Health and Social Care Bill
Baroness Meacher Excerpts(14 years ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been a thoughtful debate. At the outset, it is appropriate for me to pay tribute to the noble Lord, Lord Warner, for his strong advocacy of the need to improve the quality and funding of social care services. The noble Lord played a critical role as part of the Dilnot commission and has made strong speeches both today and in Committee on this subject.
I am in complete agreement that high-quality social care services are crucial for the health and well-being of the population. As the Government and many others have said, major reform in adult social care is long overdue. We recognise the need for lasting reform to respond to the challenges facing social care. The recent engagement exercise, Caring for our Future: Shared Ambitions for Care and Support, conducted from September to December last year, highlighted again the scale of the challenges. We know that the quality of care is variable and can sometimes be poor, as recent high-profile failures have demonstrated. The current social care system does not support people to plan for their future care needs or maintain their well-being and independence. People often have a poor understanding of what social care is and of how to navigate the system and access the services they need.
All this is compounded by the well documented twin issues of an ageing society and financial constraint. This critical context explains why the Government have set the reform of adult social care as one their key priorities, but it also explains why social care reform merits it own focus and cannot be dealt with around the edges of discussions on another important topic. The Government are convinced that the time has come for social care reform. Given that, the question before us is not whether action should be taken to improve the quality of social care services but rather how we go about doing so.
I have given Amendment 163AA a good deal of consideration, and I am afraid that I have to say to the noble Lord, Lord Warner, that I do not feel it is the appropriate mechanism to achieve what he seeks. This is because, as well as reform being needed for social care quality and funding, there is broad consensus that social care law too needs extensive reform. The noble Baroness, Lady Murphy, helpfully mentioned the Law Commission report on law reform, which put forward this argument last year. I wish to quote a short passage of the report, which states that,
“adult social care law has been the subject of countless piecemeal reforms … It is of little surprise that not only does the law perplex service users and social workers, but also the judiciary”.
This is the problem with the noble Lord’s amendment; to accept it would be to perpetuate exactly the same confusing and piecemeal approach against which the Law Commission argues. The legal framework for care and support needs fundamental reform, not further additions to an already opaque statute.
I wish to set out briefly what I see as the appropriate course of action on social care reform. We will publish a White Paper on care and support in spring this year. I repeat that undertaking, particularly to the noble Baroness, Lady Pitkeathley. We will follow this by bringing forward legislation at the earliest opportunity. The White Paper will draw on multiple sources, including the excellent work of the Law Commission and the Commission on Funding of Care and Support, for which I again express my gratitude to the noble Lord, Lord Warner. The White Paper will respond formally to the reports of both those commissions and, of course, to the Health Select Committee report on social care.
The noble Lord has proposed that a duty be placed on the Secretary of State to secure continuous improvement in the quality of social care. The Government’s proposals for embedding and safeguarding quality throughout social care will be a central theme for the White Paper. We sought views on this as part of the engagement; it highlighted that progress on quality has already been made with the publication of Transparency in Outcomes last year, which set out the Government’s approach on quality, transparency and outcomes in social care. Our approach to quality improvement is aimed at responding to poor quality, enabling improvement and rewarding best-quality services to support choice.
The ideal for social care is a sector filled with great people doing great jobs who deliver high-quality care to people using social care services. As I said, we are committed to publishing the White Paper this spring and preparations are on course. The Government are taking the broadest possible approach to achieving consensus on the most crucial long-term issues. Therefore, in that context, I do not believe that the time is right for an amendment of this sort. It would pre-empt the White Paper and could leave stakeholders unclear on the broader picture of social care reform.
Moreover—I see this as the central point—we do not want to make further changes to the existing statute when more lasting legal reform is already planned in the near future. Social care is a vital public service and deserves its own focus in its own statute. Too often, debates on social care have taken place on the margins of those on another issue.
Baroness Meacher
I apologise for intervening but I wonder whether it might be relevant to change the Title of the Bill to the Health Bill, bearing in mind the noble Earl’s very valid comments that there will be a White Paper and a totally separate Bill. The Bill’s Title is a misnomer.
Earl Howe
The noble Baroness may not have been following all our debates as closely as some, given that we have extensively debated integrating health and social care and how the Bill will improve the prospects of that. I therefore do not agree that social care is such a poor relation in the Bill. She is quite right; of course its prime focus is health, but we have not completely neglected the subject that is so close to her heart.
Specific legislation on social care will be the most appropriate vehicle for debating these critical matters and achieving lasting reform. Of course I understand the desire of the noble Lord, Lord Warner, to keep social care at the top of the political agenda. That is greatly to his credit. I can assure him that the Government have not lost sight of this. We share the same aims for a high-quality service, but it would be wrong to legislate now in such a selective way. The noble Lord may suppose that this is just another instance of a Minister following the standard line that says “resist”, but I hope he will accept that that is not so. There are genuine reasons why the amendment is a bad idea, and I hope that he will feel able to withdraw it.
Having said that, I look forward to debating these issues with him further in due course, and to benefiting from the insight that he and others bring to this topic.
Lord Marks of Henley-on-Thames
My Lords, I will speak briefly, in addition to what my noble friend Lady Williams of Crosby said, to the amendments in our names concerning the Secretary of State giving guidance to Monitor: Amendments 163C, 166B, 173A, 173B and 173C.
These are further amendments concerning the role of the Secretary of State and are intended to ensure that the Secretary of State has a practical and effective influence over Monitor’s overall approach to the work it does. The Secretary of State would exercise that influence by issuing statutory guidance to Monitor that will have to be published and laid before Parliament. The guidance in each case could be revised but the revised guidance would also have to be published and laid before Parliament.
