Accidents: Costs

Baroness Thornton Excerpts

Monday 31st October 2011 Lords Chamber

[Baroness Thornton]

My Lords, I welcome the fact that the revised blueprint of Healthy Lives, Healthy People now includes accidental injury prevention. Can the Minister confirm that that would therefore be a new responsibility added to those that public health authorities will be taking up? Has that been costed and will extra funding be available for local authorities and the new public health authorities to deliver on it given that, if they are successful, they will be saving a great deal of money?

[Earl Howe]

As the noble Baroness knows, much will depend on the priorities that individual local authorities set. This is subject to further engagement because it is early days, but accidental injury prevention is listed as one of the areas that local authorities could focus on. To my mind, they should be warmly encouraged to focus on accident prevention as there are so many levers at their disposal to make a difference in this area.

Health Authorities (Membership and Procedure) Amendment Regulations 2011

Baroness Thornton Excerpts

Monday 31st October 2011 Grand Committee

Moved By

[Baroness Thornton]

That the Grand Committee do report to the House that it has considered the Health Authorities (Membership and Procedure) Amendment Regulations 2011.

[Baroness Thornton]

My Lords, I beg to move that the Grand Committee should consider these regulations, SI 2011/2200. I thought that it would be worth while to have a discussion about these regulations—which I think have now technically come into force—because they will be used, as far as I can see, to establish at least two of the bodies which we know about arising out of the Government’s legislative programme. Indeed, my first questions are: how many more, which and when?

The first instrument concerns the establishment of the NHS Commissioning Board as a special health authority as a result of the legislation that is before the House right now and which we will be discussing in the Chamber tomorrow. The second instrument concerns the establishment of a research organisation as a result of the Public Bodies Bill and the proposed abolition of the Health Protection Agency and the Human Fertilisation and Embryology Authority. I think that the order will also be discussed in due course.

My first question to the Minister has to be this: do the Government have further proposals to use this legislation in order to set up more and new special health authorities, and if so, which ones, where and when? Will we see orders, for example, to establish special health authorities for the new sub-national bodies that David Nicholson keeps referring to? Will those bodies have formal status in legislation and will that be done by order?

I turn now to the substance of the regulations, and while I am not going to take very long, I have some questions to ask. One of the key issues is the removal of the restriction that prevents chairs, non-officers and officer members of strategic health authorities from being appointed to more than one strategic health authority at a time, a rule which I think is entirely reasonable. What has changed so much that a chair could or might want to serve, or indeed where it might be desirable for them to serve, on a special health authority as well as a strategic health authority? Do the Government propose to establish so many special health authorities that that could become a problem? For example, would it be possible for someone to be the chair of a strategic health authority that exists now, a member of another strategic health authority and a member of a special health authority as those bodies emerge? Apart from anything else, I would like to know whether those individuals would be paid for doing all those different jobs, and how much that is likely to cost. Is that envisaged as the purpose of this order?

Moving forward, what happens to the strategic health authorities in this process? Where are all the authorities going to be? Are they going to be sucked up into the sub-national bodies, and are they therefore going to be special health authorities? Is that going to be done slowly or will it all happen in one go in 2013? How will the new chairs and members of special health authorities be appointed, and by whom? Will there be an independent element in what happens in the appointments procedure—will it be open to public scrutiny or will it just be done by the Secretary of State? Will that be on the public record? How much will they be paid, for how many days and what will their jobs involve? Does the Minister expect or envisage that there may be a clash of interests as this policy develops?

As we head towards 2013, special health authorities—these sub-national bodies or whatever they are to be called—may bring forward and carry out the work of the national Commissioning Board. What will happen in those areas where you have members on the sub-national bodies and on the strategic health authorities? There may be discussions between the two about where the policy goes and there may be clashes of interest. I am thinking about things like the developing role of commissioning and the clinical commissioning groups, and the role and powers that strategic health authorities have had in the past to drive forward, for example, stroke strategies or support for cancer networks. Where does the Minister see those? What happens if somebody who had responsibility for them in a strategic health authority now serves on one of the other bodies and there is a clash of interest over where the resources are going and how they will be supported? How could that be resolved? I am thinking in particular about things like failure regime, reconfigurations, training and workforce planning. As the Minister knows, that is an important role of strategic health authorities. Who will be the arbiter if there are those sorts of clashes of interest about the new structures as they move forward? Would it be the Secretary of State or the NHS Commissioning Board?

There are a variety of questions, some of which it may not be possible to answer now, but which will have to be looked at as we move forward and if the proposals to establish more of these special health authorities are carried through with the different roles. I beg to move.

