Life Sciences
Baroness Thornton Excerpts(12 years, 4 months ago)
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Baroness Thornton
My Lords, I thank the Minister for repeating the Statement. I, for one, certainly believed it was important that we took this Statement in the House, even if it is a day later than we might normally have done, because our great panoply of scientists, doctors and experts should have an opportunity to respond to it. It is likely that we can see the Minister’s hand in this initiative as research is one of his responsibilities and, indeed, one of his passions.
I share the Minister’s pride in Britain’s strength in life sciences. We all agree in the House that the industry needs government support and focus if its potential to contribute to the country’s industrial future and to its people is to be maximised. I also think the whole House will agree that there are huge potential benefits to British patients from closer collaboration between the NHS and the industry. We all want patients to have the quickest possible access to the latest life-saving and life-enhancing treatments. Indeed, it was for those two principal reasons that when we were in government we prioritised the life sciences sector and established the Office for Life Sciences to support an industry that employs more than 100,000 people. Indeed, we created a Life Sciences Minister—a contact point for the industry and someone of huge experience and real personal commitment to it. It has to be said that one of our criticisms of this Government is we believe that they have allowed the momentum that we established behind promoting this industry to fall away. Indeed, the unexpected closure of Pfizer earlier this year exposed the Government asleep at the wheel and was a wake-up call. Therefore, to some extent we see this as the Government playing catch-up but it is nevertheless an extremely welcome development and we wish it well.
Although the Minister is concerned about the need to lift a regulatory burden from industry, I think we all agree that proper regulation on the use of patient data is most certainly not a burden that we want to lift. We want that properly addressed. My questions are around those issues. Some patient groups have already expressed concern about the media-briefed statement from the Government and the lack of accompanying detail, so I hope that the Government will be able to give some reassurance here. Will all patients have the ability to opt out of sharing their data, even in anonymised form? Will the fundamental principle of consent form the bedrock of any new system as control of data should be possible in today’s information age? I understand that the patients’ representatives walked away from the Department of Health working group on these important matters. If that is the case, why did they do so? Does the Minister accept that he needs to work harder to uphold public confidence in this process or risk undermining trust in the whole principle? Therefore, the safeguards are very important. What safeguards will there be to ensure that patient data are stored securely? What precisely are the changes that the RHG plans to make to the NHS constitution?
Is it the case that the anonymity of data cannot always be guaranteed? If that is the case, what are these circumstances, and why not? The Minister is very familiar with this issue, as, indeed, is his noble friend Lady Northover, because in May 2002 both of them were involved in a debate on precisely this issue. It was a debate on the safeguarding of patient data. It was said in the debate:
“For example, the Gulf War-related research and the research relating to leukaemia in the area of Sellafield could not have been carried out with purely anonymised data. There has also been recognition of new variant CJD and its relation to the BSE epidemic”.
It is not appropriate to use anonymised data in that context either. It was also stated, in my view very wisely:
“Apart from the medical profession, who else will be subject to the contractual duty of confidentiality? What type of contract does the Minister envisage will be entered into by, for example, civil servants and those who act with the various agencies which may process that information? What review process for the regulations will be followed by the Secretary of State in 12 months' time? Will it be an open and transparent process? Will there be an opportunity for debate? There is also the very important issue of informing patients that their information has been processed. I believe that the Minister should spend some moments explaining how patients—or, at least, doctors—will be able to tag their medical notes in some shape or form so that it is clear that their information has been processed by researchers”.—[Official Report, 21/5/02; col. 750.]
I could not have put those questions better myself, and they are the ones that the Minister needs to address in this case.
Who will judge which companies will receive this information when they are in competition with each other? The Statement assumes a very prettily organised and co-operative world but that is not the world out there in the pharmaceutical industry. Companies are competing with each other for the research they do, its outcomes, availability and how you make it available. How will the Government judge which companies they make this information available to and what criteria will they use under those circumstances?
I wish to ask the Minister a specific question about one of our great institutions which is involved in this research—Cambridge University. It seems to me that the Government need to manage these sorts of challenges, and this is a very serious one. I have given the Minister notice that I was going to raise this question. In October 2011, the European Court of Justice, responding to a reference from a German court about the interpretation of the European directive on the legal protection of biotechnological inventions, made a judgment which will have the effect of banning the issuing of patents for embryonic stem cell research. The ruling means that existing patents involving the use of embryonic stem cells are no longer valid and that future patent applications will not be considered. Many researchers at Cambridge are concerned that the ruling could damage the entire field of research and drive much of it abroad. The ruling could act as a huge disincentive for investment as patents are important if pharmaceutical companies are to recoup their investment in clinical trials and turn a profit. It could therefore set back possible new treatments for a range of disorders from heart disease and diabetes to blindness and Parkinson’s. The ruling also leaves scientists in the contradictory position where they are funded to do research for the public good yet prevented from taking discoveries to the marketplace where they could be developed into new medicines. It would be a tragedy if our great institution of Cambridge University had to take this research abroad because of a ruling of the European Court of Justice. I would like to know what the Government intend to do about that.
I am afraid that I cannot resist making this final point. It is a great irony that while Ministers are happy to offer up other people’s data, they continue to withhold the risk register on their own reforms despite a clear ruling from the Information Commissioner to publish.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Howe of Idlicote
My Lords, I have listened to what has been said by all these expert professionals and I am very much persuaded in favour of something along the lines of this amendment. I think that one of the most worrying things from the public viewpoint has been the sheer number of concerns about nursing that we have had in the press—not least, I may say, about the mortality rates et cetera going up during weekend staffing. Quite clearly there is a need for better reorganisation.
I go back quite a long way, to the time when I sat on the Briggs committee on the future of the nursing profession, and will never forget one of the nurses saying to me at the time: “I’ve been nursing for”—however long it was; she had just got her qualification—“and now I’m going to have a rest”, which was roughly what she was up to. I had a great deal of sympathy with her from that viewpoint.
I hope the Minister will bear in mind—I am sure that he must be more than aware of it—that the number of cuts in nursing staff are considerable in the present plan. Something like 8.3 per cent of qualified nursing jobs are to be lost. As the Royal College of Nursing pointed out in its briefing, that is on top of something that was done no less than about 18 months ago and is more than 10 times the original figure. Axing up to a quarter or a third of nursing posts will undoubtedly have a deep and potentially dangerous impact on patient care. Of course the training of the nurses—the experts in the really expert places—is essential. The training and up-skilling of those nurses on the real needs of patients is vitally important, but so are the numbers.
Baroness Thornton
My Lords, I thank the noble Baroness, Lady Emerton, the noble Lord, Lord Patel, and my noble friend Lord MacKenzie and other noble Lords for bringing these important amendments into Committee. Amendments 138 and 139 make provision for the NHS Commissioning Board to mandate safe nursing staffing levels and the number of patients a registered nurse is designated to care for. At the risk of stating the absolutely obvious about safe and effective staffing levels and patient ratios, where there are insufficient nurses and too many patients allocated to care for, then the level of care that can be administered will be affected. These amendments are about patient safety and well-being and the noble Baroness, Lady Murphy, hit the nail on the head. In response to her remark about speeches and the length of speeches, my observation, which is shared on these Benches, is that the Cross-Benchers are not the problem. They have been making admirably short and speedy comments. I hope that mine will be also. Other noble Lords might think about that.
This is a current problem as well as a long-term problem. As my noble friend Lord MacKenzie said, it has been with us for a long time, but it is current at the moment. The Royal College of Nursing tells us that some NHS trusts are diluting the skill mix on wards and in other care environments. This dilution is when non-registered healthcare support workers are employed in the place of a registered nurse. Healthcare support workers are paid—as one might guess—significantly less than registered nurses due to their comparative lack of vocational qualifications, so are seen by employers as a cheaper option. We think that that potentially puts patient safety at risk. Recent research by the Nursing Times has highlighted a significant variation in skill mixes between different hospitals in different regions. It seems to us that when cost becomes the overriding factor at the expense of the quality of service, patient outcomes and even patient safety become endangered. The most high-profile recent example of this was the care failings of the Mid-Staffordshire NHS Trust. Sadly, due to a range of factors—including financial pressures—costs were cut, nursing staffing levels were reduced and patient safety declined. It is vital, therefore, that stakeholders, including the RCN, work together with the national Commissioning Board to set the appropriate staffing levels and standards. There is some evidence from the NHS Information Centre that there is an accumulating problem here. Between January and August, the decline in terms of full-time equivalents in nursing, midwifery and health visiting staff in England fell by 1.6 per cent, from 310,989 to 306,028. There is evidence of a growing problem.
I would like to ask the Minister about an exchange in October when the Secretary of State gave evidence to a Select Committee. He stated that he was not aware of the down-banding, which is the issue at stake here, relating to the ratio. He was not aware that this was a problem or that the Royal College of Nursing had raised it with him. The Director of Nursing at the Royal College of Nursing then gave evidence to the same Select Committee the following day. She claimed that the Secretary of State was aware of down-banding practices; that the Royal College of Nursing, among others, had drawn it to his attention; and that it was a matter of some concern. I ask the Minister whether the department is aware that this is a problem and what it is intending to do about it.
These Benches support the amendments, and we are keen that this issue should be addressed robustly.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Thornton
“( ) Subsection (1) shall not apply to any providers who have any financial interest, directly or indirectly, in the provision of any service that the clinical commissioning group may be required to commission.”
Baroness Thornton
My Lords, I also speak to my other amendments in this group. Over supper my noble friend reminded me that the late lamented Lord Carter, a previous Government Chief Whip, used to say to Ministers and others that if we needed to save time, the thing to do was to speak only from every other page and see if anybody noticed. What I intend to do is to try and speak from every other paragraph.
These issues deal with the serious potential conflicts of interest that GPs will face in their new role as commissioners of health services. When this group of amendments first started out it contained only two amendments but it has now, quite rightly, grown substantially to address the major concerns of transparency, integrity and patient confidence and the issue of trust that must be addressed in their new role. In passing, I would say that the publication of the Government’s recent draft guidance on commissioning, Developing Commissioning Support: Towards Service Excellence, in effect decrees that by 2016 the real work of CCGs will be outsourced, presumably to large private providers, which makes me start to question what is left for CCGs to worry about. However, the issue that these amendments deal with is a fundamental issue of the Bill.
We all have high regard for our GPs and we trust them as experts and advisors. We know from the evidence that they do a cost-effective and good job. Our national system of GPs may be quirky, half in and half out of the NHS, but it works. At its best, it is the very best system in the world.