The heart of the scheme is Amendment 166B. The duty referred to in that amendment under Clause 61(9) is the duty on Monitor to exercise its functions consistently with the Secretary of State’s duty to promote a comprehensive health service. The amendment allows the Secretary of State to publish guidance to Monitor on the objectives specified in his mandate to the board and to set out guidance on how those objectives are relevant to the separate work carried out by Monitor. Monitor is, of course, required to have regard to such guidance.
Amendments 173A to 173C empower the Secretary of State to give guidance to Monitor in line with any guidance that he has published under new Section 13E of the 2006 Act. That is the so-called outcomes document issued by the Secretary of State to the board in connection with securing continuing improvement in the quality of services and outcomes achieved by the health service. These amendments make it incumbent on Monitor to have regard to that guidance, which must also be published and laid before Parliament. Amendment 163C concerns reporting by Monitor so that in its annual report Monitor would be required to state what it did to comply with the guidance, envisaged by these amendments, given by the Secretary of State in relation to the exercise of its functions.
These are modest but important amendments. They seek to weave into the fabric of the Bill a clear role for the Secretary of State to give strategic guidance to Monitor in line with the Secretary of State’s overarching duties, in particular with the objectives set out by the Secretary of State in his annual mandate to the board, and in line with the outcomes document that he publishes that is designed to ensure the board’s performance of its duty to secure improvement in the quality of services.
These amendments are part of creating a coherent and consistent framework within the new structures established by the Bill, to ensure a single and purposive approach by all the bodies within the NHS, with the Secretary of State remaining in charge of setting the strategic objectives for the service. In those circumstances I suggest that they are very welcome.
Baroness Meacher
My Lords, I rise with some trepidation, not having been involved in Committee on this Bill but having been upstairs in Grand Committee on another Bill. I therefore have not done the learning that I know noble Lords around the House have done during that process.
Many noble Lords have referred to the term “competition” without distinguishing between competition within the NHS between public sector organisations and competition between public sector and private sector organisations. It is perhaps relevant for me to quote recent research by Zack Cooper and colleagues at the London School of Economics. It came out in February, since Committee, which is my justification for introducing research at this late stage of the Bill. That research looked at competition between public service NHS organisations on the one hand, starting in 2006, and between the different forms of organisation, the private and the public, on the other hand, starting in 2008.
This considerable research looked at 1.8 million patients, 161 public sector hospitals and 162 private sector hospitals and should be taken seriously. It showed that the result of public sector competition was a reduction in lengths of stay both pre-surgery and post-surgery. Those results were significant. As the Minister knows, I support strongly competition in the public sector. I really believe that human beings thrive on competition. Therefore, if the research showed that public and private sector competition worked, I would support it because I believe in the best possible service for patients.
This research also shows that when you look at the competition between the private and public sector organisations, you will find an increase in the length of stay in the public services, albeit that there perhaps is a marginal improvement financially. If you look at the whole policing and monitoring apparatus that you need in far greater proportions once you have all this competition, I am not sure that you would even achieve a financial benefit. However, you find a reduction in quality, most particularly for people with long-term conditions. That is why I needed to speak in this debate.
I hope that whatever happens on these amendments, great care will be taken to protect public service provision. If we do not prevent the cherry picking, which happened in the provisions studied by this research and has occurred in other settings examined by research, without any question we will achieve a two-tier service with the private sector cherry picking the easier and healthier patients and the public sector having the complex care. I know that this issue will have been rehearsed at length in Committee. I do not want to go on further but it is important that we do not just use the word “competition” without clearly differentiating the competition that we are talking about.
Lord Ribeiro
For clarification, perhaps the noble Baroness would say whether we are dealing with apples and pears here. She made reference to the private sector and chronic care whereas she said specifically that the earlier 2006 report related to surgery. My understanding is that quite a lot of the competitive work done in the NHS involved ISTCs. These contracts were held by private practitioners and private companies. I have not read this report but we need clarification as to whether we are dealing with a level playing field of NHS provision or whether this is NHS provision against private provision.
Baroness Meacher
I am grateful to the noble Lord for his intervention. I was trying to conflate a number of points. The research that came out in February has to do with surgery but the point is that those findings support earlier studies which looked at a mixed public-private market by Allen and Gertler in 1991 and Ellis and McGuire in 1986 and others. Their research also showed that if you have private and public services competing with each other, you will see the cherry picking and the detriment to the long-term conditions to which I have referred. I am sorry that I slightly skipped a few things and compounded them into one. The findings are absolutely consistent whether they are concerned with surgery or other settings.
Baroness Meacher
Lower prices may be determined for simpler procedures, but this matter is far more complicated than that. If a lot of the simpler procedures are creamed off, the public sector institution may not be viable, which the research again shows. It is not straightforward. People concerned with long-term and complex conditions fear that over time such a differential organisational and pricing structure could lead to a two-tier system.
Earl Howe
My Lords, it is a concern that I understand. The destabilisation of the NHS will naturally be a concern to all commissioners, which is why they can protect that situation through the contract. They could insist through the contract that a provider provided the full range of services rather than a select few. I simply say to the noble Baroness that we are alive to that concern and I have no doubt that commissioners will be as time goes on.
On the amendment tabled by the noble Lord, Lord Warner, he will be disappointed to hear that I am not drawn to going any further than the Bill does, much as I understand that his idea is well-intentioned. I say that because of Monitor’s overarching duty to protect patients’ interests and prevent anti-competitive behaviour that would harm those interests. This amended duty reflects what the Future Forum recommended and it is right that we stick with that. I can, however, offer the noble Lord, Lord Warner, some reassurance. First, in carrying out its duty to address anti-competitive behaviour, Monitor will necessarily have to identify it. Secondly, Monitor would have the power under Chapter 2 of Part 3 to conduct market studies and to refer potential barriers to new entrants for further investigation by the competition authorities where necessary. I hope that that is of some comfort also to the noble Lord, Lord Adebowale.