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

I am grateful to the noble Baroness for tabling this debate on the Health Authorities (Membership and Procedure) Amendment Regulations, and I welcome the opportunity to respond. As she pointed out, we will gather in Committee several more times this week to review the impact of a number of pieces of legislation introduced by the Government and challenged by the noble Baroness.

I believe that the combination of these statutory instruments provides security to hard-working NHS staff to maintain the continuity and quality of services that patients need at a time of considerable pressure. We cannot forget that the NHS has been challenged to make up to £20 billion in savings over the next three and a half years, which will be reinvested back into front-line patient care. Alongside this, we are seeking to move to a more autonomous and locally accountable patient-centred NHS, focused on improving outcomes for patients. That is the background although—in reply to the points made by the noble Baroness at the beginning of her speech—I make it clear that this order has nothing directly to do with the establishment of the two special health authorities, the NHS Commissioning Board Authority and the Health Research Authority, as special health authorities. We will debate both tomorrow.

The effect of the Health Authorities (Membership and Procedure) Amendment Regulations 2011 is to allow the clustering of strategic health authorities and to provide greater flexibility among the non-executive and executive community to take up other board level posts in the health sector during the transition period. The 10 strategic health authorities have been clustered into four: NHS North of England, comprising North East, Yorkshire and the Humber and North West; NHS Midlands and East, East Midlands, East of England and West Midlands; NHS South of England, South West, South Central and South East Coast; and NHS London, which will simply encompass the existing strategic health authority.

That does not change the current structure of the NHS. There are still 10 strategic health authorities with the same boundaries which exist as legal statutory bodies. We have just simplified the governance of the strategic health authorities in order to sustain structural stability and reduce management costs. To do that, the Government are using powers that exist in legislation previously scrutinised by your Lordships' House. The correct procedures were followed in making appointments to the new clusters which complied with both the Commissioner for Public Appointments’ code of practice and employment law, as appropriate. The posts are time-limited and will be disestablished when strategic health authorities are abolished—if the Bill goes through the House and becomes law—on 31 March 2013.

Each cluster board now comprises a chair, up to eight non-executive directors, four executive directors with voting rights and up to five other non-voting executive directors who lead and scrutinise the decisions of each of the constituent SHAs within the cluster. Clustering SHAs, as we have already done with PCTs, supports the delivery of the £20 billion NHS efficiency savings through significantly reducing the cost of NHS administration—a commitment of both this and the previous Government. The creation of SHA clusters is a step towards that. PCT and SHA management costs increased by more than £1 billion since 2002-03, a rise of more than 120 per cent. It would not be possible to make savings on the scale required while retaining the administrative superstructure of PCTs and SHAs.

In addition to the pressing needs that I have outlined, the Government have a responsibility to ensure that the transition to the new system of working in the NHS—subject to the passage of the Bill—supports the integrity of the health service, as well as continuity of accountability and minimised disruption to those working hard to deliver and maintain high-quality services on the front line.

In the current system, SHAs have a key role to play in ensuring the quality and safety of services, in driving performance and delivery, including safeguarding the cash limit and in responding to the QIPP challenge. SHA managers have done a commendable job in delivering that agenda. That is in part why the Government's response to the Future Forum report extends the life of SHAs to the end of March 2013. Until then, SHAs will retain their statutory responsibilities and remain accountable for delivery and transition. Given the context of major change, with new leadership starting to take up roles in the system, it is critical that strong SHA leadership teams continue in place to provide the right focus on delivery and ensure effective accountability.

Clustering provides resilience and alignment for the future. Already, a number of senior posts in SHAs are either not filled or are being covered through interim arrangements. That is not sustainable for a 17-month period, and the position is likely to deteriorate further over time. The risk posed by SHA atrophy is therefore too great, and clustering for greater collective resilience over the next 17 months is an essential response.

Sir David Nicholson has announced that the initial sub-national arrangements of the NHS Commissioning Board will mirror the geographical footprint of the SHA clusters. To give the board a greater sense of having a stake in the future, there is a strong argument for moving early to future geographical footprints. The Government are moving swiftly with those arrangements, drawing on the lessons learnt from PCT clustering, which show that once a decision to cluster is made, it is better to implement the changes quickly. It is also important to embed these arrangements before winter to reduce the impact of the extra operational pressure that the health service is put under at this time.