We are concerned that the Bill endangers the trust that patients have for their GPs and, essentially, these amendments seek to explore and to test that. GPs are going to be decision-makers across the whole breadth of commissioning, making decisions about priorities and standards, things that may often be unpopular, and reconfigurations of service. They will handle huge amounts of money, own budgets and get bonuses for good financial performance. So patients need to be assured that they can continue to trust their GP and that their GP will always act in the patient’s best interest. This concern has been flagged up by the BMA and the Royal College of General Practitioners, so I hope that the Minister can tell the House how we will be able to protect the image and reputation of our GPs after the first CCG goes wrong. Amendment 156 starts with the obvious necessary safeguard that providers of primary medical services who have a direct or indirect financial interest in the provision of services that a CCG is required to provide must not be members of the CCG. Amendment 161 is also key in requiring the Secretary of State to issue guidance which must be incorporated into CCG constitutions on how conflicts of interest must be dealt with by consortia as part of their decision-making. Transparency and clarity about how potential conflicts of interest would be managed is essential if the confidence of the public is to be maintained.
Openness and transparency are supported by Amendment 176A, requiring CCGs to maintain a publicly accessible register of all potential conflicts of interest of individuals involved in any part of their commissioning process. Taken together, Amendments 176A and 224 reinforce this, and call for regulations to stipulate that no provider should be a member of a CCG if they have any financial interest in the provision of any service the CCG is required to commission; in other words, open book accounting.
We do not think it is enough, as Amendment 228 proposes, for a CCG member merely to declare their financial interest in a commissioning decision being taken by their CCG, or absent themselves from decision making on that provider. We expect our councillors to operate under this regime. We should expect other people responsible for public money to do the same. Indeed, this transparency and openness, and the declaration of interests, should be extended to their families, in the same way that it is for other public servants.
Finally, I want to underline that we recognise that extending GP commissioning and setting up CCGs has the potential to give GPs freedom to innovate, improve services and use commissioning to develop new models of care in the interests of the communities they serve. The safeguards against conflicts of interest proposed in these amendments are not designed to shackle CCGs. As I have said, the Department of Health commissioning guidance already does that. The safeguards will ensure that they abide by the reasonable rules, regulations and codes of practice that we would expect of any statutory body responsible for taxpayers’ money worth millions of pounds.
The public needs to be assured that robust governance arrangements are in place for commissioning consortia, and that conflicts of interest will be managed effectively. I beg to move.
Baroness Williams of Crosby
My Lords, I have a great deal of sympathy with the intention behind this amendment. Noble Lords will remember that from the very beginning of the discussion about this Bill, there has been a great deal of concern about the conflict of interest that could so easily arise. Many of us recognise that the relationship between patients and general practitioners crucially depends upon that relationship being one of trust. The same will apply, if the commissioning groups work well, to the relationship between them and the patients who are within the practices of which they are part. So I sympathise very much with what the noble Baroness, Lady Thornton, has proposed, and also with what the noble Baroness, Lady Finlay, has proposed in Amendment 161.
Our concerns on this side of the House are not with the whole motivation behind this. We believe that that is extremely important and we completely share it. It is our feeling, rather, that the remedies are not adequate to the scale. We feel, for example, that one of the weaknesses of both amendments is the lack of any effective sanctions against those who breach what would be a relationship of trust. At the moment there is not provision within the Bill for effective sanctions, which can be used to ensure that these high-minded and perfectly proper principles are lived by.
The Nolan principles have been very effective in local government—as we all know—and increasingly effective in national Government. There are references to those in the course of the Bill, but there is no specific determination that members of the partnership groups or the CCGs would be dealt with, if they were in breach of the requirement that they should not ever put their own interests ahead of those of their patients.
I suggest to the noble Baronesses, Lady Thornton and Lady Finlay, and her associates in moving these various amendments, that they would look at the amendment we have put down—and I suggest this with due humility—which effectively brings into practice powerful sanctions. We believe these will be effective in ensuring that this relationship of trust is upheld, and also that powerful requirements lie on every CCG, as well as on the board itself, that it would be absolutely clear that all interests must be declared publicly.
These will ensure that once people’s names are on the register, and they have made a declaration of the appropriate kind about their own interest never being put forward as the reason for a decision, there are then effective measures that will enable the whole issue to be dealt with in detail, with appropriate requirements of sanctions and of effective punishment for those who breach them. We believe this to be absolutely central to the working of the clinical commissioning groups and to the whole relationship of doctors to their patients.
So, with those few words, I hope I can persuade the noble Baronesses, Lady Thornton and Lady Finlay, to have a look at the proposals that we have put forward, which, I am pleased to say, have at least to some extent the support of the noble Baroness, Lady Finlay.
Earl Howe
My Lords, I know full well that noble Lords have some concerns about the potential for conflict of interest in a system of clinical commissioning groups. Those are natural concerns, but I hope to show that the approach that we are advocating has some very specific and robust safeguards within it, which meet the intentions of the amendments in this group.
The CCG constitution provides for dealing with conflicts of interest and specifies arrangements for securing transparency about the decisions of the CCG and its governing body. The governing body must in turn ensure that the group has arrangements in place to ensure adherence to relevant principles of good governance. The CCG’s governing body will have responsibility for ensuring that the CCG adheres to relevant principles of good governance. The Secretary of State can also make regulations for CCGs under Clause 71 of the Bill, which are designed to ensure that in commissioning, CCGs adhere to good procurement practice. These regulations may impose requirements relating to,
“the management of conflicts between the interests involved in commissioning services and the interests involved in providing them”.
These regulations can also confer on Monitor powers to investigate suspected non-compliance. These are the safeguards that the Bill puts in place. My view is that it is unnecessary and indeed undesirable to go further.
Requiring CCGs to adhere to examples of good practice in managing conflicts of interest, such as declarations of interest; or maintaining a register of interests; or the monitoring or registration of hospitality received by members is a temptation, but one that should be resisted. We have got to be very careful about encumbering the Bill and CCGs with inflexible prescriptions as to how CCGs should operate within the statutory framework, or procedure about how they specifically manage potential conflicts of interest. This does not mean that these are not reasonable safeguards. Requiring the governing body to discuss in public choices between potential providers, or publish any decisions made in camera, for example, would remove a necessary discretion around ensuring that sensitive issues, either relating to contract values or performance, or staff matters, were given the appropriate level of confidentiality. I would urge in particular that we do not—as proposed in Amendment 175CC—put restrictions on those from whom a CCG can commission services. Given the importance we attach to ensuring that services are delivered in an integrated way, we cannot afford to cut CCGs off from being able to commission services from local GPs with a special interest, for example, who could deliver secondary care services in a community-based setting.
Baroness Thornton
Will the noble Earl acknowledge that there is a conflict of interest there? There must be a potential conflict of interest there. How does the Bill mitigate that? How does the Bill deal with that? I cannot see from what the noble Earl has said so far that that is going to happen.
Earl Howe
I do not disagree with any of these principles, but I am not sure whether the noble Baroness understood what I said earlier: there have to be arrangements for securing transparency about the decisions of CCGs, and governing bodies have to ensure that CCGs adhere to relevant principles of good governance—think of the Nolan principles, for example, and many other ways in which good governance can take place—but there is no need to specify all this in the way these amendments suggest because the arrangements provided for in the Bill will cover these things. As the noble Lord, Lord Warner, said we are not in new territory here. There are very well established procedures for tackling conflicts of interest when they arise. There might very well be a conflict of interest in the kind of situation to which the noble Baroness, Lady Thornton, has alluded, but there are ways of addressing and coping with that.
The key to this is to have in place a rigorous framework of requirements, approved by the board as part of the CCG establishment process, to ensure absolute transparency and to manage conflicts of interest, subject to oversight—the oversight must be proportionate, but it has to be there. We can put on the face of the Bill, as Amendment 176AD would have us do, a detailed list of behaviours that we would expect members of CCGs to observe. Obviously I cannot disagree, as I say, with the stipulations on this list, but they are already provided for in the Nolan principles and indeed the GMC code Good Medical Practice, to which the noble Baroness, Lady Finlay, referred—and adherence to that is a condition of registration for medical professionals. The noble Lord, Lord Warner, was absolutely right: this code is what GPs and doctors in general fear to transgress. Of course, if one looks at that set of behavioural requirements, they are actually only an ideal and they have no specific system in place to ensure that they are met. The sanction on doctors is the threat that they will be referred to their regulator.
The NHS Confederation was very clear about this, and I have to say I agree with it. The Bill has to allow flexibility for the way that conflicts of interest are handled and developed over time, rather than being rigidly set in law. What the NHS Confederation told us was that conflicts of interest need to be managed effectively otherwise,
“confidence in the probity of commissioning decisions and the integrity of the clinicians involved could be seriously undermined. However, with good planning and governance, CCGs should be able to avoid these risks”.
I agree with that. There is a balance to be reached, and we believe the system that the Bill would introduce for managing conflicts of interest—the key points of which I hope I have described—provides that.
Baroness Thornton
My Lords, I thank the Minister. He will know, as will all those who have been Ministers, that when we are first appointed, we are told—the noble Baroness, Lady Williams, will remember this—that not only must we declare all our interests and have probity about the way we conduct ourselves, but we have to be seen to be doing it. A lot of these amendments are about being seen to do the right thing, and in terms of the relationship between GPs and their patients that becomes even more important. I agree with the noble Baroness, Lady Williams, and the noble Lord, Lord Marks, about their amendments and the need to have proper safeguards and remedies on this.
I think that if we co-operate, the noble Baroness, Lady Finlay, and I can probably crystallise these into something on the face of the Bill. I was disappointed that the noble Earl feels that this is satisfactory in the Bill at the moment, because I think the noise outside this Chamber and the comments from GPs tell us that people are very concerned about it. We need to address that in the Bill. I am happy to withdraw this amendment, but we may need to return to this at a later stage.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, before the House goes into Committee on the Health and Social Care Bill, I should like to take the opportunity to update noble Lords on the latest position with regard to the Department of Health risk registers. The House will recall that my department received a specific request under the Freedom of Information Act to release the transition risk register, which covers risks relating to the development and implementation of our health reforms. There was also a separate request to release the strategic risk register, which covers the most important risks the department faces.
We have taken the view that the information in both registers should be treated as exempt from disclosure under Section 35 of the Act on the grounds that the information contained in the risk registers is integral to government policy-making. Risk registers of this sort are a tool by which information about potential risks—both actual and theoretical—can be recorded in worst-case terms to enable them to be mitigated and managed. The Information Commissioner accepts that the information falls within this category of exemption. Following our decision not to release the registers, the two individuals who made the FOI requests lodged appeals with the Information Commissioner.
In early November, the Information Commissioner published his decision notices in both cases, deciding that the public interest lay, on balance, in full disclosure of both registers. Since then, as is allowed for under the rules, we have been considering whether we should appeal the Information Commissioner’s decisions. As I explained to the House previously, this was not a decision that the Department of Health could make on its own, as the issues which bear upon the decision have significant implications for every government department.
While the principle of openness is one to which we have adhered to the maximum extent through evidence given to the Health Select Committee in another place and the publication of impact assessments, it has been our firm view, and that of other departments, that for risk registers of this type to fulfil their function, civil servants must be free to think the unthinkable and record potential risks and mitigations fully, frankly and with absolute candour, confident in the knowledge that this information will not be publicly disclosed.