We had a most constructive debate in Committee about the Secretary of State’s accountability for securing a comprehensive health service in England and his role in holding Monitor to account for its duties. I thank my noble friend Lady Williams for proposing an amendment which adds much to the Bill in this area. Clause 61 already requires Monitor to carry out its functions in a manner consistent with the Secretary of State’s performance of his duty to promote a comprehensive health service. My noble friend’s amendment would strengthen these provisions and thereby improve the Bill on a key issue. This would help to ensure that the Secretary of State can discharge effectively his responsibility for the health service in England and that Monitor carries out its functions to that end. I support my noble friend’s amendment.
Clause 64 specifies the range of matters that Monitor would be obliged to have regard to in carrying out its duties. In Committee, the noble Baroness, Lady Murphy, and my noble friend Lady Williams raised some concerns about that list. I agreed to reflect on these concerns and have tabled Amendments 168 to 171, which would rationalise the list and make it clear that maintaining patient safety would be the paramount consideration. I hope that the noble Baroness and my noble friend will be content with that rationalisation.
On the amendment tabled by noble friend Lady Cumberlege, the Bill ensures that patient and public involvement is embedded at every level of the healthcare system. However, unlike the NHS Commissioning Board and clinical commissioning groups, Monitor would not be responsible for securing NHS services to meet patients’ needs. It is a regulator, with economic and more technical functions. Clause 61 reflects this and gives Monitor the responsibility for determining arrangements for patient and public involvement as appropriate to its functions. So I am afraid that I do not regard my noble friend’s amendment as appropriate. She asked what could be done if Monitor did not involve patients in the right way. Well, the Secretary of State would hold Monitor to account as to how it discharged its functions. Monitor would have to report to the Secretary of State on how it was discharging its duty on patient and public involvement as part of its annual report. The Secretary of State could also request a specific report on how Monitor discharged this function and intervene where there had been a significant failure in meeting this duty. The Bill provides for HealthWatch to send advice to Monitor as it seems appropriate. Monitor would then be required to respond to this advice in writing. I hope that my noble friend will take comfort from those points.
I stress once again that the purpose of Part 3 is to strengthen sector regulation in healthcare to protect and promote patients’ interests. The current system is inadequate, fragmented and duplicative. It fails to protect the interests of all patients. Part 3 recognises that the NHS is not and never has been a single institution. The reality of the NHS is a comprehensive health service that has always been delivered by a diverse range of providers.
Part 3 would address gaps in the current system by extending equivalent safeguards to protect patients’ interests irrespective of who provides their NHS services. It would also make sector regulation in the NHS more effective in driving improvements and enabling integration during an absolutely crucial period of economic challenge.
I am very happy to support the amendments of my noble friend Lady Williams, which would improve the Bill, but I urge, following the reassurances and explanation that I have been able to give, other noble Lords not to press their amendments.
Health and Social Care Bill
Baroness Meacher Excerpts(14 years, 1 month ago)
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Earl Howe
The noble Lord is right. The stance taken by a number of medical bodies and members of the medical profession is of course a matter of great regret to me and my ministerial colleagues. I say to them and to the noble Lord that once the Bill has been approved by Parliament, as I sincerely hope it will be, that will be the time to re-engage with the medial profession and work with it to ensure that the Bill delivers on the promise that we have held out for it and that we still believe in. The principles that the Bill embodies, which the medical profession has always said that it supports, can then be given substance in the form of the improvements that we would like to see delivered to patients. From all the comments that I have heard from doctors and others who are in doubt about the Bill, most of their concerns revolve around its implementation and what it will mean in practice, rather than the principles that it enshrines. We need to look forward collectively and work together to make the NHS work better.
Baroness Meacher
My Lords, I, too, applaud the noble Earl for the way that he handles this very difficult Bill in very difficult circumstances. I am sure he is aware that there is a lot of concern about the Bill in the field of mental health, particularly as private provision gathers pace. Can he give any assurance to mental health professionals and services up and down the country about what in the Bill might protect mental health services in the future?
Earl Howe
Several things in the Bill are new. One is the duty to reduce health inequalities, which is very important in mental health. Another is the duty to promote integration of services. Again, we have had many debates on that and there are mechanisms that we propose to use to support greater integration of services.
I also believe that the worries about competition are misplaced. Competition is a tool that commissioners can use, or decide not to use, in the interests of patients. It is no more than that. The Bill does not change competition law or increase the scope for competition to be used in the NHS. It leaves the decision-making to commissioners on whether competition does or does not serve the interests of patients. There is a lot of misapprehension about what the Bill does, not just among those in the mental health world but more widely. I hope that that reassurance is helpful.
Health and Social Care Bill
Baroness Meacher Excerpts(14 years, 1 month ago)
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Lord Newton of Braintree
I have two excuses for speaking. First, I have chaired two mental health trusts and, although I no longer do so, I have a continuing interest of a non-financial kind. Secondly, before my noble and learned friend Lord Mackay left for what was described as his well earned rest and recuperation, I was the nearest thing to anybody he anointed to take care of his interests while he was away, which includes this amendment.
I do not need to speak for long because I think that this is a no-brainer. Everybody agrees on the importance of mental health and endorsed the Government’s No Health Without Mental Health strategy. We are all keen on that—even the Government. Yet the little birds tell me that the amendment will be resisted on the grounds that it is not necessary and does nothing to add to the 2006 Act. I spent a lot of years as Leader of the House of Commons and I got fed up with Ministers who came to me on Private Member’s Bills and other things and said, “It’s not necessary—we are going to do this anyway”. They then proceeded to immolate themselves on a bonfire for an amendment that would have cost nothing and done no harm—it certainly would not have added anything—but would have pleased a lot of people. That is idiotic. It would not cost the Government anything to do this and, as my noble friend said, it would please a lot of people, so we should simply get on with it. If my noble friend has been told to resist it I will sympathise with him, but frankly if the noble Lord, Lord Patel, feels that he should push it, I will push it with him.
