Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 2 months ago)
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Baroness Whitaker
My Lords, in supporting this group of amendments to which I have put my name, perhaps I may first say how grateful I am to the Minister for his letter of 29 November in response to the Committee debate. He confirmed in that letter that speech language and communication needs are included in the remit of public health. This group of amendments simply makes that clear for the Secretary of State and for commissioning groups. I suggest that it would not otherwise be clear. Look at what has happened: 70 per cent of British Sign Language users admitted to A&E units will have no interpreter provided. Increasing numbers of people with hearing loss have problems even with making appointments and understanding the diagnosis of their GP.
Since Committee, as the noble Lord, Lord Ramsbotham, would have said and as the noble Baroness, Lady Hollins, said, the report of the communication champion, Ms Jean Gross, has been published with further evidence of cuts by 10 local authorities to speech therapy services of more than 15 per cent. The Royal College of Speech And Language Therapists reports that 70 of 109 such services jointly funded by the National Health Service and the education authorities had lost the NHS element. More than half of newly qualified speech therapists have not found jobs. This crisis in the provision of speech and communication therapy means that for a significant proportion of children with these conditions—I remind the House that it is the most common disability of childhood, which substantially limits the chances of reaching their potential at work and even in relationships—this problem will be neglected without the kind of emphasis that these amendments provide. It needs to be clear that the health duties will include communication needs.
Baroness Thornton
My Lords, briefly, we support these amendments and commend the noble Lord, Lord Ramsbotham, and my noble friend for tabling them again because they are indeed important. I got quite excited when I saw the original spelling which was out there because I was thinking, “Is this about TB or HIV? This is a new one on me”. Nevertheless, this is a very important group of amendments because, as the noble Lord, Lord Ramsbotham, and other Members of the House have pointed out over many years, if you do not deal with the communication, speech and language problems of children at an early stage, you are storing up problems for the future. Indeed, Jean Gross’s report on front-line speech therapy for children is a cause for great concern, because it is quite clear that significant gaps are already appearing because of the cuts that have been made to provision.
I point out to the House that the allied health professionals have expressed their very grave concern about these issues by saying that they would like the Bill not to proceed. They are among the many thousands of health workers who, in this case, have been saying that for some extremely good reasons. Perhaps the noble Baroness would like to explain to the House what she is doing to persuade the allied health professionals and the speech and language therapists why the Bill will help them do their job any better, when it is quite clear that the services to children with speech and language therapies are already suffering.
Baroness Northover
My Lords, we are very sympathetic to the points that the noble Baronesses, Lady Hollins, Lady Whitaker and Lady Thornton, have just made. The noble Baroness, Lady Hollins, is quite right about the importance of communication skills—or even “communization skills”; my dyslexic son latched on to that one. We are acutely aware that addressing these kinds of areas is critical to the reduction of inequalities.
The noble Baronesses, Lady Hollins and Lady Whitaker, were concerned to ensure that we had flagged up this area. My noble friend Lord Howe sent a letter to the noble Lord, Lord Ramsbotham, who has worked tirelessly in this area. I emphasise that the Healthy Child programme, from pregnancy to five years, is the overarching NHS framework for providing prevention and early intervention for children and their families, and consists of a programme of screening, immunisation and health and development reviews. It is led and delivered by health visitors. It provides regular opportunities after birth for the parents and the health visitor to review together a child’s development, health and well-being, including any concerns about speech and language skills. We are working to improve the coverage of the HCP by delivering the Government’s commitment to increasing the health visitor workforce by 4,200, full-time equivalent, by 2015.
As part of the HCP’s schedule, the review at two to two and a half years includes a focus on speech and language development and is a key opportunity for health visitors to identify any problem and to take appropriate steps to refer a child to speech and language therapy if required. Following the commitment in the July 2011 publication Supporting Families in the Foundation Years, the Department of Health and the Department for Education are working together to develop the two to two and a half year review to become an integrated review, covering both health and education. The Department of Health is also leading a piece of work to develop a population measure—
Baroness Thornton
How does the Minister reconcile what she has just been telling us about referring children to that service after review at two and a half years with the fact that 70 local authorities have lost their NHS funding, 25 have lost cash from the LEA and those speech and language therapists are actually not going to be there?
Baroness Hollins
My Lords, I shall speak also to Amendments 55 and 238. My noble friend Lord Rix sincerely regrets that he could not stay this evening as his wife is unwell.
The three amendments tabled by my noble friend to this Bill have been placed together in this one group. I welcome this opportunity to speak to them. Noble Lords will be aware that these issues were raised during the Committee stage of the Bill. My noble friend recently met the Minister to discuss the matters that I am about to raise in relation to people with a learning disability. It is appropriate for me to declare an interest as a psychiatrist specialising in learning disability and also because my son has a learning disability.
To be fair to the Government, it could be argued that the broader issues which these amendments attempt to resolve could have been addressed by the National Health Service many years ago. However, my noble friend and I are using the opportunity presented by this Bill in an attempt to tackle them now. The first amendment, Amendment 37, aims to ensure that health services for those with the most complex needs are commissioned by the NHS Commissioning Board. Concerns were expressed about this issue in Committee. We seek assurances that health services for those with the most complex needs, particularly people with profound and multiple learning disabilities and people with complex needs whose behaviour challenges services, will be commissioned centrally by the NHS board. This amendment would ensure that the NHS Commissioning Board has oversight in this area, including the co-ordination and commissioning of specialist services or facilities for this particular group of disabled people. Any assurances that the Minister may be in a position to provide on this matter would be welcome.
The second amendment tabled in the name of my noble friend, Amendment 55, concerns the importance of collecting data on the experience and outcomes encountered by all patients in the NHS. Where a patient has a disability, it would also ensure a breakdown of disability by impairment type. In Committee, the Minister informed the House that his department is working with the NHS information centre to explore the extent to which indicators in the NHS outcomes framework can be disaggregated to show impairment types, which we would both welcome. However, if the information is not collected at source, clearly there will be limits to which this can be achieved. The Minister also stated that the Government's NHS information strategy aims to cover this issue too, when it is published later this year. Any additional assurances that the Minister is willing to give about what steps the Government will take to ensure that data are collected at source would be welcome.