--- Later in debate ---

My noble friend Lady Jolly asked about the management cost savings that we expect from the changes. She asked whether we had factored in risk. The reduction in the number of non-executive posts will result in savings of around £367,000 per year. It is worth pointing out that the overall calculation is difficult because some people who were members of SHA boards and who have not been accommodated on the cluster board have reverted to roles within SHAs, so although they are not any longer on an SHA board, they are still performing useful tasks at a managerial level. Therefore, it is not possible to correlate the drop in the number of board members with a saving. However, we are clear that annual savings of a significant amount will be achieved from this exercise.

[Baroness Thornton]

I thank the Minister, and everyone else, for taking part in this short but extremely useful debate. The Minister started out in his introduction by saying that this is all being done in the context of the £20 billion Nicholson challenge. However, I am certainly not convinced that setting up double structures will help the delivery of that particular challenge. I accept that there has to be some clustering of strategic health authorities because, as the Minister said, the clusters are a response to atrophy and, I would add, demoralisation among the staff. On the one hand, everyone who has spoken said what valuable institutions strategic health authorities are and what a valuable job they do. On the other, there is an acknowledgement from the Government that there is a danger of atrophy here. As the noble Baroness, Lady Jolly, said, that poses risks. Those risks need to be addressed.

I will read what the Minister said, but I am still unclear whether the clusters will cease to exist in 2013 or whether they will become the national Commissioning Board’s sub-national instrument for delivery. Perhaps we will need to address that question tomorrow when we look at the NHS Commissioning Board. The issue of conflict of interest is potentially real and the Government will need to think about it as the process moves forward. When two mechanisms are in place for delivering healthcare in an area, conflicts of interest will need to be looked at. The noble Baroness, Lady Williams, raised some important points, particularly about HealthWatch. As I listened to her I thought, “I wish I had thought of that myself”—as I usually do when she speaks.

I am still not sure about the accountability of the national Commissioning Board. We will address its accountability at a national level, but I am also worried about the accountability and transparency of the clusters were they to become the sub-national boards for the national Commissioning Board. That is a bigger issue than we can possibly deal with here, but I am adding them, as it were, to the agenda of issues to be addressed as we move forward.

Motion agreed.

Health and Social Care Bill

Baroness Thornton Excerpts

Tuesday 25th October 2011 Lords Chamber

Moved by

[Baroness Thornton]

1: Before Clause 1, insert the following new Clause—
“Principles of the Health Service in England
(1) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England must have regard to the principles and values outlined in the NHS Constitution.
(2) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England, or providing services as part of the Health Service in England, must provide quality, equity, integration and accountability, not the market.
(3) The primacy of patient care shall not be compromised by any structural or financial re-organisation of the Health Service in England.
(4) There must be transparency and openness wherever taxpayers’ money is being spent, and all accountable individuals and bodies should abide by the Nolan principles.
(5) “The Nolan principles” means the seven general principles of public life set out in the First Report of the Committee on Standards in Public Life (Cm 2850).
(6) Schedule (Principles of the Health Service in England) has effect.”

[The Lord Speaker (Baroness D'Souza)]

My Lords, I point out to the Committee that in line 8 of the amendment, there is a misprint. “Must provide quality” should be read as “must promote quality”.

[Baroness Thornton]

My Lords, I thank the Lord Speaker for making that correction and assure the Committee that the correct word is “promote”, not “provide”. In the context of the Bill, as noble Lords will be aware, the difference between promote and provide is a subject on which we will have many debates in the days to come. I apologise to the Committee for not having read my own amendment more carefully when it was published.

To noble Lords who are familiar with this kind of amendment, I apologise in advance. There may be some who are not; we have many new Peers with us today. Perhaps I may explain what we are doing here. The Liberal Democrats will be more familiar with this procedure because from time to time they placed this kind of amendment before the House, aiming to set a framework for the Bill in question or to give further definition of a Bill. Indeed, from time to time, they succeeded in persuading the House to support them. I know the House appreciates a good precedent. I believe that the last time there was an amendment before Clause 1 was in the Apprenticeships, Skills, Children and Learning Bill in 2009, when the Liberal Democrats and the Conservatives both put amendments down before Clause 1. Forgive me, I am not absolutely certain if either or both of them succeeded. I have a feeling that the noble Baroness, Lady Sharp, may have succeeded on that occasion.

The aim of this amendment is to set out some principles and a framework for the Bill to follow. In doing so, we have sought the widest possible genesis for this amendment, and I will explain this to the Committee in a moment. This first amendment kicks off Committee stage and concerns the principles that ought to underpin the health service in England. The amendment stresses the rights and pledges, values and principles, as outlined in the NHS constitution produced by Labour when in government. The amendment also places protection and promotion of patient care above structural or financial reorganisation. It calls for transparency and openness in decision-making, especially those decisions on funding, to ground proper accountability at the heart of our National Health Service. It seeks to set a framework around which the debate on the rest of the Bill can follow. I tabled this amendment partly because while the Government say they agree with all of these matters, at present the Bill still fails to reassure people that it delivers them. The confusion and lack of trust will be the substantive matter in many of the almost 400 amendments that have already been put down on this Bill.