Baroness Meacher
My Lords, I support this amendment very strongly and shall speak extremely briefly. Others have spoken most eloquently and very much made the case. My fear, too, is that the Minister will regard it as unnecessary. I have absolutely no doubt at all about the Minister’s commitment to mental health, but I believe that this is necessary because of the context in which the amendment is being posed—in other words, the Bill itself. What I mean is that the Bill is designed more than anything else to introduce privatisation of the NHS—slowly, slowly. It will not be done overnight, but in 10 years’ time we can be sure that a substantial proportion of our NHS will in fact be in private hands. If we look across the world to the US, Germany and other countries, we find that privatised health services do not support mental health to the degree that we in the NHS have supported it in the past. That is the most fundamental argument in my view. We have to protect our mental health services, albeit that they have been a Cinderella relative to the acute sector, but not to the degree that mental health services are Cinderellas in other countries where private health dominates.
That is my most important point. The only other part of the context is that the Bill will do nothing to make the changes that we need in the NHS, such as closures of redundant acute hospitals and redundant acute departments. I hope that this Government, unlike many previous Governments of whatever hue, will take the leadership role and show that they support mental health. I appeal to the Minister not to say that this is unnecessary. I appeal to him to agree that it is necessary and to give and show the Government’s commitment to equality of parity of mental health and physical health in this country.
Baroness Williams of Crosby
My Lords, my noble friend Lord Alderdice made the strong point that in the real world mental health is not regarded as being on all fours with physical health. For the reasons presented by my noble friend Lord Carlile and others, clearly in the real world mental health is often hidden. It is often an issue that people do not freely address and it is vital that we send a clear signal from this House that mental health is absolutely equivalent in significance and importance to physical health, and that we believe that.
I shall briefly say what has already been said. Will the Minister at the very least consider taking this debate back and looking at whether there could be an agreed amendment that would meet his difficulties? There may be drafting difficulties, but it would not in any way resile from the statement that this House believes that mental health is vital and we want it on the face of the Bill. I plead with him to consider doing that.
NHS: Transition Risk Register
Baroness Meacher Excerpts(14 years, 2 months ago)
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Baroness Meacher
I understand the Government’s reluctance to publish risk registers. Governments do not tend to be keen to publish documents that are going to be deeply embarrassing to them. However, will the Minister invite the Information Commissioner to identify key sections of the risk registers that really should be before the House of Lords before it undertakes its work on Report, and will the Government and the Minister comply with the Information Commissioner’s recommendations?
Earl Howe
My Lords, this issue turns on a disagreement between ourselves and the Information Commissioner about where the balance of public interest lies. Our view is that the balance of public interest does not lie in disclosure, and his view is the opposite. It would be likely, if we gave the Information Commissioner a second opportunity to look at this, that he would come to the same conclusion as before, so we have to let due process occur.
Health and Social Care Bill
Baroness Meacher Excerpts(14 years, 3 months ago)
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Lord Hunt of Kings Heath
If I were to say that I did not trust the Health Professions Council, that might be taken as rather pejorative, and I would not seek to do that. It has done a good job on the health professions it regulates. I simply do not feel that it is right for it to regulate social workers. I do not think that it is prepared for it. Its philosophy is not attuned to it. That is why, if the Government insist on going ahead, some protection needs to be given.
My final amendment relates to the name of the new HPC, the Health and Care Professions Council. I am puzzled why “social worker” is not in the title. Why was it felt that when bringing 100,000 people into this body, it was not thought worth putting “social worker” in the title. I do not think that Health and Care Professions Council can possibly describe a body that will regulate 100,000 social workers.
I hope that the Government will be prepared to consider the matter again. I know that they want to reduce the number of quangos and regulators, although, if the noble Baroness had been here for the Statement on the banking system, she would have discovered that all Governments start by having a bonfire of the quangos and then inevitably they start to grow again. We saw in the past few minutes a good example of the Government starting to grow some new regulators. In this case, I do not think that the issue of money comes into it—the cost of the balance sheet is taken off the public purse, because it will be funded by registering. Because I am satisfied that the General Social Care Council can fund this through fees which would be similar to those of the Health Professions Council, I hope that the Government will give this further consideration.
Baroness Meacher
My Lords, I support the opposition of the noble Lord, Lord Hunt, to Clauses 206 and 208 to 211 standing part of the Bill, and will also speak to Amendment 338B. The noble Lord, Lord Hunt, has elaborated these issues extremely comprehensively and powerfully. I want to avoid duplication and will therefore concentrate on a few specific concerns that, for me, are the most serious, although the matters raised by the noble Lord, Lord Hunt, are also important to me.
Social work carries onerous public protection responsibilities that, to my mind, differentiate it importantly from the other professions regulated by the Health Professions Council. One issue that highlights that problem is the registration of social work students referred to by the noble Lord, Lord Hunt. This and other key matters are left to regulation under Clause 208 without any clarification of what that will mean in practice.
It is important to bear in mind that social work students have direct and unsupervised contact with vulnerable people, including children, whose lives may be at risk. That is rather different from the contact that other professionals tend to have with individuals. Following an impact assessment, the GSCC, not surprisingly, concluded that compulsory student registration was necessary. At present, the GSCC makes grants to the universities providing social work training. Those grants are conditional on the registration of students. The result is that 95 per cent of students are in fact registered. I am not sure what happened to the other 5 per cent, but in essence it is a form of compulsory registration of students.
As a result, any serious complaint about the conduct of a social work student can be referred for investigation by the GSCC. Although the number of serious complaints is small, it is larger than that of complaints about other professions. It is very important that these individuals are picked up early before they can do any severe damage to young children, or indeed other children. If a student is found guilty of misconduct and dismissed from their course, they cannot simply go across to the other side of London or to Newcastle and register on a different course, as this will be picked up by the GSCC. However, that will be lost in the new system. This system of student registration seems to be an important safeguard in public protection.