The logic of the Information Commissioner’s decision to order the release of information of this nature would entirely undermine the concept of safe space for these sorts of circumstances. The matter has accordingly been the subject of much careful consultation across Government, and a very clear and firm view has emerged that the publication of information in risk registers of this type would be likely, in the future, to undermine the very purpose for which a risk register of this sort is produced, and thus directly threaten the successful implementation of government policy. I can, therefore, tell the House that my department has decided to appeal both decisions by the Information Commissioner.
I would, however, like to respond to the request made on 16 November by the noble Baroness, Lady Thornton, by sharing with the House as much further information as I can about what my department’s transition risk register contains. On that occasion I undertook to examine whether there were any risks covered in the Department of Health transition risk register that are not already in the public domain and on which information could be provided without further ado.
While I cannot share the detailed breakdown of the information recorded in the risk register, or the wording, I am happy to set out for the record the broad issues covered by the transition risk register. They are as follows: how best to manage the parliamentary passage of the Bill and the potential impact of Royal Assent being delayed on the transition in the NHS; how to co-ordinate planning so that changes happen in a co-ordinated fashion while maintaining financial control; how to ensure that the NHS takes appropriate steps during organisational change to maintain and improve quality; how to ensure that lines of accountability are clear in the new system and that different bodies work together effectively, including the risk of replicating what we already have; how to minimise disruption for staff and maintain morale during transition; how best to ensure financial control during transition, to minimise the costs of moving to a new system, and to ensure that the new system delivers future efficiencies; how to ensure that future commissioning plans are robust, and to maximise the capability of the future NHS Commissioning Board; how stakeholders should be engaged in developing and implementing the reforms; and finally, how to properly resource the teams responsible for implementing the changes. I hope that this information will prove useful to noble Lords as the Bill continues its passage in Committee.
Baroness Thornton
I thank the Minister for that statement, of which I did not have more than two minutes’ notice. It is very disappointing indeed. Basically, the noble Earl is saying that the Government are choosing what they do and do not disclose to the Committee on this matter. It is an issue of trust—whether or not we can trust that we will know what we need to know to make judgments about whether this Bill will work.
I thank the noble Earl for the issues that he has decided that the Government can let us know about, but of course I am therefore concerned about what the issues are that the Government have decided that we should not know about. What are the risks that we cannot know about? That is a matter of grave concern to the Committee.
I shall be looking in detail at the Minister’s statement to the House and I reserve the right to return to this matter if I feel that we need to. For example, during the last two days in Committee I put two direct questions to the Minister about whether certain matters—one concerning children—were on the risk register and what the register said about them. I have not received answers to either of those questions. I shall continue to put my questions in that context and I suggest that other noble Lords do the same.
I am very grateful for the Statement as far as it goes but I do not think that this is an end to the matter. I can see why the Government might think that there is a cross-government issue here. However, no other department is in the position in which we find ourselves here—that of discussing a Bill that is going through the House right now. We need full information on this matter in order to be able to make proper decisions but I believe that we still do not have that. Therefore, I thank the noble Earl so far as this goes but I reserve the right to return to the issue in due course.
Lord Campbell-Savours
Perhaps I may ask the Minister a question. He gave us a list of all the areas which he thought it was not possible for Parliament to scrutinise in some detail. Did the Information Commissioner have access to all the document headings to which the Minister has referred, and did he have the opportunity to read all the documentation under those headings? If the Information Commissioner did have access to information on, for example, the handling of the legislation as it goes through Parliament, why did he, throughout the whole report, repeatedly say that these matters should be placed in the public domain? Again, is it not clear that the Government are trying to hide something from Parliament? The Minister’s first reference was to the handling of the legislation by Parliament. Why should not Parliament see what considerations took place within the department concerning how legislation should be handled as it goes through this House?
Baroness Thornton
My Lords, perhaps I may speak to the amendments in this group which are in my name. First, Amendment 110A concerns NICE guidelines and is very much like that tabled by the noble Lords, Lord Newton and Lord Butler. In fact, theirs may be even better than mine so I intend to say no more than that we are interested in the Minister exploring this issue, because those noble Lords both more than adequately covered the points that need to be made in that regard. I am also very pleased to support the amendments in the name of my noble friend Lady Royall and to put my name to those, because the role of specialist nurses is extremely important.
Amendments 118, 119 and 120 concern the duty of the board to reduce inequalities. Proposed new Section 13G of the 2006 Act states that the board must,
“have regard to the need to—
(a) reduce inequalities between patients with respect to their ability to access health services;
(b) reduce inequalities between patients with respect to the outcomes achieved for them by the
provision of health services”.
This seems a rather narrow definition concerned solely with health services, which I assume flows from the continual and overriding responsibility of the Secretary of State for tackling health inequalities. I would be grateful if the noble Earl could confirm to the Committee how the Secretary of State intends to tackle health inequalities—what information he will need, where he will get it from and how those decisions will then be moved through the proposed structures of the National Health Service Commissioning Board, the CCGs and so on.
Surely, the health and well-being boards would want to have some involvement from the NHS on health inequalities, so Amendment 118 seeks to ensure that the board has health inequalities in its remit. I particularly refer the Minister to the letter from the NHS Future Forum to the Secretary of State on 17 November where it devoted much attention to the NHS role in improving public health and made its claim that the NHS must design its services in a way that both promotes good health and prevents poor outcomes. It is thus important that the legislation provides sufficient leeway to allow the NHS Commissioning Board to do this and that legislation relating to health inequalities is not confined solely to the provision and commissioning of services.
What is also important, in coming to my Amendment 119, is that funding to the clinical commissioning group reflects the deprivation levels within its area. Can the Minister tell the Committee whether there has been a risk assessment on the issues of funding? What risks has the department found that go with the levels of funding that might be made available on the basis of deprivation levels within areas?
Of course, the decision of the Secretary of State not to make clinical commissioning groups area-based is a serious problem in ensuring a population base for commissioning, but it will be doubly important to ensure that clinical commissioning groups with large numbers of deprived patients receive financial support. I would be grateful if the Minister could spell out the intended principles behind the funding associated with clinical commissioning groups.
On Amendments 110B, 127ZA and 190AA, which concern maternity services, the noble Baroness, Lady Cumberlege, has adequately covered the major concerns about those services and we would be keen to support her amendments. I am grateful to the Royal College of Midwives for its briefing on these amendments. My only questions are about maternity networks and the recognition of their potential contribution to the type of maternity care and providing clinical commissioners with expert guidance and advice on driving up standards.
The Committee will be very pleased to hear that I do not intend to share any birthing stories. On the other hand, I am concerned. Without a national standard for maternity services, how will the new commissioning arrangements avoid significant variations? We know, for example, that there is a significant variation between trusts in the number of home births that take place. We can explore the reasons for that, but I would like to know how the new structures would deal with such variations and how that would be reflected in the work of the National Health Service Commissioning Board.
Baroness Williams of Crosby
My Lords, I have Amendment 112 and 113 in this group. I have a comment regarding the excellent speech of the noble Baroness, Lady Cumberlege, and would like the Minister to reply to it. NICE has suggested that all women expecting babies could have the right to consider the possibility of a caesarean birth. Before the choice is finally made, will that be associated with advice from doctors indicating that caesarean births are certainly not as straightforward as some people believe them to be, and for cosmetic reasons may be deeply regretted afterwards? I was a little worried that NICE had given this green light, as it were, to caesarean births without associating it with any form of counselling to the mothers concerned, not least because, as many people in this House will know, the outcomes in terms of morbidity and infant mortality are not as good as people imagine them to be in comparison with a normal birth. Perhaps the Minister could say something about that. Perhaps the noble Baroness, Lady Cumberlege, could also say something about it when she responds on her useful and important amendments, to which I hope the House will give an extremely warm welcome.
Amendments 112 and 113 are about strengthening the language about health inequalities. On that issue, we have had a helpful letter from the noble Earl, Lord Howe, dated 24 November, in which he sets out in detail some of the steps that will be taken, not least the creation of the Institute of Health Equity, to deal with health inequalities. My question is rather a big one but it boils down to the old problem of how one ensures that these worthy and excellent intentions are actually carried out.
The House will remember that new Section 13F of the 2006 Act proposed in Clause 20, which deals with the autonomy of clinical commissioning groups from the Commissioning Board and restricts the board’s actions in terms of having to bear that autonomy in mind, was put into a different set of considerations—the consideration of the whole of the responsibility of the Secretary of State and the responsibilities of the boards—under the headings of Clauses 4 and 10.
All of this means that we are still debating these issues without being clear about where responsibility for them ultimately lies. I do not propose to go over that ground again, but it is appropriate for this debate to notice that the whole set of duties that are laid out in detail—and to which this debate will undoubtedly add as it lays down further duties for clinical commissioning groups and the board as a whole—in a sense therefore depends upon the outcome of those discussions about the constitutional structure. That matters because we need to bear it in mind all the way through our consideration of the duties that are laid upon clinical commissioning groups.
What makes me, to be honest, even more concerned is that I recently read the discussion paper The NHS: Developing Commissioning Support, which was quite improperly, no doubt, leaked on the internet. My attention was drawn to it by a couple of doctors who had access to the internet. The paper sets out in detail the ultimate objective of moving towards a commercial market in the health service and sets it out under a considerable number of different headings. For example, there is a specific mention in this report that,
“Clinical commissioning groups will have a statutory freedom to secure the commissioning support from wherever they want”.
It goes on to say that the commissioning support should be given in a vibrant, commercial market. What worries me about all this is that I am not at all clear—and never have been in our long debate on health—about what the ultimate goal is. I suspect that we are discussing two things at the same time. One is the attempt to keep improving the existing NHS, sometimes by an extraordinary degree of micromanagement—from this House, I have to say. The other is the determination of many people in this House to ensure the safety and continuation of the NHS which is free at the point of need and which is available to people regardless of their ability to pay. Somewhere along the line and at some point, we really have to be clear what we are talking about. I do not know whether others taking part in this debate share my sense that we are walking in without knowing the constitutional responsibilities and quite where we are going.
I commend my two amendments. They both strengthen the words on equality of health outcomes. I congratulate the Government very much on establishing the Institute of Health Equity and carrying forward the detailed research we are now doing on lifestyles and many other things, which are important and which I am sure the whole House will applaud. However, I have to raise the big question about destinations. I hope that at some point before we abandon the Committee stage, we will have a clearer view about the Government’s ultimate destination: whether it is to retain an NHS; whether it is to make it more open to innovation and other contributions from the private sector, with which many of us would certainly not disagree; or whether the ultimate outcome is to move towards a commercial market system, this being essentially a transitional stage.
Lord Warner
My Lords, I do not intend to follow that in a similar style. I support Amendment 144 in the name of the noble Lord, Lord Patel, to which I have added my name. I do not want to go over the ground covered by the noble Lord, Lord Patel, but I just wish to share with the Minister in particular and the House in general my own experience from introducing near-miss reporting in the NHS when the National Patient Safety Agency was established. In those good old days the figure was around 800,000 a year. The current figure, as my noble friend Lord Patel said, is of the order of 3,000 a day; it is on an upward incline.
