NHS: GP Clinics

Baroness Howarth of Breckland Excerpts

Thursday 25th June 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness makes a good point. The old model, based largely around partners, often in small practices, is the one that I think will evolve over the next five years. We will certainly see many more salaried GPs coming into the workforce. The fact that there are now many more women doctors, who will wish to take time out to look after their children or for maternity leave and the like, means that the structure of general practice will change fundamentally. It may also mean more locums. I do not have a view on that particular aspect of the noble Baroness’s question.

[Baroness Howarth of Breckland (CB)]

My Lords, if the Minister believes that we have had the same model since 1948, what was the House doing taking through during the last Session the health legislation that changed the structure so that the business model was around GP practices? Many GPs find that extremely onerous. They want to be doctors, not business managers. There has been significant change and not necessarily for the better. Would the Minister not agree?

[Lord Prior of Brampton]

The noble Baroness—

Mental Health Services: Young People

Baroness Howarth of Breckland Excerpts

Tuesday 23rd June 2015 Lords Chamber

[Lord Prior of Brampton]

I thank the right reverend Prelate for his question. I am not aware of the Bill to which he refers. I hope he will excuse me for that; I will find out about it after today. The right reverend Prelate asked whether we will work with other parts of the Government, particularly the Department for Education. I assure him that we are doing so.

[Baroness Howarth of Breckland (CB)]

My Lords, I welcome the Government’s prevalence survey. However, does the Minister’s department have any idea at this time of the length of waiting lists and the number of children waiting for very specialist intervention from psychiatrists and psychologists? I hear from groups of people that the waiting lists are growing and the time children spend waiting is getting longer. For a child with a mental health problem, every day makes it worse. What are the Government doing about that? Does the Minister have the numbers?

[Lord Prior of Brampton]

I do not have the numbers to hand, but I can tell the noble Baroness that the number of beds that have been commissioned has increased significantly over the last three years and I think 1,250 tier-1 beds are now available. The noble Baroness puts her finger on it: the way we provide treatment for people suffering from mental health conditions—and have done for many years—falls far short of what we would expect for people suffering from equivalent physical conditions. We often talk about parity of esteem quite glibly, without putting the necessary resources behind it. The Government are determined to do so.

General Practitioners

Baroness Howarth of Breckland Excerpts

Monday 22nd June 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness speaks a good deal of truth. The model that we have been working with since 1948 in this country is largely broken. We have to deliver more care through vertically integrated units of care, not just independent hospitals. Over the next five to 10 years we will see a huge consolidation of primary care. The old cottage industry model of general practice is probably broken. The Five Year Forward View recognises that and the Government have committed £8 billion to see that forward view put into practice.

[Baroness Howarth of Breckland (CB)]

My Lords, I do not know where the Minister spends his time, but where I come from, in the country, you have to travel 18 miles to a hospital or a GP practice at the weekend. That is very difficult when you have groups of elderly people. In the rest of the country—even in the city where I spend my city time—GPs are now saying that practices are to be closed and people are waiting three weeks for an ordinary assessment. Can the Minister tell us why the Government are not seeing what is happening on the ground and taking more urgent action?

[Lord Prior of Brampton]

The Government are committed to seeing 5,000 new GPs. This is probably the biggest expansion of primary care that we have seen for many years. It is not just 5,000 GPs but a further 5,000 people working in primary care, including physician associates, practice nurses, physiotherapists and other allied health professionals.

Standardised Packaging of Tobacco Products Regulations 2015

Baroness Howarth of Breckland Excerpts

Monday 16th March 2015 Lords Chamber

[Lord Blencathra (Con)]

My Lords, I declare an interest as on the register of interests. It is a new interest—I recently joined the Lords and Commons Cigar Club, because I was concerned with how the Government have caved in to some of the fanatics in the anti-smoking brigade. They are fanatics, because they seem to hate e-cigarettes, which are good things for smokers to change to, just as much as they hate tobacco cigarettes. There is a powerful case against smoking—we all agree with that—but I would be more interested in their arguments on plain packaging if they would admit that e-cigarettes were actually a good thing for people to change to.

I deeply regret having to oppose my noble friend the Minister. In my 33 years in Parliament, he is the most knowledgeable Minister for Health that we have had in either House. In addition, he is invariably courteous and the most caring and decent man I have ever met. Therefore, I am sorry that, on this occasion, I think that he is wrong.