As I understand it, the HPC is consulting on whether the registration of students should be purely voluntary, as it is in the other health professions regulated by the HPC and as mentioned by the noble Lord, Lord Hunt. The concern is that the consultation includes all the health professions, which of course will say that registration does not need to be compulsory, and indeed it does not for these other professions. Any social work professional will recognise the importance of the compulsory registration of students, but of course they will be outnumbered by all the other professions. As a result, social work registration is likely—in fact, almost certain—to become voluntary. I understand that Paul Burstow, the Minister in the other place, has some concerns about this. Can the Minister tell the Committee what progress has been made to ensure that social work registration remains, de facto, compulsory under the student arrangements?
It is worth flagging up that Northern Ireland, Wales and Scotland will continue to have compulsory registration of social work students, and England will be out of line if this provision goes ahead. As a result, inappropriate students—potentially dangerous social workers—will come across the border into this country and practise. Do we really want that to happen?
Another issue is the assessed and supported year in employment—the ASYE. This is not yet in place but has been recommended by the Social Work Reform Board and is supported by the GSCC. I understand that senior social work professionals do not expect the HPC to introduce the assessed and supported year for newly qualified social workers because they want a common system for all professionals, as alluded to by the noble Lord, Lord Hunt. This provision is not necessary for professionals without a public and child protection responsibility.
Again, there is a problem here because of the differences between social work on the one hand and all the other professions on the other. As someone who practised social work—albeit briefly and many years ago—I fully appreciate the importance of a year immediately following qualification when social workers carry a lighter case load and receive support with more hands-on supervision to enable them to consolidate their knowledge. You could say that this was all a bit heavy-handed if it were not for the public and child protection duties of these workers. However, it really is important that those people know what they are doing and that they do not miss high-risk cases.
The GSCC wants the assessed and supported year to be a registration requirement in the future. Northern Ireland has this system. Of course, this would need to be tied in with some control over the number of social work trainees, but in my view it is a very important matter. What are the Minister’s plans in this regard?
My third area of concern is the standard of social work training. Those at the head of the GSCC would agree that we need more, rather than less, rigorous regulation of social work training. Social work standards set by the Department of Health have already fallen over a period; certainly they are quite unrecognisable to me. I think all of us who are aware of the Baby P report would agree with that assertion. We can expect these standards to fall further under the HPC because, as the noble Lord, Lord Hunt, mentioned, the HPC has basic standards across all professions at roughly NVQ level 3—not a degree level and not, in my view, a sufficiently high level—and just a few generic standards for each profession. It is not looking for intellectual rigour and does not have practice standards. Its focus is on outputs, which we all recognise and think are a thoroughly good thing. However, we all know that outputs based on book learning without any fieldwork requirements will miss absolutely essential elements of effective social work professional practice. The Social Work Reform Board is setting higher standards but these will not be regulated. Only the most basic standards set by the HPC will have that regulatory framework.
The Government are, I believe, leaving it to the yet-to-exist College of Social Work to promote excellence in social work. The BASW is challenging the establishment of the college, I understand. Will it exist and, if it does, will it be delayed? If so, for how long? I gather that even when it does exist, the college will be toothless—it will have no powers to regulate training at all. It may set standards of excellence but it will have no powers to ensure that those standards are met. Does the Minister agree that social work standards need to rise, not fall? If so, will she agree to take away these concerns and consider how best to ensure meaningful progress on the issue? That is vital to the protection of children and to avoid more Baby P scandals, with huge embarrassment to the Government. I trust that the Minister will take this seriously.
Finally, I ask the Minister what will become of the GSCC code of practice for social care workers, which is another group altogether. It is important that this code of practice is retained as an element in the standards framework for social care. This is all about standards and the quality of provision. Will this code of practice be hosted by Skills for Care in the interim before any registration of these workers, or will it be lost? I reinforce the point made by the noble Lord, Lord Hunt, about the spurious financial justification for the abolition of the GSCC. I, too, understand that, financially, keeping the GSCC would stand up perfectly well—it could be self-funding on a similar basis to the HPC. I hope that the Minister will be able to explain this.
Very real risks arise from this planned merger. England will move out of line with its neighbouring countries, and we will reduce standards and safeguards in a profession at the front line of child protection. Is it really too late to rethink this high-risk plan?
Baroness Pitkeathley
My Lords, I have interests to declare other than being chair of the Council for Healthcare Regulatory Excellence in that I chaired the advisory body that led to the setting up of the General Social Care Council, and I was its first chair.
It is not for me to question the Government’s decision on these matters, but I draw your Lordships’ attention to the fact that neither the decision nor its implementation have been easy for those involved. I pay the warmest possible tribute to colleagues at the General Social Care Council and the HPC for the way in which they have dealt with this difficult situation. In particular, I acknowledge the role of the oversight group, which is chaired by Harry Cayton, the chief executive of the CHRE, and consists of colleagues from both organisations and other interested parties. However difficult those discussions may have been at times, the professionalism and commitment of those involved to the safety and interests of the end users of social workers’ work have been exemplary, as has been the commitment to ensuring that there should be as little disruption as possible to their functions during any transition period. Thanks to that professionalism, these reforms will allow for the greater integration of health and social care regulation through the renamed Health and Care Professions Council. Regulation by the HCPC—I shall have to get used to the new initials—will extend regulation to the competence of social workers, as well as to their conduct, and thus improve public protection.