The third and final amendment, Amendment 238, concerns the provision of independent advocacy services for people who are in the process of making a complaint against the NHS. For those who are unfortunate enough to encounter it, the NHS complaints system is flawed and ineffective. We welcome the Government's proposal for local authorities to make appropriate provision to support people in the complaints process through the use of advocacy services. However, there is a risk that advocacy support could be started and then halted some time before any conclusion to an ongoing complaint has been made. In Committee, the Minister emphasised that local authorities would have the discretion to provide independent advocacy services, consistent with their legal obligations, as they deem appropriate. My noble friend is particularly concerned that such discretion could leave many families without the on-going advocacy support that they need. Is the Minister able to provide my noble friend with any comforting words on that matter? I beg to move.
Baroness Thornton
My Lords, it is important that the Minister can give us some satisfaction in answer to the remarks made by the noble Baroness, Lady Hollins, particularly in view of the tireless pursuit of these issues by the noble Lord, Lord Rix. This small suite of amendments aims to start at the top as it talks about the Secretary of State’s power to require the board to commission services including for those with profound and multiple learning disabilities. It then puts a duty on the board to reduce inequalities, which will involve collecting data on the experiences and outcomes of patients with these disabilities. It also sets out that there should be no upper limit on the length and type of advocacy support that must be provided by local authorities. Therefore, it aims to provide a suite of amendments that address the whole system and the interventions that will be necessary to provide the right framework under the new regime for some of the most vulnerable people in our country.
It was interesting that, on a more general matter concerning children and the Bill, the NHS Confederation deputy policy director, Jo Webber, said recently that the Government's plan to recruit 4,200 extra health visitors by 2015 was leading to a loss of staff in other vital roles in some areas. For example, many established and successful children's health teams are being rearranged or in some cases disbanded simply to employ more health visitors. Ms Webber’s report claimed that the Government should replace the health visitor target with one that focused on the outcomes for children rather than on the numbers of staff in place. That was a very wise remark.
I turn to the children with the most complex difficulties and the question of how under this framework they will receive appropriate assessment and treatment that will address their individual needs. At best, there will be problems with the transition to the new system, and if there are gaps in the service for vulnerable children and learning-disabled patients who perhaps have GPs with limited experience, and doubts about how GP consortia will react to the situation, that is an issue of great concern. Historically, there has been an imbalance whereby people with learning disabilities have lost out when compared with those, for example, with mental health problems—who have also lost out. Therefore, how this group of children and young people are catered for will be a way of testing whether these things will work at all.
Earl Howe
My Lords, I am grateful to the noble Baroness, Lady Hollins, for her typically knowledgeable contribution to today's debate. I hope she will accept that the Government are committed to improving the health of people with learning disabilities, to help them both to live longer and to stay healthier for longer. The Bill aims to drive improvements in outcomes by establishing clinically led commissioning, by giving patients a stronger voice and by embedding quality improvement and a reduction in health inequalities at all levels of the system.
We debated these amendments in Committee and I have since exchanged correspondence with, and met, the noble Lord, Lord Rix. I understand and share his concern, and that of the noble Baroness, that there should be robust arrangements for commissioning services for people with profound and multiple learning disabilities, and for people with complex needs or challenging behaviour. I am afraid that it may disappoint the noble Baroness to hear that I still believe that the amendments are unnecessary. However, in saying that, I hope that I can reassure her about the reasons why.
On Amendment 37, the regulation-making powers in new Section 3B are already broad enough for the Secretary of State to require the board to commission these services. The current intention is that the regulations under subsection (1)(d) will be used to give the board responsibility for commissioning specialised services for rare and very rare conditions. The current specialised services national definitions set will form the basis for the services included in these regulations. These will include a number of services for people with profound and multiple learning disabilities, and people with complex needs or challenging behaviour. The services that are not considered specialised will be commissioned by CCGs, although in practice there will need to be close collaboration between the board and CCGs to ensure that patients receive a seamless service.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 2 months ago)
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Baroness Thornton
My Lords, I think the noble Earl has answered the question as far as it goes, but he raises several points. First, this Bill did not need to be in front of us at all because many of the changes that are taking place do not need primary legislation. Secondly, his colleagues in another place have constantly said that the Bill cannot be dropped because it has gone too far. We are not in the same place now as we were at the end of Committee; millions of people in the health service have now expressed their view that this Bill should not happen at all. Given that, do the Government have a plan B in case they need to withdraw the Bill? Do they have people working on that in case the Bill has to be dropped?
Lord Warner
My Lords, before the Minister responds to that question, will he consider later—if he cannot answer now—the budgets for clinical commissioning groups? I understand from a meeting of the national Commissioning Board, which was held in open session on 2 February, that Sir David Nicholson is reported as having said that clinical commissioning governance is, in effect, moving on apace, and that more than 95 per cent of clinical commissioning groups have now agreed their constituent practices and geographies and are already seeing benefits in their services from the work that they have been doing. At the high level, around 50 per cent of the commissioning spend is already delegated to clinical commissioning groups from PCTs under various delegation schemes. That seems fair enough, but there is a final point on which I would welcome the noble Earl’s clarification. It says that the ambition is for all this to be so delegated to clinical commissioning groups by 1 April 2012. Will that delegation still be part of the present powers, or is it in anticipation of the legislation being passed in time?