At their spring conference, the Liberal Democrats made it clear that they wished to set beyond doubt that the Bill will not establish the NHS as a utility-style market based on the now outdated model that is currently failing in energy. How right the Liberal Democrats were. I share the doubts of the noble Baroness, Lady Williams, that the changes in the Bill achieve that. The need for a defining set of principles arises out of the failure of the Government to provide any reasonable explanation of what this Bill is for and what their strategy for the NHS actually is. The Government keep telling us that it has to be a different NHS so I am seeking some definition on what we can agree about and to place those principles at the front of the Bill.

We like to think of this amendment as a perfect cross-party marriage in its crafting. We have something old, something new, something borrowed and something blue. The old is the NHS constitution; although not very old, it was devised and brought about by the Labour Government and put through the House by my noble friend Lord Darzi, and we are proud of it. This is in subsection (1) of this amendment and is reflected in Amendment 52 to the schedules that list the principles of the NHS constitution, particularly with relation to patient care. I have borrowed the words of subsection (2) from the resolution that was passed at the Liberal Democrat spring conference, with the very slight addition of “integration and accountability”, which I am sure would have been there had they thought of them. I did wonder about the last three words—“not the market”—but I think everyone knows what that means. It does not mean that the NHS should not be engaged with the market, nor that there is not a place for the planned use of private and other providers within the NHS. It is there because the first Bill included a clear commitment to use competition as the main means of reforming the NHS and I think we still need to be clear that this is not the case. These Benches and the Liberal Democrats are in some agreement about this matter—at least I hope we are—and I think we should say so at the beginning of this Bill. Subsection (3) is blue, coming as it does from the coalition agreement. We will stop top-down reorganisations that get in the way of patient care. These words echo those of the Prime Minister when he said, “no top-down reorganisation”. The new, in subsection (4), is the most recent player in this Bill: the Future Forum, which has quite rightly brought the probity of the Nolan principles into this Bill.

It seems to me that only with clarity around the principles will the Government have any chance of taking the 1 million-plus staff of the NHS with them. Given the British Medical Association survey released yesterday, and GPs’ survey a week or so ago, the words of the Royal College of Nursing and many others, the Government have some way to go in persuading the staff to wholeheartedly support these changes. So I suggest that this statement of principles will help the Government in this task. It will also help the passage of this Bill. I hope that the Minister and the Committee will feel the same.

--- Later in debate ---

I hope what I have said gives reassurance to the Benches opposite that in terms of intent we are on their side. Nevertheless, I hope in the light of the quite serious flaws in the drafting the noble Baroness will think again and withdraw Amendment 1.

[Baroness Thornton]

My Lords, I thank all noble Lords who have taken part in this debate. It is a very useful start to the Committee stage and consideration of this Bill. I want to say to noble Lords who began their remarks by suggesting that somehow or other this was not an appropriate amendment to put down that this is the Committee stage. It is entirely appropriate to look at a preamble and principles that should inform the rest of the Bill. I want to thank noble Lords for all their remarks—particularly the noble Lord, Lord Hennessey, my noble friend Lady Donaghy, my noble friend Lord Rea and the noble Baroness, Lady Morgan, for their very wise words.

The noble Baroness, Lady Jolly, said the constitution is a good constitution. If that is so, why should it not be in the Bill? Indeed, at 80 minutes into this discussion, the noble Baroness also said that we might be wasting the time of the House; that it was not sensible to prolong the debate. I think the debate has shown the noble Baroness, Lady Jolly, that it was a discussion worth having. I hope that when the Liberal Democrats do not feel comfortable about things we propose from these Benches they will not suggest we are prolonging the debate.

The noble Earl, Lord Listowel, made very important points about the principles of trust and the principles that should underpin this Bill. I take comfort from the questions the noble Earl raised. I thank the noble Lord, Lord Mawhinney, for his good sense until he reached his conclusion, of course. There is nothing wrong with repeating good things in a Bill. In fact this House spends a lot of its time putting things into Bills that are repetition of what has gone before.