One knows that a government department or any organisation is scraping the bottom of the barrel to find arguments when we have 21 regulations over 23 pages, and a memorandum trying to justify them running to 103 pages and 388 paragraphs, most of which have nothing to do with plain packaging but make very powerful arguments against smoking in general. The department has scraped together every possible and bogus argument that it can to support the case. Many of the arguments that I have read in the impact assessment seem to be different from the contents of my noble friend’s speech. Paragraph 230 says that local authorities in 2007 spent £342 million on dealing with cigarette litter alone. What an extraordinary figure. That is absurd nonsense—but it adds to it by saying that plain packaging will lead to further savings on litter collection but that the department cannot quantify them. Dead right it cannot quantify them, because I think that they are quite spurious. This reminds me of the Home Office claim during the draft communications data Bill that it would bring about savings of £6 billion per annum, when that £6 billion was based on terrorist attacks which it considered would no longer take place if the Bill was passed.

All the evidence suggests that standardised packaging will lead to a big increase in the illicit market. That is the view also of Commander Roy Ramm, a former Metropolitan Police commander, who gave evidence to the Lords Select Committee. If even I as an amateur, on my £99 Canon printer, can now easily manufacture a matt standard cigarette packet—and, yes, I can do Helvetica and Pantone grey 42 at 8 point, as per the regulations—what will the big criminal gangs in Romania and Bulgaria do? At least they will increase the market for offset litho printing machines. The impact assessment makes tortuous assumptions to get out of admitting that it has not got a clue on the increase in illicit cigarettes that we will inevitably see. Paragraph 192 says:

“We conclude that there is a sizeable likelihood that there will be no discernible increase in the illicit market. However, we also conclude there is a chance that there will be an increase in the illicit market”.

I invite noble Lords to look at paragraph 192—that is exactly what it says. What a way to make policy. We do not know if it will be good or bad, but we will carry on regardless.

Then there is the Australian experience, which has been cited already, and which the Government call in aid even though it has been running for only 18 months.

Paragraph 93 of the impact assessment says:

“At this time it is difficult to conclude what the impact of standardised packaging on Australian smoking prevalence has been, due to confounding issues of a general decreasing trend and changes to tobacco prices”.

So, although we do not know whether it is working in Australia, we will carry on with our policy regardless. That is not a way to make policy. Australia is conducting a post-implementation review, but we are not even waiting to find the Australian Government’s conclusions.

All the evidence suggests that price is the big determining factor in people giving up smoking. With an increase in the illicit market and the fact that counterfeiters will be able to sell cigarettes more cheaply in the pubs, clubs and other outlets that they use, we are likely to see an increase in consumption of even more dangerous tobacco as criminal gangs are able to sell it more easily—they will use even cheaper, nastier tobacco. Nor will we be able to police it properly: the whole Codentify system is in jeopardy and will not be able to easily identify illegal and dodgy cigarettes. I say to the noble Lord, Lord Faulkner, that the system may not be perfect but it is better than nothing, which is the Government’s policy if they go ahead with plain packaging. The idea that a person in a pub will check the barcode before he buys a £5 packet of cigarettes, rather than go to a proper newsagents and get a £7.50 one, is just nonsensical.

I conclude that this is unfortunately a knee-jerk SI. We should wait until we get proper results and measured evidence from Australia. That is the only sensible way to make policy on this important issue.

[Baroness Howarth of Breckland (CB)]

My Lords, I had not intended to speak this afternoon, although I want to congratulate the noble Earl. I was with him on the beginning of this journey. I think that he has taken this through with due care and diligence. At the beginning, some of us feared that he would not be on the side of the anti-smoking brigade, but he has taken some of these measures very carefully into legislation. As the noble Lord, Lord Blencathra, was speaking, I realised that I was a fanatic—so as a fanatic, I will make just three points.

First, with the noble Lord, Lord Faulkner, I introduced the first Bill that tested the arguments in this House, the London Bill, when the noble Lord, Lord Faulkner, introduced the Liverpool Bill. At the time we were told very firmly by the smoking lobby that cancer was not caused by smoking, that we would actually take money out of the health service because of taxes and that we would lose money rather than gain it if smoking decreased. We received quite a lot of serious and personal accusations about false information. I began that journey there and was the person who brought forward the order to stop smoking in the Peers’ Guest Room. I think that many people have been grateful for that for a long time.

The second reason that I wanted to speak as a fanatic is that I think that there have been some spurious arguments this afternoon. I spent 10 years in the Food Standards Agency working with the food industry, which has had to change its packaging more than any other industry. If the smoking industry is not flexible enough to do as well as the food industry in organising itself to do something else when it loses this packaging, it does not deserve to be in business. Business has to be innovative.