Lord Eden of Winton
My Lords, we have listened to many powerful and persuasive speeches. I am tempted to go all the way with those who have advocated the inclusion of this amendment in the Bill, but I take up the words of the noble Baroness, Lady Finlay, who referred to the need for a cultural change. I think all noble Lords would agree that there is the need for a cultural change. I only question whether it is right to try to achieve that change through legislation. Surely what we are seeking to do is to change attitudes and get people to understand that there is no difference between physical and mental illness. For that reason, I think we need to hesitate before including words in legislation. What we need to do is to make people throughout the health service and everyone associated with the administration aware of the fact that there is no difference between physical and mental illness, and that those with mental illness need to be treated on an absolutely level footing with those with physical illness.
Baroness Thornton
My Lords, we on these Benches liked this amendment the first time round and we have not changed our minds. It may be symbolic in its effect—in fact, we think it all the better for that. Legislation should be the expression of policy and this amendment flows from important policy commitments by successive Governments about the parity of policy-making at all levels of the system to consider mental health alongside physical health. We give our very full support to the mover of this amendment and we urge the Minister to accept it.
I have two other remarks to make. First, I always listen extremely carefully to the noble and learned Lord, Lord Mackay of Clashfern. Frankly, if he says it is good enough for this Bill, that is good enough for me. Secondly, I agree with the noble Lord, Lord Newton, that it is a no-brainer. To the noble Lords, Lord Ribeiro and Lord Alderdice, and the noble Baroness, Lady Williams, I say that we are on Report. This is not the time for probing amendments. This is the time for taking decisions about what we want in the Bill. The Minister had the opportunity to take this away and consider it after Committee, when the House was as united in its view about this matter as it is today. Today I urge the Minister to accept this amendment but, if he will not, the House needs to express its view about this matter if at all possible.
Baroness Thornton
“(2) The Secretary of State must for that purpose provide or secure the provision of services according to this Act.”
Baroness Thornton
My Lords, we originally put down Amendments 3 and 4 in Committee back in the autumn. It has to be said from the outset that this is actually still a very bad Bill. Since Committee, the context in which we are discussing this Bill has without doubt changed. It seems that it has no support from anywhere except in the Department of Health—and possibly not even from everybody there. It still has no mandate.
Going back on previous commitments to,
“no more top-down reorganisation of the NHS”,
the Prime Minister and his Health Ministers, including the noble Earl, have adopted what we on these Benches would like to term the “Attlee defence”, in deference to the noble Earl, Lord Attlee—and I mean the Government’s Earl Attlee, not ours, as it were. Last March, during a debate on the Building Regulations (Review) Bill, in trying to explain the Government’s position, the noble Earl came up with:
“I gently remind the Committee that I answer for Her Majesty's Government, not for the previous Opposition”.—[Official Report, 4/3/11; col. 1352.]
That is a remarkable statement. Perhaps the Minister could gently remind the Prime Minister and the Health Secretary of their coalition agreement.
It is significant that the Prime Minister has had to come to the Bill’s rescue today, not least because a Downing Street source yesterday was reported to threaten the very life of the Secretary of State—I think that the words used were “taken out and shot”—for his failure to communicate the Bill and the Bill’s policy. We in the Opposition have never advocated such a thing. Perhaps the Minister would like to comment on this particular version of the Secretary of State’s ultimate responsibility in his job.
The Prime Minister’s words were also revealing in that the Government intend to push this Bill through. I do not believe that that is a respectful way of referring to the remaining stages in your Lordships’ House. It begs a question that I should like to ask the Minister early in Report stage, which arises from what happened recently as regards the Welfare Reform Bill. Will he give the House notice now as to whether the Government intend to use the financial privilege mechanism to strike down any amendments that this House might agree during the remaining stages of this Bill?
I have searched in vain for a precedent of legislation that is so unwelcomed by those who have to deliver it, so incomprehensible to those on whom its consequences will be wreaked and so difficult to explain in simple terms. But even the Minister, who is acknowledged by the whole House to be an outstanding performer and someone who can normally enlighten us about most matters in clear, plain English, has had to resort on many occasions to seeking to justify points of this Bill in the managerial jargon of his boss, Mr Lansley, which is as dense as the Bill itself. If any noble Lords doubt that, I suggest that they need only to peruse the record of the Committee stage.
We do not work in a sealed bubble in this Chamber and I appreciate that the Government might prefer it if that were the case. But the public’s view of this Bill has shifted and hardened since we completed the Committee stage before Christmas. The views of those who have engaged with this Bill for more than a year have changed and we need to hear their voices throughout Report stage.
As we all know, the discussions around the role of the Secretary of State have been of great significance. What has emerged is that the reasons for changing the role have never been made clear. As has been pointed out, there is a continuity around the role of the Secretary of State which goes way back to the founding of the NHS. I will not rehearse all the arguments that we heard in Committee and at Second Reading, and which some of us have been rehearsing during the months between those stages and up to last week. The reality is and always has been that the legal duty on the Secretary of State is to provide services. Even securing the provision of services has been delegated to organisations which deliver that duty on behalf of the public. Public accountability is and always has been vital to maintaining public confidence in the NHS. Ultimate political accountability exists in the person of the Secretary of State.
In no way can the Secretary of State argue that any failure to provide necessary NHS services is not his or her responsibility. The argument that if there is an issue the Secretary of State must work through failure regimes, regulations and directions to others is not good enough. As the Health Select Committee and many noble Lords, including the noble Lord, Lord Mawhinney, said in Committee, it would not be believed anyway.
We will be moving to the alternative wording in the next debate. We on these Benches have supported the process that has led to that wording. However, I should like the Minister to explain—I would be very happy to hear that explanation when he responds to the next debate—the difference between these words and those that are before the House. I am giving the Minister notice that this remains a bit of a mystery.
As with so much else in this unloved Bill, we are left with the question: why? Why on earth did the original Bill propose a radical change to the role of the Secretary of State? The Minister in the Commons, Simon Burns, was ready to die in a ditch for the wording. It was a liberation ideology for him. Why, throughout the scrutiny in the Commons, was the line rigidly held by coalition Ministers and MPs, and why is the Secretary of State—I really do think the House needs to know the answer to this question, but again I am quite happy to wait—now briefing royal colleges saying, “Actually, the changes that noble Lords have agreed in their Chamber will make no difference to the Bill”?