The noble Baroness, Lady Finlay, made a very wise speech. She said our NHS is the envy of the world and that is indeed true. She also made a very good point about the importance of the statement of principles and what it might achieve. We think that this is a good statement of principles, drawing on a variety of sources, and I shall probably test the opinion of the House on it. However, if we fail on this occasion, I should be very happy to work with the noble Baroness and any other noble Lord to find another form of words which we might bring back at a later stage of the Bill—indeed, the noble and learned Lord, Lord Mackay, might have given us the drafting.

The noble Lord, Lord Ribeiro, said that it was motherhood and apple pie. There is a mixture of messages here, but I actually think that motherhood and apple pie are really rather good. The noble Lord spoke about entering the market. As I made clear in my opening remarks, the part of the amendment which refers to the market addresses the priorities and principles that should be used to underpin the future of the NHS. If those priorities and principles are applied clearly, they are not the market in those terms.

I took some comfort from the remarks of the noble Baroness, Lady Barker, because she knows that we have been round this course on many occasions. The noble Lord, Lord Owen, prayed in aid Bevan and Beveridge, and I thank him for his support. To the noble Lord, Lord Phillips of Sudbury, I say that it is clear my charm offensive is not going to work on his Benches, which I regret. However, if he wishes to raise the issue of the number of pages in this legislation and its supporting documentation, he probably needs to address those remarks to the Minister and not to me.

The noble Lord, Lord Alderdice, misunderstood the point about the constitution. I do not know which light he thinks the amendment seeks to shut off, because we think that it provides us with a broad base of principles.

The Minister provided his usual forensic interpretation of the amendment. I had a great sense of déjà-vu, because all the arguments that he used against it were exactly those that I had heard my noble friends use against having a statement of principles or preamble in a Bill when they were Ministers.

[Earl Howe]

The difference was that in the 2009 Act I gave way to those arguments.

[Baroness Thornton]

The noble Earl set up, and then knocked down, a series of Aunt Sallies about the market, about how the amendment would halt change, and about how it was too big, too small and too detailed. It is actually rather small. I understand the Minister’s position on this. We have a long way to go on this Bill and this is just the beginning of it. We do not see why passing the amendment will inhibit further debate or discussion on the Bill in its entirety. In fact, I know this House too well not to know that nothing will inhibit noble Lords from discussing the Bill in the detail that it merits.

[Earl Howe]

Is the noble Baroness saying that the NHS Constitution needs to change by virtue of her amendments?

[Baroness Thornton]

No, that is not what the amendment says.

[Earl Howe]

It is, my Lords, because Amendment 52 does not repeat the NHS Constitution. Ninety per cent of the principles are missing from it and we therefore move into a new world. The previous Government laid down very clear procedures as to what to do when a Government wished to change the principles of the NHS. That involves public consultation and so on. Does the noble Baroness wish to bypass all that?

[Baroness Thornton]

My Lords, this is Parliament. We can take a decision. It is not about changing the NHS Constitution. We are seeking to put some of the principles of the constitution in the Bill. We think that that is a perfectly proper thing to do. I beg to test the opinion of the House.

--- Later in debate ---

[Lord Newton of Braintree]

I strongly supported and continue to support that, which is very reflective in ensuring that we do rest on the original foundations. I never thought I would be a natural Bevanite, but it appears that I have become one, together with a number of others.

That was not quite the point—we were then talking about a preamble. We are now talking about a slightly different provision. I would be entirely happy to see the preamble of the 1946 Act incorporated into this, with—as I said in my speech earlier—perhaps a little tweaking. However, we are now talking about the best way of ensuring and establishing the responsibilities, in the real world, of the Secretary of State. I have another sense of unreality in all of this, born of many years in the Commons. The idea that, whatever this Bill says and however precisely it is worded, the British political system—the House of Commons in particular—would allow the Secretary of State to dispense £120 billion per year of public money without being answerable and accountable to Parliament, is inherently ludicrous. The system would not allow it to happen. I am all in favour of writing that into the Bill if we can find appropriate terms, but in reality that will be the case whatever we have in this Bill.

I agree—and not for the first time—with everything my noble friend Lady Williams said about the importance of making this clear beyond a peradventure. I am quite happy with that.

[Baroness Thornton]

My Lords, I hesitate to intervene, but the problem we face is that this Bill does precisely what the noble Lord is saying he does not want to happen, which is that the Secretary of State will be properly accountable for £120 billion of taxpayers’ money. The Bill puts into statute the ability for the Secretary of State to be challenged, when and if he faces those issues. That is the problem we have.

[Lord Newton of Braintree]

I hope that noble Lords will forgive me for not sitting down, but it may be obvious to the House that one of my more strenuous activities is moving from the sedentary position to a standing one. I prefer not to do it unnecessarily frequently.