The issue at stake in those days was not the principle of trying in effect to copy the airline industry and improve safety by having people come clean about near misses—some very serious, some less serious. No one disputed the merits of trying to learn from those experiences. Where everybody got a little concerned was around the making public of the information. I will not delight the House with some of the discussions that took place in Richmond House about whether the first lot of information should be made available, because who knew what the Daily Mail would do with it? Noble Lords will be pleased to know that the Daily Mail behaved in a predictable manner and ran screaming banner headlines about how near to death 800,000 people came each year.
The important point was that one was beginning to change the culture of the NHS, which knew that the information was being put in the public arena. The problem with the Bill is that it leaves to the board the decision about how to disseminate information. We as citizens would be better off putting in the Bill the specific organisations to which the information should be disseminated—which is what the amendment of the noble Lord, Lord Patel, does. I strongly support it and hope that the Minister will give it very careful consideration, and will carry on the publication and dissemination of the information on an agreed basis.
I will make a couple of remarks in response to the concerns expressed by the noble Baroness, Lady Williams, about a market in commissioning skills. I have no particular wish to promote a market in commissioning skills. However, as a former Minister responsible for the performance of primary care trusts, I say that many trusts seriously lacked commissioning skills. These were lacking particularly in areas such as collecting information, analysing it and using it to establish need and to procure services to meet those needs. We should not in the Bill do anything to limit the ability of the new clinical commissioning groups to receive and acquire the skills to enable them to do their job effectively, wherever the skills may be located. That is a very important part of introducing successful new arrangements for clinical commissioning.
I pray in aid of that approach the history of Dr Foster. The dear old NHS had been collecting data for decades but was unable to use them effectively to improve performance. It took an outsider coming in—Dr Foster—to use the information and turn it into something that was useful to the NHS in terms of improving its performance. We should not be too hung up on precisely where clinical commissioning groups get their skills from to do their job.
Baroness Thornton
My Lords, I forgot to speak to my Amendment 137A. I will make three points. The first is not about my amendment. I say how much I agree with the noble Baroness, Lady Williams, on the issues that are the subject of all the amendments to Clause 20, and of the debate and discussions that we are having in the Chamber and outside it about the mandate. I also say to the noble Lord, Lord Marks, and my noble friend Lord Harris that there is clearly an issue about information and confidentiality that must be addressed before the Bill leaves the House.
I will also say how much I agreed with the orphan amendment of the noble Baroness, Lady Finlay. Mine, too, is something of an orphan amendment but is rather important. Amendment 137A states:
“The Board must ensure that in relation to its duties under sections 13C to 13N, those persons in the private sector contracted to provide health services must contribute in the same way as public providers towards the achievements of those duties”.
Those duties are to do with the NHS constitution, effectiveness, quality, reducing inequalities, patient involvement, patient choice, innovation, research, integration, and the impact of those services. It is very important that we have clarification that all providers have a duty to promote those.
Baroness Thornton
Baroness Thornton
My Lords, we move on now to discuss innovation and research. The amendments in this group are very important and were prefigured to an extent by the discussion we have just had. The amendment tabled by the noble Lord, Lord Hunt, and me, is modest in some ways. However, it strengthens the promotion of innovation in the provision and commissioning of health services. Taken together with the amendments tabled by my noble friend Lord Warner and the noble Lord, Lord Patel, it strengthens the Bill significantly and in a very important way.
We have come to what seems an intractable problem: how to encourage innovation in the NHS. This is part of the Minister's area of responsibility and was also part of the area of responsibility of my noble friend Lord Warner when he was a Minister. I look forward to both of their contributions on this matter.
We know that often, the taking up of great innovation is a painfully slow, complex and bureaucratic process. Our amendment strengthens the promotion of innovation through commissioning as well as through the provision of health services. I would like the Minister to explain why that should not be possible—because it would strengthen and help innovation—and also how it could be done, because we are looking for incentives to promote and spread innovation throughout the NHS.
Last week, the noble Lords, Lord Willis and Lord Ribeiro, and I, with others, enjoyed a dinner and an evening with organisations and businesses to discuss how to ensure that innovation is disseminated, promoted, supported and invested in throughout the NHS so that both the NHS and UK plc benefit. The point was made during the evening that often we do not talk about sophisticated issues but about simple changes to nursing practice, such as the way dressings are done, or to information management, that nevertheless can have an important impact on patient care and progress.
I will not speak further on the amendments because I will be very interested to hear what other noble Lords speaking to their amendments in the group will say. I hope that the Minister, with his passion in this area, will give us some comfort on the matter. I beg to move.
Lord Warner
My Lords, I will speak in support of Amendments 129 and 129A in the group. First, I will take up the point made by my noble friend Lady Thornton about the long-standing problem of the slowness of the NHS to take up innovative ideas, and the frustration often felt by people in this country who have invented new approaches and created new innovations, only to find that they have had to go abroad to get them projected, promoted and sold, with the NHS being one of the last to take up the innovation, which was often funded in one form or another with public money by the British taxpayer. It is a long-standing problem and not a party-political issue; it has been a challenge for successive Governments. One of the most embarrassing moments one has as a Minister is when one meets foreign delegations or travels abroad to back Britain and is asked, “Has this innovation been taken up in the NHS?”, whereupon one has to shuffle one’s feet and think of a suitably weaselly form of words to avoid answering the question directly. It is a very long-standing and difficult issue.
Amendment 129 draws attention to the importance of the procurement of goods and services in the promotion of innovation, and to the duty that that places on the national Commissioning Board. There are many reports about the importance of public procurement in advancing innovation and in ensuring the take-up of UK inventions and innovative practices. The latest one was by the Science and Technology Committee of your Lordships' House, of which I was a member. The report brought out some of the dilemmas around using procurement to take forward innovation. Yet again it cast doubt on central government's use of their purchasing power and muscle to drive the take-up of UK innovations in public services.
The NHS is not alone in having this problem, but it is part of the problem and it is a big part of the public sector. A major and long-standing problem is that too many purchasing decisions are taken too far down the organisational food chain, with too little intervention at senior level and too little willingness to use large-scale purchasing to spread the use of innovative approaches. Whatever else the national Commissioning Board has, it has a lot of financial muscle. It must use that, through the NHS’s purchasing capacity, to drive innovation, which often comes from publicly funded research. I hope that the Minister, who is well aware of the issue, will see the sense in putting something like Amendment 129 in the Bill. We cannot say too often that public procurement is a way of helping to establish and drive innovation in the NHS.
Amendment 129A seeks to add the idea of an innovation fund to the board's armoury on innovation in new Section 13K. There is nothing novel in this. The amendment continues and builds on the proposals of my noble friend Lord Darzi, which led to regional innovation funds that strategic health authorities currently manage. Again, we need to strengthen the mechanisms in the Bill for driving innovation in an NHS that historically has been slow to take up innovations and apply them to scale for the benefit of patients. We are not talking about huge sums of money in the innovation fund, but relatively modest amounts in relation to the scale of NHS expenditure. However, an amendment of this kind would ensure the continuance of the useful work that has been started by the strategic health authorities following the promptings of my noble friend Lord Darzi.
It is typical of what we sometimes do in this country. We start an initiative with a fund at strategic health authority level and then shuffle the cards so that somehow, along the way, some of the initiatives and their benefits get lost. I hope that we can get some reassurance from the Minister that some kind of innovation fund will be available so that we can continue the work that my noble friend Lord Darzi so ably started to ensure that patients can secure the benefits of UK innovations.
Earl Howe
My Lords, the NHS has a long and proud track record of innovating and delivering better care for patients. That must continue—we all agree about that. That is why new Section 13K of the 2006 Act places a duty on the board to promote innovation when exercising its functions, including innovation in the provision of services and the,
“arrangements made for their provision”.
That last phrase means the commissioning of services. As a result, although we completely sympathise with the principle behind Amendment 128A, it is not necessary. The duty is intended to support the delivery of quality and productivity improvements across the NHS to help transform healthcare for patients and the public. In response to the noble Lord, Lord Warner, I say that I expect that innovation in procurement of goods and services will be an essential part of this. The duty certainly allows for it as it stands. It is an important part of the QIPP programme at the moment, and I am sure that it will continue to be. If we were to specify one area of activity in which the duty should be exercised, as Amendment 129 suggests, we would face the perennial problem of listing those areas where the duty should be exercised to the detriment—
Baroness Thornton
I am sorry to interrupt, but it strikes me that if none of us understood that that was what those words meant—that was what led us to table the first two amendments in this group—maybe the Minister should look at those amendments, because they offer more clarity.
Earl Howe
I am always keen to accept the wise suggestions of the noble Baroness, and I will of course go away and consider the words that she has proposed.
I was just referring to the amendment proposed by the noble Lord, Lord Warner, on procurement, and saying that we would face the perennial problem of listing those areas where the duty should be exercised to the detriment of those not listed.
Earl Howe
I recognise that and, after what I said a moment ago, we know that procurement can be an important lever in the innovation agenda. Indeed, that will be recognised in the innovation review, which is due to be published next month. Furthermore, we are planning to launch a procurement strategy by April 2012. I will not go into huge detail about it, although I have it here, but it will consist of three elements—system levers, standards for procurement and system level support. We can look to take forward some of the ideas that the noble Lord, Lord Warner, put forward in his speech.
All this goes to show that there is a substantial amount of work already under way to create the right conditions for innovation to flourish. These include dedicated regional innovation funds to support front-line innovation and innovation challenge prizes to recognise and reward ideas that tackle some of the biggest health and social care challenges facing the NHS and in future. I have named only two from a long list of current initiatives.
I will just say to the noble Baroness, Lady Finlay, that the Secretary of State already has a power to awards prizes. New Section 13K of the 2006 Act, inserted by Clause 20, simply gives the board the same power. Should it choose to use the power to make payments as prizes—and it is a power rather than a duty—this is one way in which it might decide to promote innovation in the provision of health services. Recently I presented the very first group of innovation challenge prizes, and it was a very heart-warming and exciting occasion.
The noble Lord, Lord Warner, rightly made the point that the NHS was slow to take up innovation and that people were forced to go elsewhere to take their new ideas forward. Again, this is an issue that we are tackling with considerable energy in the NHS chief executive’s review of adoption and diffusion of innovation, which will be published next month. I look forward to talking more to the noble Lord about what is in that review in due course.
I say to the noble Baroness, Lady Morgan, in particular that the main way in which the board will collaborate with research funding bodies is to fund the treatment costs of patients who are taking part in research funded by government and research charity partner organisations.
The existing innovation funds were not put in primary legislation; there is no need to put a specific power in the Bill, as Amendment 129A seeks to do, to enable the board to establish an innovation fund. As with prizes, establishing innovation funds is only one way in which the board might seek to exercise its duty to promote innovation; innovation funding is being considered as part of the chief executive’s innovation review.