Our amendment and the others that deal with the role of the Secretary of State are important and we have undoubtedly prised improvement out of, if not a reluctant noble Earl in this Chamber, certainly out of a reluctant Government. Many of these issues are proxy arguments about what kind of NHS we want. During the rest of the Report stage we will focus our energies on the many other things that need to be changed, particularly in Part 3. These are part of the argument about why we do not want a full market, why we do not want regulation along the lines of that for the utilities or for the banks, and why we need to protect and preserve the tradition, well established and well understood, of the role of the Secretary of State.
I will be withdrawing the amendment, as I promised the Minister I would, but I would like some answers to the questions that I have posed in these remarks. I beg to move.
Earl Howe
I am grateful to the noble Baroness, who is of course quite right.
I have been handed a note which says that when I said that there would be no legally enforceable duties on quality improvement, I should have clarified that that would have a follow-on. I should have said, “across the NHS system”.
The noble Baroness, Lady Thornton, referred to potential privilege responses from the Commons. My noble friend the Leader of the House made a Written Statement last Thursday about the financial privilege of the House of Commons in which he drew attention to a paper by the Clerk of the Parliaments, available in the Library. I think that questions about procedure may be best directed to my noble friend, but I shall do my best to assist. The Clerk of the Parliaments makes it clear in his paper that,
“until the Commons asserts its privilege, the Lords is fully entitled to debate and agree to amendments with privilege implications”.
That is what we should do. I would much regret it if the House thought that I was trying to restrict its role of revision. The Marshalled List sets out more than 100 amendments in my name, tabled in response to debate in Committee, and if the House agrees to those amendments I can assure noble Lords that the Government will encourage the other place to accept them.
The essence of the noble Baroness’s question is about privilege reasons for the Commons rejecting amendments proposed by this House, and on that I can say two things. First, any amendment with implications for public expenditure might involve privilege, but that is a matter for the Commons alone. Decisions on financial privilege are for the Speaker of the Commons on advice from the Clerks of that House. If the Commons reject a Lords amendment in which the Speaker has determined that privilege is engaged, the only reason that it can send this House is a privilege reason. There is no discretion.
Secondly, this debate is by its nature premature. I hope that our debate and dialogue will lead to this Bill being sent to the Commons in a form that that House will accept. Until we see how Report unfolds, it is too early to speculate on the reaction from the Commons. One cannot have a reply to a question until the question has been asked.
Baroness Thornton
My question was actually about the Government’s intentions. That was a very enlightening and helpful remark about privilege. The Speaker of the Commons will not presumably, by and large, take a view on privilege unless the Government ask him to. So my question was about the Government’s intention on this matter.
Earl Howe
I have taken advice on this, and I believe that what I am about to say will not mislead the House as I have been given this advice on authority. It is not for the Government to do anything; it is not within our power to do anything. The noble Lord, Lord Martin, who spoke last week on this matter, is par excellence an authority on this. A view is taken by the Clerks in another place on the amendments passed in this House as to whether privilege is engaged. The Speaker is then advised. The Government have no role in that process at all; it is a Commons privilege, not the Government’s privilege.
I hope that what I have said will persuade your Lordships that the course down which the Opposition would wish to take us is the wrong one. The Bill, once amended—if that is your Lordships’ wish—through the amendments that have been jointly agreed on a cross-party basis, will therefore be fit for purpose in clarifying beyond peradventure the Secretary of State’s accountability for the health service and the exercise of his powers. With that, I hope that the noble Baroness, Lady Thornton, will feel able to withdraw her amendment.
Baroness Thornton
I thank the Minister for that response. I made it clear in my opening remarks that I would not seek to push the amendments to a Division, although the remarks of the noble Baroness, Lady Williams, and the Minister made me wonder whether I ought to do so, because certain things that were said were not justified.
First, the noble Earl took us through a list of things that without the Bill would not be happening. On almost every single one, I thought that without the Bill you could do all those things. You do not actually need this Bill to do most of the things that the noble Earl listed as being desirable objectives. I am sure that we would agree about most of them being desirable objectives.
The noble Earl mentioned the listening exercise as being proof that this is not the unloved Bill that I would suggest it is. Only yesterday, a former special adviser to Downing Street said that the listening exercise was a tactic as part of managing the Bill. Frankly, I was horrified by that. If I had been Professor Steve Field or one of the 40-odd people who, with every good intention of doing a public service unpaid, gave their time to take part in that listening exercise, I would think that it was really shocking. So I think that the noble Earl should be careful about praying the listening exercise in aid in explaining how loved or unloved this Bill is.
It is time that we moved on. I intend to reserve my praise for the next debate and leave my criticisms in this debate. I intend to withdraw my amendment, even if the noble Earl will not withdraw the Bill.
Baroness Young of Old Scone
My Lords, I am afraid that I will be even more discordant. I do not want to denigrate the congratulations that have been offered to the noble Baroness, Lady Jay, and her colleagues and the process that has been gone through to reach agreement on this amendment. However, I share the view of the noble Baroness, Lady Pitkeathley, that we must not forget not only how deeply unpopular the Bill is but that it is flawed.
I had not intended to speak on this amendment but I cannot let the moment pass as I think that the noble Baroness, Lady Jay, referred to a spirit of improvement that she was seeking in moving this amendment. However, we have to remember that the improvement is a bit like trying to paint the face of a harlot; at the end of the day, it is still the face of a harlot, no matter how improved. We are seeing real impacts on healthcare in this country as a result of the Bill, as we speak. I come from a background of having run health services for 20 years. I have also been the regulator for health and social care and am now part of a patients’ organisation. Patients are telling me that we are seeing the fragmentation of responsibility for the commissioning of healthcare and that services are suffering as a result of the financial squeeze; for example, diabetic specialist nurses are disappearing and patient education is being cut. The things that are important for the quality of care are being removed.