I do not agree with that, but I have also made it clear that I have no objection to this being made a little clearer than it is thought to be in the drafting, which is what the noble Baroness, Lady Williams, is looking for. If I might just go on, I will not do so at great length. The noble Baroness was also very sensible and right to acknowledge that the way forward suggested by my noble and learned friend Lord Mackay was better. At the moment, on balance, it probably is. I am agnostic on that; I am naturally supportive of my noble and learned friend, but these are different ways of achieving an objective that we all share.

I will not say much more except for one point on the autonomy clause and issues that have more recently been raised by the noble Lord, Lord Warner. I have some sympathy with my noble friend Lady Williams on the autonomy clause, which we have yet to get to. I hope the noble Lord, Lord Davies of Stamford, was listening to what the noble Lord, Lord Warner, said: a lot of people who have commented on the apparent or alleged withdrawal of Secretary of State powers in this Bill have not actually read what is in the Bill.

I will give one example. Under the arrangements made by the previous Government for Monitor to be the controller and regulator of foundation trusts, I think I am right in saying that the Secretary of State had no power to intervene. In this Bill, he does. If Monitor fails to do the right things, the Secretary of State can intervene. That was not the case before.

One thing that I was very iffy about—I do not know how Hansard will deal with “iffy”; perhaps I should say “uncertain”—in the previous Government’s record was their setting up of foundation trusts. The rhetoric was that the Secretary of State was abandoning responsibility to foundation trusts and Monitor without any power to control what happened. That situation was introduced by the Labour Government and is corrected by the Bill. We have heard a lot of distortion about what the Bill is intended to do and what it actually does. My concern is to reassure the public about what in my view are unfounded fears. The noble Lord, Lord Warner, has materially helped us in that.

Health: Cardiology

Baroness Thornton Excerpts

Monday 24th October 2011 Lords Chamber

[Earl Howe]

My Lords, I agree that deprivation is an important consideration. The population density of the West Midlands conurbation and the very high case load of Birmingham Children’s Hospital suggested that the Birmingham service should be, as it were, a fixed point. However, I am afraid that the same cannot be applied to Leeds because although the Leeds catchment area has a high population it has a much lower case load than that of Birmingham. The analysis of the expert group suggested that there needed to be two centres in the north of England because of the population density; that was either Liverpool and Leeds or Liverpool and Newcastle. It was not possible to have a Leeds and Newcastle combination since Newcastle could not achieve a credible network.

[Baroness Thornton]

My Lords, as a Bradfordian I have to say that that is a very great shame because I cannot see how the people in Bradford will find it easy to go to Newcastle to visit their children in hospital. When you add up the number of surgical cases performed on adults as well as children in England each year, you reach a figure which would require nine or 10 centres across England, not the six or seven proposed by the Safe and Sustainable review. Therefore, does the Minister share my concern that, by deciding the future of children’s heart services without reference to adult congenital heart services, the review is not looking at the full picture? Indeed, why are adult and children’s services subject to two reviews?

[Earl Howe]

My Lords, surgery for children with congenital heart disease is much more complex than surgery for adults with congenital heart disease. The focus of the review has been on paediatric services up to now. As the most immediate concerns were around the sustainability of the children’s services, the paediatric cardiac services standards include the need for links with adult services and for good transition services between the two.

Health: Healthcare Assistants

Baroness Thornton Excerpts

Monday 24th October 2011 Lords Chamber

[Baroness Greengross]

My Lords—

[Baroness Thornton]

My Lords, I often take my lead from the noble Baroness, Lady Masham. In an article in the Times today she said that a voluntary register was no cure. This, taken with the confusion created by, I am afraid, the noble Earl’s remarks about struck-off nurses, underlines the point at issue. I ask the Minister: is it really satisfactory that there is a chance that no one would know that a nurse was a struck-off nurse? Is it satisfactory that thousands of nursing care assistants are taking blood and carrying out procedures, but patients cannot know whether they are on a register and properly regulated? That is the problem. The noble Earl needs to think about the kind of juggernaut that is heading towards him on this one.

[Earl Howe]

No, it is not satisfactory that people should not know that a nurse has been struck off and is on the barred list. That is why it is incumbent on employers to make exactly those inquiries when taking on a new employee. As regards patients, the presence or absence of statutory regulation will not change one jot the responsibilities of employers or the responsibility of nurses to delegate appropriately on a ward or in a care home. Unsupervised, unregistered healthcare assistants should not be working without the proper authority and supervision.