Amendments 130 and 131 reflect the similar and previously debated Amendments 39 and 41 on the equivalent duty on the Secretary of State in Clause 5. I agreed to undertake a closer consideration of that duty and I shall do that. I reassure noble Lords that our discussions will include the board’s duty. Work is under way to look at these duties ahead of future stages of the Bill. Indeed, I undertake to reflect carefully on the points raised by the noble Baroness, Lady Morgan of Drefelin, and to write to her with answers to her questions. I have also written to all noble Lords who spoke in that earlier debate, picking up points that I was not able to cover at the time. I explain in that letter how public health falls within the definition of the health service, which was one of the points touched on by the noble Baroness. It will therefore be covered by the existing duty on the board to promote research in proposed new Section 13L of the 2006 Act.
The noble Lord, Lord Patel, spoke about the role of the tariff in promoting innovation. He is absolutely right to do so; the new tariff could indeed play a key role in encouraging innovation. The Bill introduces a new, independent, transparent and fair pricing system where the board and Monitor would collaborate to set prices for NHS services. That would create a more stable and predictable environment, allowing providers and commissioners to invest in technology and innovative service models to improve patient care. We are actively looking at the way in which the tariff could drive that.
My noble friend Lord Willis and, indeed, the noble Baroness, Lady Morgan, asked how exactly the board will go about promoting research. As previously set out, we will make sure that the systems and processes for commissioning used by the board and clinical commissioning groups ensure that research is promoted, supported and funded by the NHS. That will include the tariff, the commissioning guidance and the processes for authorising and supporting development of clinical commissioning groups. However, noble Lords will be aware that a great deal of the practical detail of the board's role is still under development. Further detail will be published in due course and we must respect the autonomy of the board in devising for itself how exactly it will undertake this function.
I turn to Amendments 147, 149A, 150, 215 and 218. Given the wide range of statutory duties placed on the board and CCGs, the approach we have taken in the Bill is to emphasise a few key duties that the board must look at—in particular, in its business plan, annual report and its performance assessments—and that CCGs must, in particular, look at in their commissioning plan and annual report. We feel we have chosen the right duties to emphasise, not because they are the most important but because they are duties about which any annual report, business plan, commissioning plan or assessment should provide explicit evidence, specifically linked to the exercise of the board’s or CCGs’ functions.
That said, with respect to clinical commissioning groups I say to my noble friend Lord Willis that the department has published Developing Clinical Commissioning Groups: Towards Authorisation and that, to be authorised, a CCG will need to demonstrate that it has in place the systems and processes both to promote patients’ recruitment to and participation in research, and for funding the treatment costs of patients taking part in research, so this will not be overlooked. However, we are clear that an annual report, business plan, commissioning plan or annual assessment should provide an assessment of all the body's functions, including the exercise of its innovation and research duties. There is also nothing to prevent the documents going into significant detail about the exercise of a specific duty. I add that the board has the power to issue guidance to CCGs on the contents of commissioning plans and directions as to the form and content of the annual report. I hope that those remarks are helpful in answer to the questions and points from noble Lords, and that they will be sufficiently reassured by what I have said not to press their amendments.
Baroness Thornton
I thank the Minister for those remarks and all other noble Lords for theirs. This has been a very high-quality, expert debate. I do not want to delay noble Lords from their supper and, indeed, on this side, from an opportunity to defrost—we have hypothermia on this side. The Committee has again shown its great expertise, commitment and enthusiasm to innovation and research and there is great consensus across the Committee about this. This suite of amendments would have given practical action and voice, and would have strengthened this part of the Bill on innovation and research. We need to look at what the Minister has said. I am grateful for those areas where he said that he would reflect upon these issues and let us know. However, it is safe to say that because of the consensus in the Committee on these issues, we would all be keen to make sure that the issues of innovation and research are, indeed, put beyond doubt in this Bill. I beg leave to withdraw the amendment.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Thornton
Baroness Thornton
My Lords, three amendments are tabled in this group in my name and those of my noble friends. They are principally probing in nature on some important points that need clarification. Amendment 136 would leave out the duty on the board in respect of the variation of the provision of health services; while Amendment 268 would leave out the instruction that:
“Monitor must not exercise its functions for the purpose of causing a variation in the proportion of health care services”;
while the third element of the group seeks that Clause 144 should not stand part. This clause relates to the:
“Secretary of State’s duty as respects variation in provision of health services”.
It would seem that this group of provisions provides the Secretary of State, Monitor or the NHS Commissioning Board with the ability to increase or decrease the share of market for the provision of health services held by a particular group of providers. I assume that this also applies to CCGs, but I would be grateful to the noble Earl if he could explain whether that is the case. I would also be grateful if he could say how these will impact on the provision of primary medical services and the contracting for them by the NHS Commissioning Board. Can he further say how this will affect the commissioning of services by CCGs when they propose to commission services either from hospitals, other primary care providers or private sector hospitals? I suppose that what we are seeking is clarification of the definition of “providers”. For example, let us say that a strategic decision was made by a clinical commissioning group to switch priority from secondary care to community care and that it was a deliberate decision to increase or decrease the share in the market by a particular group of providers, what would be the implications of that for other providers? We also need to think about the issues of cherry-picking that have been mentioned.
This clause was added with a certain amount of fanfare as the Government’s response to the Future Forum and attracted claims of victory by the Liberal Democrats over the threat of privatisation. I give them credit for trying to protect the NHS from the full force of the then draft Bill. But the reason why we want to explore these provisions is that we are concerned that they will not achieve what has been claimed for them. As with so many concessions, you need to scratch beneath the surface to see whether they actually achieve what you want from them.
First, are these provisions effective in achieving the aim of preventing the overt promotion of private companies in the National Health Service? The impact assessment of the Bill still states that the aim is to promote a so-called “fair playing field”, and it goes on to say that, an important way of making the market work will be to rebalance so-called fair playing field distortions, citing a report which calculated that the NHS enjoys a £14 cost advantage over the private sector for every £100 it spends. We know that at present around 3 per cent of NHS funding is spent on the private sector. This is also taken as an indicator of an unfair playing field for private providers. Therefore, in order to achieve parity between the sectors, the Bill requires that all CCGs, Monitor and the Secretary of State should provide extra subsidies to the private sector, and to promote it so that it does have parity. If this does not happen then, according to the Government’s own impact assessments, these reforms will fail.
We also know that other words and actions from the Government suggest that the promotion of the private sector is continuing unabated. The noble Earl himself reportedly told a private health company conference that the reforms offer huge opportunities for the private sector. Most recently, we have had the continuing agenda confirmed by an operating framework that sets out both the agenda for the commercialisation of commissioning support, which is a deliberate policy to remove commissioning from the public sector, and the announcement of a performance measure of the trend in value/volume of patients being treated at non-NHS hospitals. On this side of the House we are unconvinced that this intention has gone out of the Bill and remain concerned that the long-term aim of using competition law and the market to provide a wedge for privatisation has not been removed. I ask the Liberal Democrats to look at these questions very carefully. On this side of the House we question this clause because we do not think the NHS can—or should—be blind to the governance and ownership of its providers.
We think it is right that the Secretary of State should be able to say that the NHS is the preferred provider in certain situations, particularly where existing services are performing well through performance management, collaboration and professional motivation. It may be desirable for a commissioner to maintain continuity of emergency and critical care services that are not amenable to the open market and in order to do so it may need to manage the system of providers locally. We are learning the hard way from Southern Cross what happens when commissioners turn a blind eye to the governance and business models of providers of social care. We should not be afraid of saying that organisations with a social purpose should sometimes be promoted above those driven by narrow financial interests.
That is not about preserving the world the way it is, or perhaps once was. We think this clause could actively prevent policies that this side supports and which have been promoted in government, including the right for NHS staff to request to set up a mutual social enterprise—we will be discussing that in a later group of amendments—with support to do so and protections from well-financed bids from multinational companies. We understood that the parties opposite supported these aims as well, but in supporting this clause they may show to the third sector that they will have no more assistance in development from this Secretary of State.
It is worth noting that while the amendment was introduced following the Future Forum, Peers will have received a briefing from ACEVO whose chief executive chaired the choice and competition strand of the Future Forum exercise. Therefore, my final remarks are from that briefing. This is what ACEVO has said:
“We believe that the unintended consequences of the Government’s policy to ‘outlaw any policy to increase the market share of any particular sector or provider’ would be that people in the NHS Commissioning Board and NHS more widely would interpret the Health and Social Care Bill to mean that capacity building and other policies which support the development of voluntary and community organisations would become illegal”.
It goes on to say that this would have the unintended consequences of:
“Stymying various Government policies, from building the capacity of charities and community groups to supporting public sector staff to form new mutuals/social enterprises (the Department of Health previously said it wanted to ‘create the largest and most vibrant social enterprise sector in the world’ … Making it harder for charities and community groups to provide services and support that many (particularly those who are vulnerable and hard to reach) rely on”.
This is a very serious probing amendment. Between now and Report it is going to be very important that all those organisations and parties who think that they have solved the problem, consider that they may, in fact, have made the situation worse. I beg to move.
Baroness Williams of Crosby
My Lords, I remain puzzled by these amendments from the Labour Benches because it seems quite clear that the purpose of the provision was to make sure that the commissioning groups and the board would not use their considerable influence and power to change, for dogmatic reasons, the balance between private and public sector provision. That must be right. It must be right that only quality and the response to patients’ needs should determine what that balance is. I very much welcome this provision. I thought it was an important safeguard against anybody seeing the Bill as having a particular dogmatic purpose. I was quite surprised that the Labour Front Bench took a different view and put down these amendments. It seems as if it was determined to find some flaw in this provision and it is a provision that is intended to show genuine commitment to a level playing field. It is perfectly proper for the Labour Front Bench to pursue questions about the provision but it is quite clear that it refuses to take the provision, even for a moment, at face value.
I have one or two questions. I know that the hour is late so I do not intend to keep the House for more than a moment or two, but there are some interesting questions to raise. One question was about the position with regard to the partnership that has been advocated by the Minister in other parts of this Bill and the deliberate attempt to reach partnerships between the private and public sector. For example, the private sector in its role of innovating and coming up with new ideas would be very properly in some cases partnered with a public sector body, such as a clinical commissioning group. How does the Minister see that as compatible with the wording of the Bill?
The wording of the Bill is pretty clear. It relates first to the board and then to Monitor and makes it plain that in both cases those boards should not use their particular powers to advance the cause of one side or the other. Therefore, I found it puzzling that this set of amendments should be tabled—in particular the attempt to decide that Clause 144 should not stand part of the Bill.
With those words, I wait for the Minister’s reply. I do not want to delay the Committee, but I have to say that I was genuinely puzzled by the Labour Front Bench’s decision to put down amendments of this kind and to question Clause 144.