I am experiencing a huge loss of momentum in getting any change implemented in the care for people with diabetes. Whenever I speak to the Secretary of State, he tells me that it is no longer his responsibility and that I should talk to the NHS Commissioning Board. However, when I speak to the NHS Commissioning Board, staff say, “We are still working out how we do this”. When you talk to clinical commissioning groups, they are still not clear about the framework in which they are operating. Therefore, we are losing one, two or three years of headway on issues where there needs to be real improvement for patients.
Because of the preoccupation with reform, we are seeing a lack of real focus on the task in hand, which is how we make the health service more efficient. The Minister and the Secretary of State have repeatedly told me that these reforms will deliver that necessary improvement in care and efficiency. However, my experience over 40 years leads me to believe that that is not the case. In saying that, I am not making a political point; I speak from my knowledge of what is happening in healthcare. We will continue to try to improve the Bill because we are good and honest toilers in the House of Lords, but we are trying to improve something that is deeply flawed.
Baroness Thornton
My Lords, we must be thankful to my noble friend Lady Jay and the Constitution Committee for their initial work and their second report, which has enabled us to reach the point that we have. I am grateful to my noble friend Lady Pitkeathley and the noble Baroness, Lady Young, for saving us from the gloopy treacle of self-satisfaction into which we were sinking, to which my noble friend Lady Jay referred.
I, too, thank the noble Lord, Lord Laming, the Convenor of the Cross Benches, for chairing the seminars that have been referred to. We all know that chairing seminars attended by opinionated Members of this House and lawyers is not an easy task. He did an excellent job and led us gently towards the consensus that has resulted in the amendments being tabled that we are discussing. I pay tribute to the noble Baroness, Lady Williams, the noble Lords, Lord Hennessy and Lord Owen, whose wisdom brought the great importance of this issue to the attention of the House.
We support this amendment as it is clearly an improvement on what was in the Bill originally. We are still perplexed as to why we could not simply have kept the 2006 wording, but we are where we are. However, I wish to repeat the question that I have already put to the Minister. The Secretary of State has let it be known that he does not think that this measure makes a difference. That shows no respect for the work that we have undertaken and the place in which we find ourselves. Therefore, I should like clarification on that point. We need to know why that is the case. This measure constitutes a significant change because, as I think the noble Baroness, Lady Williams, said, it will have repercussions on other parts of the Bill. I welcome that and hope that it is the case. We need to look at the changes proposed in this and the following amendments as they should make easier our job of testing other parts of the Bill against them.
I say to the noble Lord, Lord Mawhinney, that this is still a very political Bill. The noble Lord’s party and the Liberal Democrats pushed the original drafting on the Secretary of State’s powers through the Commons. I have tried to keep my remarks about the highly politicised nature of the Bill separate from this debate because I thought it was important that we should also recognise the work that has gone on and the consensus that we have reached in this House. That is due to a combination of clarity, wisdom and our consideration of the Constitution Committee’s report. I compliment noble Lords on my own Benches because we were determined not to accept the well meaning and imaginative original proposal of the noble and learned Lord, Lord Mackay of Clashfern. We had very trenchant support from noble Lords such as the noble Lord, Lord Owen. The Minister, in his wisdom, took these clauses off the Floor of the House and we are now where we are. That is a great credit to everybody concerned, including my own party. Therefore, we are very happy to welcome this amendment and hope that it bodes well for our future discussions on Report.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 2 months ago)
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Lord Hennessy of Nympsfield
I shall speak also to Amendment 150, which is in my name on the Marshalled List. These amendments are a product of the conversations chaired by my noble friend Lord Laming, designed to bring the highest possible level of consensus to what the noble Earl, Lord Howe, calls the suite of clauses dealing with the accountability of the Secretary of State. I am very grateful to my noble friend for his sensitive chairmanship of the discussions and to the Minister for generously accepting the argument—that the special essence of the National Health Service as distilled in the NHS constitution be enshrined in the Bill.
With this new status, the NHS constitution will shine even more, both as a beacon for all involved in healthcare, whatever their place in the proposed new mixed economy of service provision, and as a statement of enduring values, which occupy such a central place in how we wish our services to be undertaken and how we conceive of ourselves as a people.
I shall not detain your Lordships long, as I am confident that these amendments, for all the friction and division that other clauses have generated, are ones that embrace the views of the vast majority of your Lordships as they do the country they serve. But I must also express my gratitude to the noble Lord, Lord Darzi, and his colleagues in the last Labour Government, for commissioning the wide consultation whose streams of thought fed into the NHS constitution when it first appeared in January 2009. It managed to contain the key principles in seven well worded paragraphs, which I shall not recite as your Lordships have the text to hand and will be familiar with its ingredients.
The Bill, when an Act, will take a great deal of bedding down, and it will take the second coming for the rifts between the political parties and the anxieties expressed by so many health professionals to be assuaged—and perhaps not even then. However, with the NHS constitution in its prominent place towards the top of the statute, we shall have a touchstone, not just for aspiration and inspiration but for behaviour and conduct, a shared talisman for the tougher moments when the implementation of this Bill throws up its inevitable problems and controversies. When we find a lustrous patch of consensus on the NHS’s road from 1948, as represented by the NHS constitution, we should cherish it through thick and thin, for we are never better as a country than when we concentrate on those things that unite us rather than divide us. I beg to move.
Baroness Thornton
My Lords, I am very pleased to put my name to this amendment and I congratulate the noble Lord, Lord Hennessy, on his tact and diplomacy in getting us to this point, and in getting agreement to have the constitution mentioned in the Bill, and in such a prominent part of it. In preparing a few supportive remarks, I had a look at the constitution because I was working for my noble friend Lord Darzi in a similar role to the one the noble Baroness, Lady Northover, has—as his support and his Whip—when we were working towards the constitution, and when it was discussed and adopted across government and Parliament.