Health: Obesity

Baroness Thornton Excerpts

Wednesday 19th October 2011 Lords Chamber

[Earl Howe]

My Lords, my noble friend makes what is in fact a very complex point. Many of us believe that there is a genetic element to this, and indeed the 2007 Foresight report underlined the complexity around the causes of obesity. Genetic, psychological, cultural and behavioural factors all have a part to play in it. I do not have specific advice to give my noble friend—far be it from me to do so—but there is obviously a balance to be struck between calories in and calories out.

[Baroness Thornton]

My Lords, if the Royal Society of Paediatricians, other medical organisations, Which? magazine, Jamie Oliver and many others regard the Secretary of State’s most recent obesity announcement, which presumably is based on corporate relations and the nudge theory, as, variously, “worthless”, “patronising” and “inadequate”, does the noble Earl regard this as people not understanding Mr Lansley—again—or could it be that the obesity strategy is actually not adequate and the Government need to go back to the drawing board?

[Earl Howe]

It is only inadequate if we as Government fail to work with partners as we have the ambition to do. We do have that ambition, and obviously we are disappointed by some of the reactions that have been published. However, we share the concerns expressed by Jamie Oliver and the bodies mentioned by the noble Baroness that urgent action is required to tackle obesity, and we all have a role to play in that.

Nursing: Elderly and Vulnerable Patients

Baroness Thornton Excerpts

Wednesday 19th October 2011 Lords Chamber

[Earl Howe]

The noble Baroness, with her expertise, makes a powerful point. We fully agree that there is an issue over unregistered healthcare assistants; I think the debate is around what we should do about it. We believe that the case for statutory regulation has not been made, although we would not close our minds to it. The point that the noble Baroness makes relates much more to nursing supervision, appropriate levels of delegation on a ward or in a care home, and appropriate supervision and training. That is a matter not for regulation but for nurse leaders in hospitals and care homes.

[Baroness Thornton]

My Lords, this is yet another report to add to others highlighting these issues. I think that the Minister has gone some way to explaining what change is needed, so that elderly people get treated in hospitals with the respect and dignity they deserve. However, how does he suggest that the nursing community should resist dangerous cost-cutting exercises by trusts, which are placing patient safety at risk by replacing experienced clinical staff with more junior nurses and healthcare assistants?

[Earl Howe]

We believe that patient safety is paramount and that it is a matter not just for staff on a ward but for the board of an organisation as well, to assure itself that the highest standards are being maintained. That means having proper staff ratios—ratios of staff to patients, that is—and ratios of trained and untrained staff within a ward. These are messages that we are consistently putting out.

EU: Food Labelling

Baroness Thornton Excerpts

Monday 17th October 2011 Lords Chamber

[Earl Howe]

As I hope my noble friend will allow, that is a little bit wide of the Question. I do not have an answer for her in my brief, but I will write to her.

[Baroness Thornton]

My Lords, I congratulate the noble Baroness, Lady Oppenheim-Barnes, on her Question but I have to say that I think her target should not be the EU but actually her own Government. If you put “food labelling” into a search engine, you will get hundreds of different versions of how food can be labelled. It feels like we are going backwards because of the flexibility that the Government have sought through the EU regulations. What part have the Government’s relationships with the corporate sector played in this matter, and, indeed, if food labelling is going to become more confusing, will that not count against the drive to have good and well balanced diets?

[Earl Howe]

My Lords, as the noble Baroness will know, there are various points of view from various sectors of industry about what constitutes the best and most helpful form of food labelling. As a matter of fact, that has lain at the heart of the difficulty in reaching agreement in Europe, because there are so many divergent views around this. It is quite true that we do have very strongly held views—not least by the Food Standards Agency—about the value of traffic lights. We have equally strong views, held by certain sectors of industry, on the GDA model. As I said earlier in answer to the noble Baroness, Lady Howarth, it would be desirable to have consistency, but we are not there yet. We will continue to work at that objective.

Health: Charities

Baroness Thornton Excerpts

Wednesday 12th October 2011 Lords Chamber

[Earl Howe]

The noble Baroness makes a good point and I shall ensure that it is passed on to my right honourable friend at the Treasury. She will understand of course that I cannot give her a categorical answer at this point.

[Baroness Thornton]

Will the Minister confirm that the Department of Health has a strategy for encouraging and supporting charities, social enterprises and mutuals, both as patient and carer advocates and as providers of healthcare? In addition, would the Minister care to say how that policy might be enacted by the proposed commissioning structures in light of, for example, the failure of Surrey Community Health—a local and qualified social enterprise—to win a very large contract, losing it to Richard Branson’s Virgin Healthcare?