Baroness Thornton
I think that I explained to the noble Baroness earlier today that these are probing amendments. When we received the briefing from ACEVO, we were very concerned, and that is why we tabled the amendments. It is very important for those of us who have been promoting the voluntary sector all these years that we find out what the truth is. They are probing amendments; there is no intention at all to press them, and I said that from the outset. They are to explore the meaning and the effect of the provisions. Sometimes amendments can have unintended consequences. I hope that the noble Baroness will accept that this is not partisan; it is a genuine effort to get some explanation for how this part of the Bill might work.
Lord Warner
My Lords, I hesitate to intervene in this debate, but I am prompted by the intervention from the noble Baroness, Lady Williams of Crosby. I speak as someone who is probably some way away from the Labour Front Bench on the subject of competition. I do not start from the same position as my noble friend, but like her I am extremely puzzled about what the Government are trying to do. We may be in the realm of unintended consequences.
We go back to July 2010, when the Government published a White Paper that said that the aim was to make the NHS the largest set of social enterprises in the world. That was the Government’s policy. It is quite difficult to achieve that, I would suggest, without some capacity building—and I was one of the Ministers involved in setting up the Social Enterprise Unit in the department, under the previous Government. The Minister will know about the case of the East Surrey nurses and their attempt to set themselves up as a social enterprise. It is very difficult for people to set up these new forms and organisations without some assistance and capacity building.
Looking at the data, you can see that the voluntary and community sector currently delivers only a tiny proportion of NHS services. The National Audit Office estimated that over 2007-08 PCTs spent less than 0.5 per cent of the NHS budget on commissioning services and support from the voluntary sector. So we are dealing with a minute proportion of the provider side of the NHS when we talk about social enterprises and voluntary organisations. Those sectors cannot grow bigger without some assistance; they have to be given some help; there has to be some investment of resources in capacity building so that they can compete for contracts and provide alternative ways of providing services outside hospital in a community setting. In many parts of the country, they are the big hope for actually producing a set of services which are not based on in-patient care of individuals. We are never going to get to that brave new world without some capacity building. As far as I can see, in their attempt to reassure their coalition partners on the subject of competition the Government may have shot themselves in the foot on this issue.
We need some clarity about what the Government are up to on the subject of the voluntary and social enterprise sectors. Forget the private sector; we need to know how they will grow those sectors, which seems to be their declared aim, without some capacity building and without altering the proportion of services that those sectors provide in the coming years. I would be glad to be reassured by the noble Earl but, as I and ACEVO understand it, the Bill as drafted freezes the proportion. We need to understand from the Minister whether the Government are going to amend it to clarify that position, because it is certainly exercising the outside world.
Earl Howe
My Lords, let me explain. Monitor cannot on its own do anything. It cannot drum up competition from thin air even if it wanted to. We will come to that in a later part of the Bill. The aim of these duties is to prevent national policies which aim explicitly to influence market share. The duty would apply in the same way as it does for secondary care—the noble Baroness, Lady Thornton, asked that question in the context of primary care. The board may take steps which have the effect of increasing market share in order to meet some other purpose—for example, filling a gap in provision—but the board cannot act with the aim or intention of increasing or decreasing the market share of a particular type of provider. That is the distinction. We are clear that there should be an absolute prohibition on Monitor and the board acting with the intention of varying the market share of a particular type of provider.
Baroness Thornton
My noble friend is puzzled and I am too. How will they do that? What mechanism will be used to change the market share?
Earl Howe
My point is that either for the board or Monitor to act with a specific view to change the market share for its own sake would run counter to these provisions. However, that does not mean that the market share of the NHS, the independent sector or the voluntary sector could not change. It depends entirely on what is seen to be in the interest of patients. In a particular area of the country, one might find that there was a considerable case for increasing the share of social enterprises in order to meet the needs of patients. That would not be illegal. What would be illegal would be the board setting out with the express intention of expanding a particular sector for the sake of it. That is the distinction here.
Earl Howe
My Lords, we will come quite soon, I hope, to Part 3 of the Bill, which deals with competition more generally. Much will be revealed at that time, but I can say to my noble friend Lord Greaves that I would be happy, if it would help him, to wrap up the meaning of that particular phrase in the letter which I am going to send on these examples. They are—I ask him to believe me—well chosen words.
Baroness Thornton
My Lords, I thank the Minister for his answer. I wish I could say that I now completely understand everything about these clauses, but I do not think that is true. I will read what the Minister has said and look forward to reading his letter. It may be that what we actually need is to have some discussion with the voluntary sector—with ACEVO, NCVO, the Social Enterprise Coalition—so that we, and they, can be completely clear that this is indeed a benign part of the Bill and is not going to affect their work or their future. If the noble Lord, Lord Greaves, thinks that this wording is a bit difficult, just wait until we get to Part 3. I beg leave to withdraw.
Funding of Care and Support
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Thornton
My Lords, I thank my noble friend Lady Pitkeathley for initiating this debate and pay tribute to Andrew Dilnot and his colleagues, including my noble friend Lord Warner, for the report which they produced in July this year. I am sorry that no Conservative Members on the Benches opposite are present to take part in this debate because the band of “usual suspects” to which reference has been made includes members of the Conservative Party. Their voices have been missed in this debate.
I am grateful to all noble Lords who have taken part in the debate for their insights. We felt that it was important that those on these Benches should initiate this debate as we seem to be at a standstill, or making slow progress, on many social care fronts, and in some areas are possibly moving backwards. That is a matter of grave concern. I echo the final words of my noble friend Lord Warner that we cannot afford not to do anything.
We can all agree that the need to secure a sustainable funding settlement for social care has never been more urgent, with local government and NHS finances under significant pressure and demand for services increasing as the population ages. We all agree that the NHS will never work properly without a sustainable approach to social care funding. The Dilnot report therefore offers a credible and costed way forward. We believe that the Government must move quickly to undertake detailed work on the report’s recommendations and honour their pledge to publish a White Paper, followed by legislation in 2012.
The adoption of the capped cost framework recommended by Dilnot offers a fairer and more transparent way of sharing the costs of care between the individual and the state. This will make it easier to tackle the deeper problem of underfunding that has led to the tighter rationing of services and escalating levels of unmet need, which have also been mentioned by several noble Lords, including my noble friends Lord Lipsey and Lord Warner, and the noble Lord, Lord Sutherland.
The much mentioned budget deficit is no reason for delay. The questions of affordability go beyond the current economic situation, and the additional public spending needed to fund the proposals, as we have noted, is less than 0.25 per cent of GDP. The social care system is widely regarded as inadequate, unfair and unsustainable. Under the current means-testing arrangements, anyone with assets of more than £23,250 must pay the full cost of their care. This leaves one in 10 people over 65 facing costs of more than £100,000. Eligibility criteria for council-funded services have been tightened whereby in most areas only those with very high needs now qualify for help.
The squeeze on local authority budgets over the next four years will widen the gap between needs and resources, despite the additional £2 billion announced in the spending review and the best intentions of all local authorities to protect social care. As my noble friend Lord Warner mentioned, the King’s Fund estimates that a funding gap of at least £1.2 billion could open up by 2014 unless all councils can achieve unlikely and unprecedented efficiency savings.
In addition, only this week, the report of the EHRC, led by the noble Baroness, Lady Greengross, shone a light on the too often invisible experiences of older people receiving care at home. It reveals a service stretched to the limit and older people denied the dignity and respect they deserve. It is shameful and unacceptable for elderly people to be left for hours without food and drink and not properly cleaned.
We know that the Dilnot report called for the improved integration of health and social care. Evidence suggests that this can improve outcomes for individuals and deliver cost savings. We know all this, and we have been talking about it not only for the past 40 years but in the past few days during the proceedings on the Health and Social Care Bill. However, despite notable successes, the progress has been limited, with less than 5 per cent of NHS and social care budgets being subject to joint arrangements and wide variations across different parts of the country in the quality and achievement of joint working. Indeed, part of our scrutiny and testing of the Health and Social Care Bill is whether it will make that situation better or worse.
Nor should we forget that Dilnot did not claim to have the whole answer to the challenges that we face. He claimed that his report was part of the process and addresses very importantly, among other things than those I have mentioned, the injustices of portability of care assessments. The Government’s response to the Law Commission report is most important and was mentioned by my noble friend Lady Wilkins and the noble Lord, Lord Pearson of Rannoch. The Minister should be able to respond that progress is being made on this and other matters.
The proposals for carers are also important in the Dilnot report, as is the establishment of a national source of advice. The commission recommends that better advice should be complemented with a national awareness campaign on the cost of care and a new funding system. I look for that to be part of the Government’s response to this report. Indeed, the assessment and provision of services will be available using the same system as for older people, but the funding cap will work differently for younger adults and the report sets out how this might be achieved.
We must not forget that the need for timely, effective social care not only involves the long-term disabled, those in old age and people with long-term conditions. I thank Macmillan for its briefing and for reminding us that integration across health and social care is also vital in helping to meet the practical, emotional and financial needs of people living with cancer and those reaching the end of their lives. Macmillan welcomes the findings of the Dilnot commission, as it believes that the report also represents the foundation for a fairer funding system for social care.
I have mentioned all the things on which we agree, and I have done so quite deliberately. We all agree that we urgently need a long-term solution for the funding of social care, and that is why Labour offered cross-party talks on this issue from the outset. I urge the Government to get round the table so that we can tackle the care crisis and find a fair and sustainable solution for the future.
I hope that what I have to say now may help the scepticism of the noble Baroness, Lady Barker. Indeed, when I explain how we would like to proceed, I hope that she will nudge her own Government into conceding on this and making faster progress than they have done so far.
As the Minister will recall, when the Dilnot report was launched in early July, my right honourable friend the leader of the Labour Party welcomed it and offered cross-party talks on the future of social care, using the report of the Commission on Funding of Care and Support as a stepping stone to secure a better, fairer system of care for older people and the disabled. I understand that there was an exchange of letters in September and October, and most recently a letter to the Secretary of State dated 8 November.
There are some outstanding questions that the Government need to address in their commitment to this process, and I should be grateful if the Minister would indicate to the House whether progress on them has been made. There are four points. First, securing agreement on funding and implementing the Dilnot proposals clearly goes beyond the remit of the Department of Health and the Secretary of State for Health—it should involve all the departments affected. Given the public spending implications of both the Dilnot proposals and the rising costs and needs, the engagement of the Treasury in this process is crucial. Does the Minister agree with that, and is there agreement that that is how we need to proceed?
Secondly, the Government should nominate an independent person to chair the talks. Again, does the Minister agree with that, and when might it happen? Thirdly, we would like to see established an independent secretariat with the specialist expertise to provide equal access to the negotiations as required. Fourthly, there should be a party leaders’ meeting to agree a clear timetable to demonstrate that we are all equally and seriously committed to talks at the highest level.
Those commitments do not stand in the way of the process: rather, they will facilitate it. I put them on the record now, as they have been put to the Secretary of State for Health, and say that I think it would help the House and the process if the Minister would take the opportunity to respond on this matter. Finally, I thank all noble Lords for taking part in the debate.
