the ministerial team, my noble friend Lady Northover, who from our point of view has played a very important part by being a link into the Government and getting many of the changes which have taken place.

It is about not just the changes to the Bill but the implementation—the work that starts after this Bill has been passed, as no doubt it will be today. A huge number of ministerial assurances have been made, which may or may not be put upon people’s bedroom walls as the noble Baroness, Lady Cumberlege, wants to do with hers. Nevertheless, this is a Bill which has had more outside scrutiny and involvement from people out there, as far as the House of Lords is concerned, than any other Bill I can remember in 12 years in your Lordships’ House. That will continue with the implementation, and it is absolutely crucial how the Government now implement this Bill. Will it be gung-ho privatisation, which is what people were very frightened of when the Bill was first introduced and many are still frightened about, or will it be implemented in a cautious and careful way to allow the health service to breathe and to cope with the changes? This will be absolutely crucial, and we will know the answer to that in a year or two’s time.

The noble Earl, Lord Howe, said that we have had debates of unparalleled length and scope, and that is true. However, as I have just said, the public interest and lobbying on this from outside has been unprecedented. One of the lessons that we all have to learn is that we—whether the House of Lords, members of the Government or our party—have not coped with that very well. I do not think that the Opposition coped with it terribly well either because, even this morning, I was getting e-mails telling me what the Bill did, some of which was absolutely untrue. They were still telling me that the Bill removes the duty on the Secretary of State to provide health services. We are still getting that, and the amount of education or information which goes out from debates within this Chamber to the outside world is pretty poor.

Several people have said, “We have been trying to follow this Bill. We have been trying to follow your Marshalled Lists, having discovered where to find them on the internet. We have been trying to follow the parliament channel, and we haven’t understood a word of it. It is interesting, but we can’t understand it”. I have to tell them that that applies to quite a lot of Members of your Lordships’ House while the Bill is going through.