I have some concerns about the proposals for the governance of the HCPC, as they do not reflect the general direction of travel in recent reforms across professional regulation. These have emphasised and focused the regulator’s governance and operations on the primary duty of public protection, not of professional representation. Historically, allowing reserved places for particular professionals in councils and committee structures was thought to be damaging to public confidence in regulators and in their decisions about standards and fitness to practise. These proposals might therefore represent a step backwards and not demonstrate good governance principles for professional regulation.
The HPC has a strong track record in taking on new registers, and has established quality assurance mechanisms to facilitate appropriate input from professional expertise, where appropriate. I hope that we shall be able to see that this is an important development, and one that protects all those professions, as well as, most importantly, the public, in the integration of social care and health in the way that we have been calling for in so many debates during the course of this Bill.
Baroness Northover
As the noble Lord will be aware, the figures provided by the General Social Care Council indicated that the costs would rise from £21 million to £25 million per annum, which would indeed cost about £250 per social worker. I realise that the council later revised this downwards, but the noble Lord knows as well as I do that those were the original figures based upon what the council estimated at the time. Even with the revision downwards, it was still not in line with the HPC, as I am sure the noble Lord is well aware.
However, it is extremely important to make sure that the arrangements that are in place regulate the social work profession properly and separate out the professionalisation of social work. The noble Lord will remember that he asked a question on this, and I drew the distinction for the medical profession with which the noble Lord, Lord Walton, will be familiar; the GMC regulates the medical profession, and the royal colleges do a fantastic job in promoting the profession and taking it further. The original arrangements that the noble Lord introduced were an earlier stage for social work, and the task now is to take it to the next level of development.
Regulation by the Health and Care Professions Council will bring social work regulation in England within the scope of the professional standards authority, with the added scrutiny that that will bring. It is our view that it would be wrong to require the Health Professions Council to move away from its tried and tested system of regulation solely for the social work profession.
Baroness Meacher
May I ask the Minister whether she agrees that the standards set by the HPC are just lower than standards that social workers are used to and require to do the job properly?
Baroness Northover
I am not sure that I would agree with that. If the noble Baroness bears in mind that the HPC will regulate the profession and that other means will be used to drive further forward the training standards and the education of the profession in conjunction with the regulator, it may very well be that those two things have become conflated and it is important that they are separated out.
Baroness Meacher
Would the Minister be willing to write to me to explain how these things will work? As I understand it, some standards might be set elsewhere but the standards that will be regulated will be those of the HPC, which will be very low. The HPC is the one with the regulatory powers and therefore it will not regulate the higher standards that might be set, for example, as good examples by the college. It would be helpful if we could have an explanation of how that will work in practice.
Baroness Northover
I am more than happy to write to the noble Baroness. In the discussions that I have had with various organisations, including the HPC, that is not the conclusion that I come away with. I hope that she is reassured.
Baroness Meacher
I wonder whether the Minister would consider that there should be a compulsory requirement. If the HPC is registering these courses, could it not be made compulsory that the course must register the students?
Baroness Northover
As I just said, the HPC is currently consulting. I strongly suggest that the noble Baroness feeds into the consultation her recommendations and the evidence on which they are based so that they can be properly considered.
The question was raised of how social workers might be linked to the wider reform programme. The Health Professions Council is represented on the reform board and will be able to contribute its expertise to the ongoing reform of social work. Moira Gibb, chair of the reform board, is also a member of the Social Work Regulation Oversight Group. Her professional expertise and knowledge is contributing to the transfer process. Many organisations on the HPC’s professional liaison group, which has developed draft standards of proficiency for social workers in England, are also on the Social Work Reform Board, which has ensured that the development of standards has been informed by wider developments in social work in England.
I hope that noble Lords will see that a lot of attention is being focused on trying to ensure that the change will operate as effectively as possible and will be in the interests of those with whom social workers work. It is exceptionally important that we protect the vulnerable people whom social workers look after, and we are acutely aware of that. On the basis of what I have said, I hope that noble Lords will not press the amendments in this group.
Health and Social Care Bill
Baroness Meacher Excerpts(14 years, 3 months ago)
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Baroness Meacher
My Lords, I rise to speak in support of Amendment 260EA which, as I understand it, seeks to maintain the essentials of the role of Monitor as set out in the 2006 Act. I support the extending of Monitor’s roles beyond those of foundation trusts. However, in response to the argument of the noble Earl, Lord Howe, that we need to change the functions of Monitor in order to achieve cost-effectiveness, improvements in quality and productivity in the years ahead, I would argue that with Monitor as it stands, together with the National Institute for Health and Clinical Excellence and the CQC—a great improvement on its predecessor—we have all the tools we need in the kitbag in order to improve our productivity, quality and cost-effectiveness.
I want to focus on one issue which I believe to be the greatest threat presented by these reforms to the improved quality and cost-effectiveness of the health service. There are two powerful reasons for avoiding the reorganisation of Monitor. The first is that if it ain’t broke don’t fix it. Monitor has been, in my experience, an extremely successful organisation, with one exception to which I will return. The second is that the main new ingredient is, indeed, the promotion of competition that has been addressed so effectively by other noble Lords. Although this will not be based on price, I have absolutely no doubt that it will drive financially driven decision-making.
I want to touch on these two points. Monitor is not broke, as it were. Having been on the receiving end of Monitor’s demanding regime for accreditation as a foundation trust service, I can vouch for the fact that Monitor has been the engine behind the transformation of inefficient organisations, run by boards with weak non-executive directors—who therefore offered very little professional challenge to the executive directors—weak financial systems and weak financial management. That is what we had, and that is what other trusts have had, prior to undergoing the rigorous process driven by Monitor to become foundation trusts. In my case, as chairman, I had no alternative but to get rid of my chief executive officer—no easy task but somehow this process enabled that to happen—and, indeed, to get rid of my non-executive directors. It was as simple as that. The same process continues to take place all over the country. I know this because others tell me. My belief is that we owe to Monitor, more than any other organisation with the possible exception of NICE, the fact that the NHS is now one of the most cost-effective health systems in the world, as the noble Lord, Lord Owen, has said very clearly. We should be proud of that.