The importance of having it in the Bill is there in various key parts of the constitution, which are worth mentioning on the record here because we need to remember them as we move forward to discuss this Bill in all its glory in the next five or six weeks, or however long it takes us. The constitution says:
“The NHS is founded on a common set of principles and values that bind together the communities and people it serves—patients and public—and the staff who work for it”.
It goes on to say that it,
“establishes the principles and values of the NHS in England. It sets out rights … and pledges which the NHS is committed to achieve”.
It says:
“All NHS bodies and private and third sector providers supplying NHS services are required by law to take account of this Constitution in their decisions and actions”.
That is a very important part of why this needs to be in the Bill.
The final part which I would like to draw to your Lordships’ attention is point 6 of the guiding principles in the constitution, which is a commitment,
“to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. Public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves”.
That is exactly right. It is not the shareholders of companies and not individuals who might seek to make a profit but the people whom the NHS serves, and the taxpayer.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am very grateful to the noble Lord, Lord Hennessy, for tabling these important amendments and for the eloquent way in which he introduced them. As he said, they seek to require the Secretary of State to have regard to the NHS constitution when exercising his functions in relation to the health service. I say to him in all sincerity that I very much welcome his contribution throughout this debate. I identify myself entirely with the enthusiastic remarks that he addressed towards the constitution itself, which is a most succinct and inspiring document, and I agree with him that we have reached a very workable and satisfactory outcome to the question that he originally posed to me and to the House.
I fully support these amendments. It is right that we continue our commitment to the principles set out in the NHS constitution. I hope that these amendments together provide noble Lords with reassurance of the Government’s continued commitment to the core principles and values to which the noble Lord and the noble Baroness have referred. I commend them to the House.
Baroness Thornton
My Lords, when we were having our negotiations on this part—on which I was very happy to take part, even if I was regarded on some issues more as grit in the oyster than as co-operative help—they were about these issues, including autonomy. I have not changed my view. I shall speak to Amendments 10, 36 and 52.
We have no problem with the concept of autonomy. In principle our position is that autonomy has to be earned, and that it should be able to be taken away as well. That formed the principle and the basis on which the foundation trusts were established. However, we part company with the Government on their view of autonomy, and we are not completely convinced by the point made by the noble Lord, Lord Marks of Henley-on-Thames. On first sight of the Bill it seemed that autonomy was to be presumed and that each part of the service would be subject to less interference from the other parts in a way which could be detrimental. There would therefore be less performance management, and giving various bodies more powers with less need to sign off an agreement could mean that there would be less co-operation. Bodies acting in their own interests via a market process will mean that the motivation could be something that does not have the NHS and patients at its heart, and that there is less planning and system management, which sometimes actually is required. That is how you deal with things like postcode lotteries. You have to collect the information, compare it between different parts of the country experiencing different levels of deprivation, and then you have to take decisions which are about planning how to use your resources to ensure that people are not disadvantaged. So there are some very good reasons why planning and systems need to be in place.
The original briefing on the Bill stated that CCGs would not have PCTs or SHAs above them to performance manage them and that the commissioning bodies were not meant to performance manage but only to step in if there was a danger of failure. Again, that was the original briefing. It is not surprising that when we first discussed this in Committee there was general agreement across the House that the Bill would be better off without Clause 4 and what was then Clause 10 but is now Clause 12.
Since then the Constitution Committee has done what I think is really rather a good job. Although I was not deliriously happy about it, I was prepared to live with the draft produced by the committee. However, I do have problems with the draft that the noble Lord, Lord Marks, and the Minister have brought to the House. The provisions are not strong enough and some of the dangers that we originally expressed about problems with the autonomy clauses still exist. Furthermore, I take very much to heart the questions that both of my noble friends have raised. From different points of view they have asked pertinent questions and shown up the problems with the autonomy clauses. That is why, certainly in the process of our negotiations on Clause 4, I reserved my position to come to the House and explore whether what we actually wanted to do was delete it completely at this stage. On Clause 12, for the sake of consistency we feel that it should also be deleted. However, I have to say that because of the amendments that were accepted in the process of our negotiations, we feel less strongly about it.
I am not any more convinced as a result of this debate that our original position is not the right one—that if we cannot have the Constitution Committee’s version of Clause 4, we should delete the whole clause. Obviously I will listen to the Minister’s summing up of the debate, but at the moment I remain convinced that our position is indeed the correct one.
Earl Howe
My Lords, the noble Baroness, Lady Thornton, has spoken to Amendments 10 and 52, which, as she has said, would remove altogether the autonomy duties on the Secretary of State and the board. The noble Lord, Lord Harris, asked me what the problem is that the Bill is trying to solve in this regard. The duty is intended to promote a culture of fostering local autonomy rather than to outlaw specific practices; but without a focus on autonomy, it is possible that the mandate from the Secretary of State to the board or the framework document from the board to CCGs could impose disproportionately burdensome requirements on the system. The Government believe that local operational autonomy is essential to enable the health service to improve the outcomes of care for patients, provided that autonomy is within the framework of clear ministerial accountability.
The noble Baroness will be aware, because I have said it before, that we are aiming to free those closest to services to take decisions that are right for patients, free from central micromanagement by either the Department of Health or the NHS Commissioning Board. The amended duties, with the caveat that the interests of the health service take priority, achieve the right balance between autonomy and accountability. Without the clause, a future Secretary of State could choose to ignore one of the fundamental principles of the Bill, which is that those closest to patients are best placed to take clinical decisions. Without the clause, a future Secretary of State would be free to use his extensive powers to micromanage the NHS. The autonomy duty is a necessary part of the Bill, placing a duty on the Secretary of State to consider the expertise of those in the health service while recognising that there will be circumstances—
Earl Howe
I challenge the noble Lord to think of one Secretary of State, with the distinguished exception of my right honourable friend Mr Lansley, who has not succumbed to the temptation of micromanaging the NHS. No Secretary of State has been able to resist that temptation because, frankly, Parliament expects them to do it. That is what the system has expected of the Secretary of State. This is a burden on commissioners and clinicians, and, in the end, it does not well serve the interests of patients. It is all very well for the noble Lord to say, “Well, just stop”, but the system encourages it and the duties on the Secretary of State are there to encourage it.