The third reason I am a fanatic is that I have a niece who I brought up as a daughter. She has two children. The youngest has a heart complaint, which is very serious if she gets into any situation where there is smoke. I say that as a personal comment, but noble Lords will know how strongly and passionately I feel about the protection of our children. It seems extraordinary: if packaging with coloured outsides and attractive labels is not attractive to children and selling the product, why is the industry so keen to save it? That is the sheer, simple logic. If any noble Lords are wavering, perhaps they should wonder why so much money is being spent by the industry to protect packaging if it has no impact; it wants to protect it because it does.

So in some ways I suppose that I am proud of being a fanatic. I hope that your Lordships will be with the Minister and oppose the amendment in the name of the noble Lord, Lord Naseby, as I do.

NHS: Financial Tariff for 2015-16

Baroness Howarth of Breckland Excerpts

Wednesday 4th February 2015 Lords Chamber

[Earl Howe]

My Lords, we remain absolutely committed to achieving parity of esteem between mental and physical health. The proposals for mental health services in the national tariff arrangements for 2015-16 will get us closer to that aim, should they be finally agreed.

[Baroness Howarth of Breckland (CB)]

My Lords, a great deal of concern has been expressed by specialist providers, particularly in the heart field where there is a review ongoing at the moment, that there might well be a reduction in funding. That would be disastrous for services. Can the Minister reassure those groups that there will be a fair assessment in relation to specialist provision?

[Earl Howe]

It is the view of Monitor and NHS England that providers of specialised services should make every effort to deliver care that is both clinically appropriate and cost-effective in order to manage demand—where, after all, their clinicians have significant influence. NHS England considers the proposed rule to be warranted—this is about the 50:50 split in the tariff—because rapidly growing expenditure that exceeds population prevalence growth is unlikely to reflect efficient and effective services, which, when one thinks about it, are in patients’ best interests overall.

Autism

Baroness Howarth of Breckland Excerpts

Wednesday 4th February 2015 Lords Chamber

[Earl Howe]

My Lords, the new statutory framework for children and young people with special educational needs and disabilities, SEND, is designed to improve the integrated working across health, education and social care so as to deliver improved outcomes for a child and his or her family. Clinical commissioning groups and local authorities will be working together according to that statutory framework.

[Baroness Howarth of Breckland (CB)]

My Lords, the Minister clearly accepts that speed of diagnosis ensures that a child or young person gets into treatment faster. The faster they are in treatment, the more likely they are to make some progress in how they are able to function. However, does he accept that there is a disconnect between that diagnosis and the service delivery, particularly with under-fives, where children are waiting a considerable time for their local authorities to sponsor them into nurseries or facilities? What is happening to ensure that that improves?

[Earl Howe]

The noble Baroness makes a very good point. That is exactly why we have given clinical commissioning groups new duties to commission services for nought to 25 year-olds and young people to ensure that procedures are in place, to agree a plan of action, to secure provision which meets a child’s or young person’s reasonable health needs in every case, and to work with the local authority to contribute to the local offer of services for children in this position. That is now a statutory duty and I think it is a step forward.

Alcohol: Addiction

Baroness Howarth of Breckland Excerpts

Monday 12th January 2015 Lords Chamber

[Earl Howe]

No, my Lords, they are not. The Government have regular dialogue with the industry, but the industry does not formulate policy and never will do. There has been a delay on the new guidelines; the consultation on them had been planned for December last year but will not now happen until shortly after the general election. That is simply due to problems with Public Health England commissioning expert advice on guideline methodologies, which took longer than intended. The academic body that PHE wanted to do the work decided that it did not have the capacity to do so. A tender exercise was therefore necessary and the work is being carried out by a team from Sheffield University.

[Baroness Howarth of Breckland (CB)]

My Lords, the Minister is well aware of the effect of alcohol on unborn children. What are the Government doing for young mothers who are either addicted to drink or unaware of the difficulties that alcohol creates for their children in terms of education both through the health service and the education system?

[Earl Howe]

My Lords, the Royal College of GPs has a special focus at the moment on giving advice to GPs. We are also dramatically increasing the number of health visitors, who are, of course, highly instrumental in influencing the behaviours of mothers-to-be and young mothers.

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Baroness Howarth of Breckland Excerpts

Wednesday 5th November 2014 Lords Chamber

The removal of a regulatory framework is liable to inflict significant damage on our society. A good example of this, on a practical level, has been provided by the Government’s National Planning Policy Framework. This replaced more than 1,000 pages of guidance and regulations with 50 pages, written simply and clearly, that were aimed, so it was claimed, at allowing people and communities to participate in the business of planning. In reality, a set of sophisticated and carefully crafted documents, which had provided policy guidance in many specific circumstances and which had been developed and refined over the past 25 years, has been tossed into the rubbish bin, to be replaced by 50 pages of vacuous pieties. The same damage is being inflicted on the regulatory framework governing the provisions for our care homes. We believe that it is not too late for the Government to think again.