At this stage I ought to mention Mid-Staffs, because this is, indeed, the one failure to which people refer. As I understand it, the problem was that Monitor at that stage had no information about quality, and the Healthcare Commission, which at that stage was responsible for quality inspection, did not pass data to Monitor. All those problems have been resolved, and they needed to be, because without the quality information, Monitor was ill-equipped to do the job it had to do.
I come now to my second point, which is about the promotion of money-based competition. I want to emphasise “money-based”, because I support competition, but it must be based on the quality of services to patients. The promotion of money-based competition and private sector provision of health services will be a detrimental and costly experiment. We have only to look to other countries, as the noble Lord, Lord Owen, has said, to realise that this is nothing short of a disastrous route forward. I refer to page 19 of the Department of Health’s document Protecting and Promoting Patients’ Interests: The Role of Sector Regulation. It states:
“Regulation and competition will always play an important role”.
I know that the word “competition” here means money-based competition: not price-based, but financially based or commercially based. It goes on to say that Monitor will,
“provide a fair playing field for all, regardless of ownership”.
I understand that the existing foundation trusts will remain as they are as long as they remain solvent. The document refers to patients wanting more choice. As we know, we can get any answer we want from surveys, as long as we ask the right questions. No patient would want more choice if they were aware of the costs and the appalling consequences of the dominance of the money motive in a commercial system. Patients want choice within the systems that we currently have.
I will not focus on the US, because we know that with health costs soaring towards 20 per cent of GDP and 30 million people excluded from remotely satisfactory health care, this cannot be a model to follow. However, Germany is held up as a good example of a health system which has worked with more competition in the system for a long time. I will start with an anecdote. A German orthopaedic surgeon we met on holiday a few years ago happily referred to the fact that he and his colleagues regularly undertake unnecessary operations if they are short of work. What was remarkable was that he seemed completely unembarrassed that this should be the case and that he should admit such a terrible thing to somebody who is used to working in a country with a national health service. It seemed completely normal; it clearly is.
I want to make available to your Lordships the more considered experience of one of the German consultants, Professor Priebe, who worked as a clinician in Germany for 17 years before emigrating—utterly disgusted with the German system—to the UK to work in the National Health Service. He gave me his comments and pleaded with me to make them available to the Government, because he is so alarmed at the thought that he escaped the German system to come over here only to be followed by something rather similar. I will try and draw on his comments as quickly as I reasonably can.
In Germany, the contractual agreement between commissioners and provider organisations define the funding arrangements. Clinical decisions are then strongly influenced by financial incentives. Computer-based algorithms have been developed to guide doctors on what diagnostic interventions and medical treatments patients should receive in order to maximise the income for the provider organisations. These algorithms consider the characteristics of the given patient as well as the characteristics of the broad category of patients with that particular diagnosis in order that the doctor achieves the,
“most profitable average treatment costs across a diagnostic group of patients”.
Is that really what we want in our country?
In Germany, evidence-based medicine and the interest of patients are much less important. In the UK in recent years, the emphasis has been more and more on evidence-based medicine; that is based, of course, on the professional work of NICE, which I have already referred to. If the drive towards competition threatens this ethos, Britain will lose something extremely precious. Competition not only reduce the flexibility needed to provide individualised effective care, but also requires ever-increasing documentation. Ministers often refer to the bureaucracy of the National Health Service, but if they had the experiences of the bureaucracies of other systems, they might be slightly less critical.
This documentation is supposed to ensure that clinicians can demonstrate that these income-generating interventions have indeed been provided. Commissioners mistrust the providers and require more controls and ever more documentation as well. This waste and inefficiency inevitably drives up costs.
Financial incentives and competition encourage commissioners to accept less costly patients. The providers are inclined to do the same. Here is another major fault in the system. As a result, patients with severe and chronic disorders become disadvantaged. It is no accident that mental health services are relatively well funded in this country, when compared to these competition-based systems, though I should emphasise that even in the UK, mental health remains the Cinderella of the health service.
Financial incentives also lead to the prescription of useless treatments—my anecdote makes the point—and the over-provision of services. Apparently, this is widely known across the German system. The providers then argue for the funding for all these unnecessary operations and superfluous services.
Competition and fragmentation of local service systems create the need for more referrals and associated paperwork and further increased costs. There are multitudes of downsides from these financially driven systems. Our consultant concludes that,
“most of these downsides of a more market orientated system appear to be intrinsically linked to the promotion of competition in health care and to having a system based on independently negotiated contracts rather than one controlled by agencies that are directly accountable to the public”.
In this country, we know from other sectors that markets do not work. The name Jarvis will mean something. Jarvis was, of course, the private maintenance company for the rail companies. Jarvis was found negligent following various rail disasters and, of course, Jarvis no longer exists.
Do we really want to generate these risks of negligence in the health sector? Surely not. I realise that at this point in time, the plan is not to go all the way down the rail route, but the direction of travel is extremely clear and I have no doubt that that is where we shall arrive unless there are safeguards within this Bill to prevent it. Some may point to the apparent savings achieved by fundholder GP practices. The evaluators apparently found, however, that GPs bumped up their prescription costs immediately before becoming fundholders by going to special drugs only to return to generic prescribing once they became GP fundholders.