Baroness Barker
I thank the noble Baroness very much—I did not know about the correspondence. However, can she explain why an independent chair is necessary for the process? I understand the other three points but I do not understand that one. What is the reason?
Baroness Thornton
We think that having an independent chair is a sensible way to move forward. We have not suggested that we should appoint the chair; we have asked the Government to suggest the name of the person who might chair those talks. I do not think that any of those things is a barrier to progress in this matter.
Finally, we on these Benches think that this is one of the most important issues facing our society today. It is one that we cannot neglect or leave in the long grass, and it is one that we are determined to resolve.
Health: Flu Vaccine Research
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Thornton
My Lords, the recently published Department of Health report on winter preparedness says that by the end of the 2010 flu vaccine season, only about 50 per cent of those under 65 years old in the clinical risk groups had been vaccinated. The Chief Medical Officer states that we need to,
“ reach or exceed 75% uptake”,
of this group and for pregnant women. Unlike Scotland and Northern Ireland, I understand that this year there will be no advertising campaign in England to raise awareness of the importance of flu jabs. Will the Minister rethink this policy to ensure that this target is achieved?
Earl Howe
My Lords, the difficulty with advertising is that there is no evidence either way as to whether an advertising campaign has an impact on vaccine uptake, although there is no doubt that it has an impact on vaccine awareness. Without a marketing campaign last year, it was notable that the flu vaccine uptake was very similar to that achieved in previous years. We believe that the best way to access those who are at risk is through GPs. We know that from surveys that ask patients what has prompted them to get vaccination.
NHS: Waiting Times
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Earl Howe
It does seem to be a combination of all three, although it is clear that in certain areas there is a shortage of the necessary specialist consultants. Sir Bruce Keogh, the NHS medical director, is addressing this urgently with the British Orthopaedic Association in particular. That is expected to result in a solutions paper being put to the NHS Operations Executive in the new year.
Baroness Thornton
My Lords, this weekend the Royal College of Nursing reported that around 50,000 nursing posts are either in jeopardy or lost completely due to the ill conceived implementation of the economies being driven through the NHS. Does the noble Earl accept this figure and what effect does he think that figure might have on waiting times and waiting lists? Is it not time for the Government to accept that cuts to front-line staff are going to have an effect on patient care?
Earl Howe
My Lords, in that press release, which I think was from the Royal College of Nursing, there was a blurring of the distinction between the number of nursing posts which have been lost and the number which might, if certain things happen in the future, be lost. We recognise that in some cases local organisations will have to make difficult choices about staffing changes in the coming years. In making any changes, we have been clear that we expect them to ensure that the quality and safety of care is maintained or improved. That may involve changing the skill mix of the workforce in a particular hospital but, if that happens, it has to be safety and quality assured so that there is no adverse effect on patients.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Thornton
My Lords, I wonder if I might speak to both of the amendments that are down in the name of my noble friend, but also to take a step back from the very competent and skilled amendments and presentations by my noble friend Lord Warner and the noble Lord, Lord Patel. All these amendments also reveal what might be called a profound lack of agreement about what “integration” actually is. It seemed to me that at this point it might be useful to go and scope what people think integration means, and then perhaps ask the Minister to say which of these meanings he prefers, or which he would like to use. For example, the Royal College of Nursing is extremely worried that the combination of a maximum tariff and any qualified provider means that delivering integrated services will become increasingly difficult.
The NHS Confederation confirmed that the definitions of “integration” and “integrated care” to be used by Monitor,
“will allow different kinds of integration. For example: bringing together specialist services like trauma at one site, or integrating a person’s health and social care into one package, or offering a ‘package’ of care across a large population”.
However, it also goes on to say that:
“Though extending the tariff is the best way to ensure competition is on quality”,
in some circumstances,
“it must be recognised that getting the tariff right is a highly complicated task”.
How will this deliver integrated care?
The King's Fund states that:
“Organisational integration appears to be neither necessary nor sufficient to deliver the benefits of integrated care, notwithstanding the achievements of integrated systems such as the Veterans Health Administration”.
It goes on to talk about the Kaiser example mentioned by the noble Lord, Lord Patel. The fund also says that the Government’s reforms being centred on extending patient choice and provider competition includes encouragement to any willing provider to deliver care to patients and to complete separation of commissioning and provision with the NHS. However, the results could be a system in which there is commissioning from and choice between an “increasingly fragmented array” of competing public, private and voluntary sector providers. As a consequence, integration would be difficult to achieve.
The Nuffield Foundation says, on the tariff and incentive integrated care, that the payment by results tariff was designed primarily, as my noble friend said in his initial remarks, to support choice in competition and bring down waiting lists for elective treatment. It does not appear to be well suited to supporting integrated care for people with long-term and complex conditions.
I am sure that the noble Baroness, Lady Young, will talk to us about diabetes, but briefing to us said that people with diabetes already need at least 14 different sorts of NHS services for them to lead long and healthy lives. That seems to be a challenge.
Arthritis Care’s recent response to the Future Forum consultation on integrated services, published a couple of days ago, is very pertinent indeed. It says that:
“‘Integration’ should be broadly understood as providing patient-centred, joined-up care which meets the clinical and personal needs of the patient at every point of their pathway. Arthritis Care fully endorses and recommends National Voices’ Principles for Integrated Care as a key reference point for all discussions on this issue … There must, above all, be a firm focus on the patient. What ‘integration’ looks like is likely to vary geographically and by service, but the specific structures and arrangements matter less than whether services are successfully meeting patient needs and expectations. What it ultimately comes down to is better care for patients and smarter use of resources”.
I think that is absolutely right.
The amendments that my noble friend and I have tabled are Amendments 104A and 178A. Like others in the group, they seek to place a duty on both board and CCGs to take account of the interdependence of services and the impact that the arrangements might have on sustainability, both financial and clinical, of other services. We are concerned that the regime that has been outlined in the Bill places a risk on the coherence of those services. I ask the Minister whether that is on the risk register and what it has to say about the risks that that places on those services.
My noble friend Lord Patel of Bradford, who is unable to be here this evening—I am happy to make these remarks partly on his behalf—is concerned about the disadvantaged people in the care system who are detained under the Mental Health Act. By definition, this is a group of service users who have very little ability to exercise choice or control. In a way, I think that this is a group of people against whom the test of integration and the test of this system should be used. If it can work for this group of people, it may work for others. As they are in a highly vulnerable position, there is an absolute need for integration among health and social care providers that starts at the point of hospital admission and goes right through to the end of their aftercare in the community. The effective provision of such a care pathway requires multiple agencies to work closely together. We know that from many inquiries into suicides and homicides involving people with mental illnesses, and it is highly challenging. There is a very real concern shared by patients, carers, doctors and nurses that encouraging competition in this complex area, without checks and balances to ensure that integration is a primary driver, is very damaging indeed. I know that the noble Baroness, Lady Hollins, will refer to her amendment, and we would support that; I could not have put it better myself.
This is a very complicated and complex issue. It is the first time that we have talked about it in Committee. One thing that the Minister needs to do at this stage is to focus on what the Government mean by different forms of integration and where they will apply and how the Bill will deliver them.
Lord Clement-Jones
My Lords, the noble Baroness, Lady Thornton, has given us a very wide range of views on what integration consists of. In putting forward Amendment 135A, perhaps I can add another perspective from the point of view of specialised commissioning.
On 14 November, the Minister lifted the veil, to some extent, on how specialised commissioning would work under the Bill. The Bill brings the budget and responsibility for commissioning specialised services together under the NHS Commissioning Board. That has been welcomed by many, including the Specialised Healthcare Alliance, and it gives a real opportunity to deliver the recommendations of the Carter report of 2006. However, the expected benefits of this new system will be fully realised only if there is effective and real co-ordination between the various parties involved in the commissioning, provision and use of specialised services. However, that increases the challenge of integration under this clause, given the gap that would open up between the board at national level and providers at local level, if no steps were taken to bridge it.
There is a danger that the board’s work would become isolated from local commissioners, providers, clinicians and patients and that proper involvement, collaboration and dialogue with those key stakeholders may not occur. In particular, that could lead to pathways of care becoming disjointed, resulting in a poorer experience for patients, inefficient care and higher costs. In addition, it will be imperative to ensure that clinicians and patients are at the heart of all aspects of specialised services, including specialised commissioning. However, although the full subnational offices of the board which, as I understand it, are proposed would nominally give it a more local presence, they bear no real relationship to where the specialist providers are based and patient flows. The patient organisations within the Specialised Healthcare Alliance, therefore, see it as essential that there should be a more local presence; in their view, four clusters would be inadequate.
At col. 541 of Hansard on 14 November, the Minister was not able to be specific when he spoke about this, but as I understand it there will be around a dozen major hubs. An assurance on the parliamentary record would be very welcome. What form of substructure will there be for specialised commissioning if that is not to be the shape of it? Can he give further clarification today? Will this be delivered by the board or will it be delivered in other forms by way of senate, networks or in other forms?
Having heard from the NHS Alliance yesterday about the need for local variation, I am very attracted by Amendment 197E in the name of the noble Lord, Lord Patel, which to me seems to hit the spot in allowing that variation and giving the CCGs the final say in how they conduct themselves. That has been put to several of us by the NHS Alliance as being absolutely crucial in allowing the various innovations and initiatives to thrive at local level in the CCGs, which are already becoming an interesting and improved way of delivering healthcare.
Baroness Williams of Crosby
I would not disagree with the noble Baroness on that issue. I agree with her, but I am trying to make a different point, which is that I think we have been left with, by sheer good fortune, if you like, a much better starting point for serious integration than many other health systems. It relates also to Amendment 203A, which was tabled by the noble Baronesses, Lady Hollins and Lady Finlay, about the role of competition, about which I am rather less confident than some others.
I shall mention two other findings from the report because it is a remarkable and impressive story. On the doctor/patient relationship, there was a question about how far patients felt that they had close relations with their doctors and the ability to speak to them and to discuss their cases with them. Once again, quite remarkably, the United Kingdom comes out second to Switzerland in the 11. To take a final and very surprising finding in this study, on medical, medication or lab test errors in the past two years, the figure for the United States was 22 per cent, for the Netherlands it was 20 per cent and for the United Kingdom it was 8 per cent. It is extraordinary that we so rarely blow our own trumpet in this country, and very occasionally, we should.
Baroness Thornton
The noble Baroness, Lady Williams, is right. It is a great report, and I have read it. Would she care to join me in speculating about why the department has not made it its headline story?
Baroness Williams of Crosby
I think the answer to that had probably better come from the department rather than from me, but I am consistently surprised by the failure, not of this Government but of Governments of the United Kingdom for a long time, to say what the real achievements of the NHS have been and to recognise that outside this country it is widely regarded as perhaps one of the most outstanding health services in the world. It is worth saying that from time to time because we have 1.2 million people employed in the NHS and they deserve a great deal of the credit for having maintained a high standard in the face of very considerable financial pressures, even in the past. We have always had among the lowest expenditures per patient in the 11 highly industrialised countries, with only a couple of countries—Australia and New Zealand —spending less than we do.