[Baroness Howarth of Breckland (CB)]

My Lords, I will be brief, as I always am. I do not want to repeat what has been said before, much as I would love to be led down the path of talking abut the problems faced by care homes in the present financial climate. I must first declare an interest as a trustee of Livability, which provides a large number of care homes for disabled people and for other groups. I am therefore, as a trustee, in the role of a provider. I also want to speak very briefly on behalf of families and carers.

First, I say to the Minister that I welcome the regulations. I was interested in his spirited defence of them, and I know his great belief in them. There are aspects of the new regulations that strengthen the potential to hold care providers—such as my organisation—properly to account. That is all positive, but I simply want to address myself to the issues around the amendment on the Order Paper, because there is an issue and I would very much like the noble Earl to think about it.

We have been approached by a number of organisations which said that families and residents are very concerned about these three aspects of the regulations. I have looked at the old wording and at the new wording, and I found that the new wording is more elegant but much more obscure for ordinary people to relate to. It is terribly important that ordinary folk in a care home—both the providers and those receiving the service—understand that they have a right to be told about complaints procedures.

Clearly, that is there already. I disagree with those who say it is not. All of it is to be found within the regulations and the follow-up documents by those who actually dig through them. I believe that the noble Earl hoped—as he listened to all the hours of discussion of these issues—that this would be absolutely crystal clear. If these issues are clear, they also help leadership and management. It is much easier for providers to tell their staff how to take things forward if the words are absolutely clear, and if there is some sense of being given flexibility or whatever the expectation is.

When it comes to proper planning for emergencies, providers have an absolute responsibility to ensure not only that they have those plans, but that in the interests of health and safety everybody understands them throughout. Not only the providers but the residents themselves must understand. It is possible to have a great discussion about these issues among those who are receiving care. It is possible to discuss complaint procedures, choice of food and what happens if there is a fire and people can only be got out of certain areas by particular routes.

What I am saying is much simpler than the rest of the discussion. I would like the Minister to look at the wording, because in my opinion this is about language rather than intent. We have excellent regulations but, if families and users are concerned about these three areas, the Government have a responsibility to listen. I know we have a listening Minister.

[Earl Howe]

My Lords, I am grateful for the questions and comments raised by noble Lords. I will do my best to answer them in the time available. Perhaps I may begin with the issues raised by the noble Lord, Lord Hunt. The noble Lord expressed his regret that certain phrases no longer appear in the regulations, and those concerns were echoed by the noble Viscount and the noble Baroness, Lady Howarth. I should like to reassure the House that, although the regulations do not include express references to the three things highlighted in the amendment tabled by the noble Lord, Lord Hunt—informing service users about complaints procedures, having emergency procedures in place, and offering choice of food—nevertheless providers must still demonstrate to CQC that they are doing those things.

This is possible because the fundamental standards work in a different manner from the current regulations. They set the outcomes about quality and safety that must be met, rather than just the processes that must be in place. They set out the ends, rather than merely the means. Because we describe these outcomes in regulation, we no longer need to spell out a long list of processes in regulation as well. However, all the areas highlighted by the noble Lord nevertheless fall within the scope of the new regulations. For example, planning for emergency procedures is covered by the new safe care regulation, which requires providers to ensure that care is provided in a safe way, and that they do all that is reasonably practicable to mitigate the risks of unsafe care. A provider that had no plans in place to deal with emergencies such as floods or staff shortages could not claim to be meeting the regulation, because they would not be doing all that is practicable to mitigate the risks to the health and safety of service users from emergency situations. In practice, not having a plan in place for emergencies will therefore be a breach of the regulations.

The obligation to offer a choice of food and drink falls within the new person-centred care regulation, and the newly drafted nutrition regulation. We have introduced a new person-centred care regulation which requires that a person’s needs must be met, and that their preferences must be taken into account and, where possible, met. I emphasise that this applies not only to food preferences, but to all other aspects of care as well. This is a significant step towards greater person-centred care, advocated by many over recent years.