NHS: Front-line and Specialised Services
Baroness Meacher Excerpts(15 years, 2 months ago)
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Baroness Meacher
My Lords, I, too, applaud the noble Lord, Lord Turnberg, for initiating this debate. I am sorry that I was not aware of it until rather late in the day, hence my having been slotted into the gap. I must apologise to the House for that. I want to raise two questions which have perhaps received less attention than others. Before doing so, however, I want to set out two examples of the direct implications for services of organisational change. The first concerns the major rationalisation of the acute sector, particularly in London, which was inherited by this Government. The aim of that rationalisation was to reduce the considerable excess supply of hospital beds, particularly in London, in order to make the absolutely essential savings to enable the NHS to balance its books and to improve radically its productivity. These major changes have been put on hold awaiting the completion of the development of the GP consortia arrangements. The failure to make those rationally-argued changes in a timely manner will have direct implications for the funding of front-line services.
My second example is local. I am not in any way suggesting criticism of the organisation or individuals concerned, but the commissioning changes are already inevitably distracting managers from their day-to-day essential decisions, again with severe adverse consequences. A particular trust with which I am associated, and I declare an interest, has to cut its budget by 4 per cent each year for three years—by £10 million a year. To achieve that, two very significant rationalisations were evaluated and planned, but the PCT’s approval is essential before we can go ahead. If those vital savings are delayed—and they are being delayed, as we will not have the PCT decision in time—then we will have to turn away from those well planned changes. The risk is that we will have to make quick cuts on front-line services. Those are my concerns about organisational change and its direct impact on front-line services.
I have two questions. The first concerns the planned removal of the power of the National Institute for Health and Clinical Excellence to determine whether a specific—
Baroness Meacher
Two minutes? I am sorry; nobody warned me about the two minutes. I will very quickly raise the questions. The first is about the power to determine whether a specific drug or treatment may be given under the NHS—I am now completely thrown, but there is a concern about the loss of that power of NICE. The second question concerns the role of Monitor as the regulator and the removal of its compliance framework under the new proposals, as I understand them. It is an excellent provision under the old system, which we are going to lose. I have concerns about that and look forward to the Minister’s response.
Health: Addiction to Prescribed Drugs
Baroness Meacher Excerpts(15 years, 5 months ago)
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Baroness Meacher
My Lords, I thank the noble Earl, Lord Sandwich, for creating the opportunity to raise important issues relating to the over prescribing of benzodiazepines and other prescribed drugs. The noble Earl referred to the huge numbers of patients who remain addicted to these hypnotic drugs for decades, and set out graphically the side-effects and symptoms of withdrawal. It will not surprise some noble Lords, least of all the Minister, that for me this debate raises the possibility that regulating rather than criminalising medical marijuana use might help to reduce the pressure on GPs to prescribe benzodiazepines. Has the Government’s review of dependence on and withdrawal from benzodiazepines considered this possibility? If not, will the Minister extend the review to assess the possible benefits and savings from a medical marijuana use policy in terms of the reduced use of costly and dangerous prescribed drugs?
We know that benzodiazepines prescribed for anxiety can, over time, exacerbate anxiety rather than alleviate it. We also know that elderly people on benzodiazepines are more likely to suffer falls and broken hips than other elderly people. Would cannabis be a safer option for people in constant pain or other discomfort who have difficulty sleeping? No GP should recommend cannabis for people with anxiety—I wish to be quite clear about that. They should be recommended for cognitive behavioural therapy, a well-tried and highly successful treatment.
International research, however, shows the considerable medical benefits of cannabis for a wide range of ailments and I shall mention a few. I could go on and on about this but I will not, your Lordships will be glad to hear. Benzodiazepines have no such benefits. Patients with respiratory complaints, for example, who are prescribed cannabis in other countries to help them sleep, and who use a vaporiser for the smokeless delivery of cannabis, show meaningful improvements in respiratory function; not only do they sleep better but they recover, at least to some degree, from their respiratory disease. Cannabinoids, a key ingredient of cannabis, which would be enhanced in a regulated system of MMU, can grow new brain cells, researchers tell us, fight brain cancer, aid mental health and reduce inflammation. Again these matters need elaboration but there is no time tonight.
So what is the international experience of medical marijuana use? In at least 14 US states and Washington DC, covering more than 20 per cent of the population, the law stipulates that individuals who receive a recommendation from a medical doctor for marijuana use for medical purposes are allowed, in most cases to grow, and in all cases to possess and use, limited amounts of the drug. The law also protects caregivers who are involved in those activities.
In Canada, the medical marijuana access programme was established after a ruling by the Ontario Superior Court concluded that the blanket prohibition of cannabis use violated constitutional rights for individuals who could derive medical benefits from marijuana use. In 2003, another ruling of a higher court required the Government to establish a government-sponsored supply of marijuana for medical use. This is crucial. It has been estimated that 40 per cent of patients in these other countries prescribed marijuana suffer from serious illnesses such as cancer, AIDS, glaucoma, epilepsy and multiple sclerosis. The remainder have ailments such as anxiety, sleeplessness, ADHD and assorted pains. How many of such patients in this country, where cannabis is illegal even for medical use, are prescribed benzodiazepines or equally dangerous prescribed drugs? Will the Minister include an exploration of this issue within the review?
The Minister may think that such a step would run counter to the UN conventions and the United Nations Office on Drugs and Crime. I can reassure the Minister that every step away from the criminalising of drug use towards a health-based approach is in line with UNODC policy. That august body, which is responsible for the UN drugs conventions, issued a ground-breaking discussion paper in March arguing for the first time that UN conventions need to be reinterpreted, leaving behind the criminalising policies in relation to drug use of the past 50 years. The new executive director of the UNODC, none other than a Russian, Mr Fedotov, in his first statement on taking office, reaffirmed the commitment of his organisation to promoting a health-based focus on drug use policy across the world.
Many patients are suffering unnecessarily because of the misguided drug use policies of the past 50 years in this country. The coalition Government are looking for significant opportunities for public sector cost savings which deliver improvements in public experience. The drugs policy is probably the most fruitful candidate for making a major contribution to public sector savings in a constructive way which will benefit our communities. The introduction of a medical marijuana use policy would be a valuable start. I hope the Minister will agree.