Baroness Thornton
I cannot resist saying that the noble Earl’s right honourable friend Mr Lansley has dabbled and intervened on at least 12 occasions since the Bill started. He is on the record as saying on one of those occasions that certain managers should be sacked. Is the noble Earl saying that that will cease when this Bill is on the statute book?
Earl Howe
I am saying that the Secretary of State will not have the ability to micromanage the health service as he does at the moment. Whether the examples cited by the noble Baroness constitute micromanagement, if my right honourable friend is just expressing a view, I rather question.
The autonomy duty is a necessary part of the Bill because it places a duty on the Secretary of State to consider the expertise of those in the health service while recognising that there will be circumstances in which they must be able to step in to protect the interests of health service patients. That is the balance that we are trying to strike.
The noble Baroness, Lady Finlay, asked whether the autonomy duty would allow a clinical commissioning group to justify not commissioning the full range of services. The autonomy duty does not apply to CCGs; it is a requirement on the board and the Secretary of State. If a CCG chooses not to commission services and the board considers that this is not consistent with the interests of the health service, the board can intervene to direct a CCG. If the board fails to intervene when necessary, the Secretary of State has power to intervene. Finally, the Secretary of State can set out services which CCGs must commission, and he can do that in the standing rules if he considers it necessary. The CCG’s key duty is to arrange services as it considers necessary to meet all reasonable requirements of the population that it is responsible for, and the amendments do not change that in the slightest.
Health: Children and Young People
Baroness Thornton Excerpts(12 years, 2 months ago)
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Earl Howe
My Lords, accident and emergency services will be commissioned at a local level. I am afraid that I do not have in front of me detailed information on the split between adult and children's services in an emergency context. If I can get the information, I will be happy to write to my noble friend.
Baroness Thornton
My Lords, given that responsibility for commissioning for 0 to five year-olds will be at a national level, and commissioning for six to 19 year-olds will be the responsibility of local arrangements, as the noble Earl described, what are the risks for the continuing responsibility for safeguarding the health of the most vulnerable children in our society?
Earl Howe
My Lords, the two main outcomes frameworks relevant to this are the NHS and the public health outcomes frameworks, which we are trying to align as far as possible. They set a clear direction for the health and healthcare of children and young people, but there is more to do. As our data improve, we need to ensure that the outcomes measured are the ones that matter most to children and young people. That is why we are developing a health outcomes strategy for children. This will be the first example of an outcomes strategy as part of the health reforms model.
Tobacco
Baroness Thornton Excerpts(12 years, 2 months ago)
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Baroness Thornton
My Lords, it was as a direct result of the evidence of the underhand tactics of the tobacco industry that the UK very wisely adopted Article 5(3) of the Framework Convention on Tobacco Control. In 2008-09, the noble Earl’s noble friend Lady Northover successfully asked the then Secretary of State Alan Johnson to write to all his ministerial colleagues drawing attention to and outlining the importance of Article 5(3) and asking for their assurance that they were abiding by the article in their dealings with the tobacco industry. I invite the Minister to agree to ask his right honourable friend the Secretary of State to do the same with this Government.
Health: Stroke Care
Baroness Thornton Excerpts(12 years, 3 months ago)
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Baroness Thornton
My Lords, I congratulate my noble friend Lady Wheeler on being patient enough to allow this debate to take place tonight. I thank all noble Lords who have taken part in this debate.
When Andrew Lansley was appointed to the Cabinet by David Cameron in May 2010, we might have expected that the new Health Secretary would take the trouble to introduce himself to the leading players in his department. I have to say that this was not the case. Sir Roger Boyle, who had been toiling away as the Government’s national director for heart disease and stroke for more than a decade, did not actually meet the Secretary of State until just before he parted company with the department. As someone who judges the success of something by the action that is taken, not by the rhetoric, I think that that is decidedly unimpressive.
Sir Roger Boyle was appointed as national director for heart disease in March 2000. He led the implementation of the National Service Framework for Coronary Heart Disease, which led to a 50 per cent cut in deaths from heart attacks. That has been in the news very recently. He published the National Stroke Strategy in December 2007, and indeed was working on the implementation of that stroke strategy when he left the department last summer. My question to the Minister is this: I understand that Sir Roger Boyle has not been replaced. If he has not been, why not? Indeed, what does that say about the priorities of the department on the issue of stroke?
It is a pity that Mr Lansley did not make more of an effort to find out what Sir Roger was up to. He would have learnt some important lessons about the NHS and what it had achieved without the benefit of the market revolution that is being ushered in under the NHS reforms before the House.
The second question I would like to ask the Minister is what future, therefore, will the national stroke strategy have in a reformed NHS, and who will be responsible for its implementation under the proposed new system?
My third question picks up the points made by my noble friend Lady Wall. It concerns whether something as successful as the London stroke strategy could be replicated and how that would be achieved. I make no apology for repeating the question that I have been asking, on and off, at every opportunity over the last year or so, because I think that so far we have not received a satisfactory answer. The London stroke strategy was achieved through a London-wide strategic plan driven by clinical co-operation. I would like to know how, and in what timeframe, such a strategy would be possible under the new levels of decision-making bureaucracy and, some might even say, fragmentation that are being proposed by the new Bill.
Would there be a great risk that the clinical competition that allowed the London strategy to move forward, if it were to be an economic or financial competition, would have to be based on the failure of some centres, to allow others to emerge as winners? That is my understanding of how things would have to move forward. I hate to say this to my noble friend Lady Wall, but it seems at present to be less rather than more likely under the new regime.