There are two points to this argument. First, we are in a much better place to integrate care than we seem to think we are because we have already clearly established relations of trust between doctors and patients, and between hospitals and doctors, to an extent that other countries clearly regard as enviable. Secondly, one has to ask why we suppose that competition is a better way to deal with healthcare than are integration and collaboration. There is one area where competition is clearly crucial, and I accept that. It is in innovation and in trying out new ideas. None of us would in any way be opposed to that happening. However, I would like to put it on the record that if we are going to move in the direction of collaboration and integration, we have a very strong base on which to do it and we have the makings of something very impressive and important. The makings of that appear to be stronger in this country than in most others.
Earl Howe
My Lords, the subject of the tariff may, to an outsider, seem rather dry but I will begin by saying to the noble Lord, Lord Warner, that I agree with him that it is fundamental to having an effective and efficient health service and better care for patients. Indeed, as noble Lords have articulated so well, this group of amendments takes us to the heart of one of our running themes in Committee; namely, the integration of NHS services, both within the NHS and more widely with social care services. I agree that this is a subject of profound importance. The NHS Future Forum highlighted this while also identifying that some people had real concerns that competition in the provision of NHS services could act against the development of integrated provision.
First, what do we mean by integration? A number of noble Lords have asked that question. The duties to promote integration would cover both integration between service types—for example, between health and social care—and integration between different types of health services. Whatever the combination and however they are integrated, the practical effect should be that services are co-ordinated around the needs of the individual. This duty would apply right the way through the system. It would certainly apply to the board when exercising its functions, not just its commissioning functions.
I agree with the noble Baroness, Lady Wheeler, who made a very important point about vulnerable people in particular. For example, CCGs could comply with their duty of integration by choosing to commission services jointly with local authorities. We have always envisaged that happening. The joining-up of services could, as I say, be between different organisations or between workers within an organisation or even with advice that is given to patients about self-care and the treatment that is delivered by providing organisations. What matters is that the service is based around those patients, not the other way round.
It might be helpful if I said something about the Government’s approach to competition in the NHS. We are clear that in some circumstances competition is a force for good. Competition can create incentives for providers to innovate and improve effectiveness, as well as enabling greater choice for patients. My noble friend Lady Williams made that point very well. However, there is no single model of competition that will be right in all circumstances. Indeed, in some circumstances, competition will not be appropriate at all. Who should decide questions of this kind? Our view is that it should be for commissioners to decide whether—and if so, how—to use competition to further patients’ interests. In doing so, commissioners must act transparently and would need to consider the type of service and the needs and preferences of patients who would receive it, and be able to demonstrate the rationale for their decisions.
The noble Lord, Lord Warner, made a helpful intervention on this issue. The NHS Future Forum report stated:
“We have also heard many people saying that competition and integration are opposing forces. We believe this is a false dichotomy. Integrated care is vital, and competition can and should be used by commissioners as a powerful tool to drive this for patients”.
The Government agree. That is why the Bill set out duties for both the board and CCGs on promoting integration when commissioning services. The board, CCGs and health and well-being boards, as well as the regulators, Monitor and the CQC, will have duties to encourage integration and work across health and social care.
These changes should make it easier to deliver higher quality service pathways of patient-centred care. To help support commissioners, health and well-being boards will provide a forum to bring together people from across the health and social care sectors. Furthermore, the Bill gives the boards a specific duty to encourage health and care commissioners to work together to advance the health and well-being of the people in their areas. I might just mention that we have also asked the NHS Future Forum to consider in more detail how we can ensure that our reforms lead to better integrated services, and its conclusions on that topic will be with us shortly.
It is perfectly possible to have responsive, joined-up services working in patients’ interests and competing for their choice. For example, commissioners could decide to run a tender for a whole pathway of integrated services to be delivered by a single provider. This could encourage providers to bring forward innovative, integrated care solutions that deliver greater patient benefits and greater efficiency. Only a few weeks ago, I visited in Oldham an example of exactly that: musculoskeletal services delivered in the community, specialists from a variety of disciplines situated in one building and accessible to patients directly, and with short lines of communication. It is very popular with the clinicians and patients involved, and is achieving great results.
Of course, as the noble Baroness, Lady Hollins, pointed out, the extent to which particular services will benefit from both integration and choice will vary. Diabetes networks provide high-quality services with a high degree of integration but limited choice for patients between providers. I am sorry not to have a contribution from the noble Baroness, Lady Young, on this point, but I am sure she would agree. Certain mental health services may be another example of this. For other services, more choice may deliver better outcomes. This is why the provision in the Bill enables services specified in a particular way in the national tariff to be unbundled and paid for separately. That should happen, however, only where this is demonstrably in patients’ best interests. The comments made by the noble Baroness, Lady Hollins, in support of her Amendment 203A were very helpful in that context.
Monitor would have duties to support commissioners by enabling integration through the exercise of its functions. This reflects the fact that, as I have indicated, the driver for integration within the reformed healthcare system must come from clinical commissioners rather than from the regulator. Having said that, we are clear that, consistent with its duty to enable integration, Monitor will have an important role here. For example, the Commissioning Board would specify services for the purpose of tariff-setting, which may include bundling services together or specifying care pathways. Monitor’s role would be to devise methodologies for pricing those services.
I would not want to go further than that and make it a statutory requirement that the tariff could specify services by reference to clinical pathways, as some amendments in this group imply. That would be overly prescriptive and unnecessary. While tariffs for whole pathways of care may be appropriate in some circumstances—and I have mentioned an example or two of this—that may not always be so. For example, it might be appropriate to give patients choice about which provider provided a particular element of their care along a pathway. If the tariff enabled only a single payment for a whole pathway of care, it could deny patients that choice. Hence, we need to retain flexibility within the tariff and remain focused on outcomes.
My noble friend Lord Clement-Jones spoke with great authority about specialised services. Sir David Nicholson, as chief executive designate of the Commissioning Board, published Developing the NHS Commissioning Board in July, which set out proposals for how the board will operate and how it will be organised. It is envisaged that the initial sub-national structure will reflect the arrangements that have been made for PCTs and SHA clusters. It is envisaged that the field force, as he describes it, will be responsible for commissioning specialised services, providing the flexibility for this to be organised at different levels according to what is most appropriate for that condition. My noble friend was absolutely right to draw attention to the need for integrated pathways of care in specialised services. We believe that we are setting up the structures to deliver just that.
The noble Lord, Lord Warner, helpfully indicated that the tariff should be based on four main principles: integrated care rather than episodes of care; best practice, not average costs; a full range of services; and particularly the need to avoid costs that did not need to be built in and windfall gains. Those factors form the basis for the new tariff structure provided for by the Bill. Provisions will allow currencies based on integrated services and pathways of care by specifying bundles.
Monitor will set the costs based on a fair level of pay for providers. The board will be required to work towards the standardisation of currencies, which will enable the extension of the tariff to a wider range of services. What the noble Baroness, Lady Finlay, said about tariffs reflecting clinical complexity was absolutely right. We tabled amendments in another place to prevent providers from benefiting from cherry-picking services, including providing for a fair level of pay and a requirement for transparency in patient eligibility and selection criteria.
My noble friend Lady Tyler spoke compellingly about addressing inequalities. The Bill does not lose sight of that. The board’s duty under new Section 13M, to be inserted into the NHS Act under Clause 20, and that of clinical commissioning groups under new Section 14Y to promote integration—
Baroness Thornton
I am thinking about Monitor, what it is doing and its role as an economic regulator. Why is it the best body to decide on the price, cost and value of things?
Earl Howe
It needs to be a body that is separate from the NHS Commissioning Board. Determining what represents an appropriate price in the system is a very specialised discipline. We think that it will be helpful to have a sector-specific regulator doing that work. I would be happy to write to the noble Baroness setting out our rationale on this, but I make no pretence that this is a complex job. We do not think that it can be done very readily at the local level, although it would not be impossible. We think that local commissioners will need to be supported in this task.
Baroness Thornton
Perhaps when the Minister writes to me, he could explain why it is better that economists and regulators dictate those decisions rather than clinicians.
Earl Howe
Yes, I will. To address the point that I began just now, the board’s duty to promote integration specifically requires it to exercise its functions to ensure that services are provided in an integrated way where it considers that this would reduce inequality in outcomes. Those words are very important. That is mirrored by Monitor’s duty to enable integration.
I completely understand the intentions behind the amendments in this group. We have had a very helpful debate. We believe that the duties in the Bill, coupled with the wider levers in the system to promote integration, address the points that have been made. In the light of what I have said, I hope that the noble Lord will withdraw his amendment, although I am sure that this is a theme to which we shall return.
Health Research Authority (Establishment and Constitution) Order 2011
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Thornton
My Lords, I thank my noble friend Lord Turnberg for introducing the debate on this order. As noble Lords know, this order establishes the Health Research Authority to facilitate and promote research related to the health service through the research ethics committee that will check that research proposals meet ethical standards and will establish and appoint members to those committees. I think everybody would agree that the provenance of this initiative is the Academy of Medical Sciences’s review, which was published in January, and that the urgency arises from the abolition of the National Patient Safety Agency.
I will first ask a couple of questions about the National Patient Safety Agency because I would like to get some issues on the record. We are all aware of the reason that this order has been brought forward. The Minister has been completely clear with the House about the process. It needs to be there to scoop up the National Research Ethics Service. What is happening to the National Reporting and Learning Service and the National Clinical Assessment Service? The National Patient Safety Agency had three functions, and those were they. What is going to happen to the other two very important functions?
In addition the National Patient Safety Agency was responsible for commissioning and monitoring the National Confidential Enquiry into Patient Outcomes and Death, the Confidential Enquiry into Maternal and Child Health, and the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. I would like to know what will to happen to them. Where are they going to live when the National Patient Safety Agency no longer exists? Indeed, what will happen to the special programmes that the agency has conducted over the years, such as the programme into maternal and newborn babes? This is very important work, with accumulated knowledge and skilled staff, and I am concerned about that.
I agree with the noble Lord, Lord Willis, about the momentum that there is to establish an independent health research body. That was underlined by the discussions we had on the Public Bodies Bill over the future of the Human Tissue Authority and the HFEA. It would also benefit the Committee if we could be brought up to date as to where things are with them, and their future. But the outstanding question is: why can we not start now and include the new agency in the Bill, and get on with it? We will have that debate on the Floor of the House.
I have just a few more questions. How will the independence of this special health authority be guaranteed, because it is not the arm’s-length body that will ultimately be created? What costs are involved with this? Are there any extra costs for which funding will have to be found to set up this ethics committee? How will that be progressed? Finally, what will happen to the current board members of the National Patient Safety Agency led by Sir Liam Donaldson?