In addition, the nutrition regulation states that a person’s nutritional needs must be met, and it will be a criminal offence to fail to meet this regulation in a way that causes avoidable harm or significant risk of such harm. These two regulations work in tandem to require that a person’s individual nutritional needs are met and their individual preferences are reflected wherever possible. This is a stronger position than merely requiring that people be offered a choice. Such a requirement could be met by offering a person a choice of two things that are neither desired nor suitable. On the issue of complaints, the new complaints regulation states:

“The registered person must establish and operate effectively a system for identifying, receiving, recording, handling and responding appropriately to complaints, and requests for action to be taken, by service users and other persons”.

A provider who does not make patients and service users aware of their complaints system could not claim to be making it accessible, or claim they had an effective means of identifying complaints. Therefore, they would be breaching the regulation. CQC’s draft guidance about compliance with the regulations, which is currently subject to consultation, includes more information about all of these areas. It is this guidance that sets out in more detail what CQC will look for when checking whether providers are meeting the regulations. If noble Lords are in any doubt or have anxiety after this debate and after what I have said, I assure them that I would be happy to feed in the concerns which have been raised this evening in the context of the guidance that is now in preparation.

The noble Lord, Lord Hunt, described the regulations as light-touch, and the noble Viscount, Lord Hanworth, suggested that the Government were somehow pursuing a deregulation agenda by introducing these regulations. I must say to the noble Viscount in particular that that is a complete misreading of these regulations. Indeed, his speech indicated to me that he is labouring under a number of serious misapprehensions. Past experience has shown that there are limitations to prescriptive regulation. It is very difficult to make regulation exhaustive. The list might come to be the upper limit of what is provided, rather than the floor below which care should never fall. For example, the old national minimum standards for care homes included very specific requirements that set out the minimum bedroom sizes in square metres. In practice, this minimum became the default normal size for rooms.

The guiding principle behind the fundamental standards is that they set an overall outcome that must be met. The responses to our consultation showed that the vast majority of respondents agreed with this, and thought that the regulations were clearer as a result. I hope that that reassures the noble Baroness, Lady Howarth, in particular. Importantly, this approach allows the CQC to take a more rounded look at quality and safety as it inspects, rather than taking a tick-box approach to inspecting done solely against prescriptive regulations.

Health: Rheumatoid Arthritis

Baroness Howarth of Breckland Excerpts

Monday 16th June 2014 Lords Chamber

[Earl Howe]

My Lords, we are encouraging single-handed practices not to disband but to federate themselves—if that is a good word—with other practices in the area, and certainly to seek the support of their clinical commissioning group. That would ensure that the range of professional training available is utilised and that there is peer support where appropriate. Therefore, while many single-handed practices do a very fine job, there is scope for them to collaborate with their colleagues in the local area.

[Baroness Howarth of Breckland (CB)]

My Lords, I am sure that the noble Earl will tell me that it is the responsibility of either NHS England or the local health commissions, but is he not alarmed by the number of GP practices being suggested for closure at the moment, and by the long waiting times that patients have to endure in many areas? In some country areas you cannot see your GP for four weeks. Should the Government not have at least some concerns on that?

[Earl Howe]

My Lords, we are concerned by reports of patients having difficulty accessing their GPs. That is why a whole range of work is currently going on in NHS England to look at the issue, to see how general practices can be helped and to enable them to see more patients. However, more generally, we in the Government have amended the GP contract to free up GPs’ working time. We have abolished well over a third of the QOF indicators precisely to do that. The Prime Minister’s Challenge Fund—£50 million-worth of funding—enables GPs to open up different ways of working; for example, consulting patients on Skype and working hours other than nine to five.

Health: Transition to Adult Health Services

Baroness Howarth of Breckland Excerpts

Wednesday 11th June 2014 Lords Chamber

[Earl Howe]

I fully agree. I think that much of this will succeed only if services work together around the needs of young people as well as their families and carers, and if the families and the young people themselves feel involved in the way in which their care is being organised and planned.

[Baroness Howarth of Breckland (CB)]

My Lords, in terms of developing the specification, can the noble Earl tell us how stakeholders are to be involved? In particular, will the young people themselves now have a voice? I declare an interest as the president of Little Hearts Matter, which deals with children with single-ventricle problems.

[Earl Howe]

I think that we can pay considerable tribute to the Children and Young People’s Health Outcomes Forum. It is one of the bodies that have highlighted the need for more effective transitions and for new outcomes indicators to measure them. Its framework for this year includes a proposal that, where possible, all data should be presented in single-year or five-year age bands up to the age of 25 to support better monitoring. Moreover, the forum asked the National Network of Parent Carer Forums to develop a narrative of what good integrated care looks like in transition. The CQC report has drawn quite heavily on that report in its conclusions.