I thank all noble Lords who have covered what seem to be all conceivable questions about the matter of stroke, and I look forward to the Minister’s reply.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 3 months ago)
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Baroness Thornton
To ask Her Majesty’s Government what were the estimated costs of implementing the Health and Social Care Bill when it was originally introduced to the House of Commons one year ago, and whether they have changed.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in January 2011, we estimated the costs of implementing the Health and Social Care Bill at £1.4 billion. When we published the revised impact assessment in September, we estimated the costs of implementing the Bill to be between £1.2 billion and £1.3 billion. This will reduce administrative costs across the system by one-third by the end of this Parliament, saving £1.5 billion per year from 2014-15 onwards.
Baroness Thornton
My Lords, I thank the Minister for that Answer. Many people in the medical world believe that the cost is mounting and that the cost which the Minister cites is not accurate. It is safe to say that this upheaval is costly both in money and in the risk to patient care. As well as the cost, at a time when the NHS has to find £20 billion of efficiencies, today the nurses and midwives have asked for the Bill to be dropped, arguing that their concerns have not been answered. Can the Minister give the nation and the NHS a first birthday present by listening to what is said and advising his right honourable friends Mr Lansley and the Prime Minister that it is time to pull back—
Baroness Thornton
I am asking a question; I am in the middle of asking it. You may not care about the NHS but, on these Benches, we do. When the medical professions and nurses say that the Government should think again, it would be wise for the Government to do so. My question is whether the noble Earl will ask his colleagues to do so, and whether we can then move together, with consensus, as my right honourable friend Andy Burnham has now twice asked the Secretary of State to do.
Earl Howe
My Lords, I understand that the noble Baroness is asking me to deliver a certain message to my right honourable friend. I am not quite sure what that message was, but if it is to do with the Health and Social Care Bill, I have to say that we need that Bill. We believe that reform of the NHS is essential if it is to be sustainable in the future. Every penny saved from this reform will be reinvested in front-line patient care. The previous Government had, as we do, an ambition to save £20 billion—the so-called Nicholson challenge—over the next three or four years. This reorganisation will enable us to contribute to that total. The modernisation will also move the NHS to a much more patient-centred system where good providers are rewarded for high-quality services. We are spending money on redundancy now to gain in the future.
NHS: Transition Risk Register
Baroness Thornton Excerpts(12 years, 3 months ago)
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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.
Baroness Thornton
My Lords, the strategic health body in London was perfectly content to make the register of risks on the health Bill available, so the House needs to know, first, what the difference is—except in terms of size—in the national Department of Health making its risk register available. Secondly, I realise that in appealing the Information Commissioner’s decision the Government have said, in effect, that this decision has cross-government implications. Does the Minister accept that it also has wider implications for Parliament? In this House, our ability to scrutinise legislation effectively must be in doubt if any Government withhold important information from us, so what course of action does the Minister suggest that noble Lords in this House should take under these circumstances?
Earl Howe
My Lords, to answer the second part of the question first, a substantial number of the risks pertaining to the Bill are already in the public domain and we are considering whether there is scope to draw these sources of information together in a single place, so that noble Lords can look at them more easily. To answer the first part of the noble Baroness’s question, I made inquiries about NHS London. Its situation is very interesting and quite different from that of the Department of Health. NHS London developed its risk management strategy with a view to it being visible to stakeholders and the public, as its document says. It is therefore a reasonable assumption that officials will have worded their risks for inclusion in the register in the knowledge that that wording would be likely to form part of a document placed in the public domain, so there is a very real difference between the two situations.
Health: Pathfinders
Baroness Thornton Excerpts(12 years, 3 months ago)
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Earl Howe
My noble friend is right. We were very pleased to see the NHS Future Forum says that running right through the Health and Social Care Bill is the desire and aim to integrate services. That is certainly right. We recognise that there is a balance to be struck between allowing local ideas to spring up and people to progress their own ideas and having the necessary support from the centre to do that. We have established a national learning network for pathfinders to complement the support given to them by strategic health authorities and PCTs. Those learning networks will ensure that best practice is spread and, specifically, that pathfinders support other local groups which are less developed.
Baroness Thornton
My Lords, perhaps I may ask a question concerning clinical commissioning groups and the legal advice and support they might be receiving. Has the Minister taken advice on the impact of EU procurement law as regards the tension in commissioning and delivering integrated services and the legal requirements concerning procurement of services which are integral to the Health and Social Care Bill that is before the House? Will the Minister make any such advice available to us?
Earl Howe
My Lords, my understanding is that procurement law, which already applies in the NHS, is certainly part of the learning sets that clinical commissioning groups have been provided with. I would be delighted to supply the noble Baroness with further information but I do not have it in front of me.
Health: Breast Cancer
Baroness Thornton Excerpts(12 years, 3 months ago)
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Earl Howe
I could not disagree more with the noble Lord. He refers to the policy of “any qualified provider”. That policy gives absolute assurance to every NHS patient about the quality of the treatment that they get if they are treated by the NHS, whatever the provider setting. Therefore, the idea that this incident has any bearing on the provisions of the Health and Social Care Bill is absolutely misplaced. I cannot emphasise that more.
Baroness Thornton
The noble Lord, Lord Low, asked a legitimate question. Any qualified provider goes through a process of approval in which the CQC is responsible for regulating clinics and services. That is exactly what the CQC has done for these private clinics. They have all been given a stamp of approval to carry out these operations by the CQC. That, surely, was the point of the noble Lord’s question. Therefore, what are the implications for “any qualified provider” under the fragmentation and increased marketisation of the NHS by the Bill?
Earl Howe
The “any qualified provider” policy was instigated by the Government of the noble Baroness. There is no suggestion that these clinics have been carrying out procedures badly; the issue is around the quality of the implant, which they could not be expected to know about. Nevertheless, the CQC is conducting inspections, some of them unannounced, on cosmetic clinics to assure itself that everything is being done properly. I will not stand here and say that any of these clinics have carried out the procedures badly. We have no evidence to show that they have.