[Earl Howe]

I agree with the noble Baroness that it is important we do not lose vital local services that achieve high-quality outcomes. We shall be working with PCTs, therefore, in the transition to the new arrangements between the NHS Commissioning Board and clinical commissioning groups as they develop, to ensure that the sector’s contribution to improved public health and social care is fully recognised. In the end, however, she will appreciate from our preceding debate that these matters will continue to be determined at a local rather than a national level—and it is quite right that they should be—because centrally we are not aware of local circumstances in the detail that we should be.

Health and Social Care Bill

Baroness Thornton Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Thornton]

My Lords, along with everyone in the House, I thank the Minister for his most competent and coherent introduction to the Health and Social Care Bill 2011. The Labour Benches have a great team dedicated to working on this Bill. It includes my noble friends Lord Hunt, Lord Beecham, Lady Royall and Lady Wheeler; our new Whip, my noble friend Lord Collins, who recently retired as the general secretary of the Labour Party and joins us as our junior member of the health team; and, of course, a galaxy of experience behind us.

I became so desperate to see this legislation that I even got involved with the Localism Bill in the summer, so desperate was I to be doing something. Long awaited, the delayed Bill we are considering today is in its fourth version so far. Indeed, it may not be the last. The first was definitely the Conservative version. It was prepared before the election based on the ideology of markets and regulation. It is now a much more complex Bill but the core intent remains the same. This Bill, with its 303 clauses and 24 schedules, creates a framework that will fundamentally change the nature of the NHS. It will change the NHS from a health system into a competitive market. It will turn patients into consumers and patient choice into shopping. Most crucially, it will turn our healthcare into a traded commodity.

Therefore, I start with a fundamental and simple point. People did not expect, did not vote for and do not want these changes. The Government were not elected to do this. They do not have the electorate’s mandate. I know we will hear arguments about whether or not this Bill is a mere continuation of the work of my former Government. I assure noble Lords from the outset that this is a specious argument, which I urge them to put aside. Our reforms were in our manifesto. They helped to improve and strengthen the NHS. They most certainly were not this Bill.

This Bill was not mentioned in anyone’s manifesto; nor was it in the coalition agreement. As for the democratic mandate mentioned by the Minister, top-down reorganisation, which is what the Prime Minister said, does not seem to be a mandate. One can scour the manifestos of the Conservative Party and the Liberal Democrat Party, and the coalition agreement, for anything that suggests a fundamental change to the powers of the Secretary of State for Health. Nothing suggested wholesale dismantling of the structures of the NHS; nothing about the biggest quango in the world being created, the NHS Commissioning Board; nothing about the intention to allow £60 billion of taxpayers’ money to be spent by GPs, originally on their own and now through clinical commissioning; nothing about the creation of a huge bureaucratic economic regulator, the new Monitor; and nothing about many other parts of this Bill, some of which is good and some less so. There is no mandate for this Bill. That is a serious constitutional issue for this House, which is signalled to us by, for example, the Constitution Committee report.

In the context of the most draconian changes for 60 years, the least we could have expected was a raft of analysis and evidence that would form a convincing and arguable case for the direct benefits of these changes to patients. If the evidence exists—I would say that it does not—it has manifestly failed to convince those who work in our NHS, those who study our NHS and certainly those who use it: so, no mandate, no evidence and no support. In addition to that, there has been one of the worst impact assessments that most experts have ever seen, showing no cost benefits. I suggest that this is not much of a basis for a change programme, which, to quote David Nicholson, is so large that it can be seen from space.

It is a sad day for this House and for Parliament that we are being urged to expedite this Bill. As informed commentators keep telling us, the state of disorganisation in the NHS is past the point of no return. Indeed, the Minister circulated a letter minutes before this debate started in which the last paragraph points to and emphasises the need for us to get on with this rather than the need for us to scrutinise this Bill.

There has been a breathtaking disregard for the democratic process. The reforms are being implemented in such a way that there is now paralysis, uncertainty and lack of leadership in the system. This has been inflicted on the NHS by this Government. Is it too late for a fresh look? I do not think so. I urge noble Lords not to be panicked, bullied or browbeaten. Our job is to scrutinise and improve this Bill, because it is certainly the most significant legislation that we are going to see in the whole of this Parliament.

On these Benches, we take this responsibility very seriously—indeed, I think that all noble Lords feel this responsibility—because we must not fail. All eyes are on us. If the Bill proceeds into Committee, these Benches will not delay this Bill in its passage through the House. I have promised the Minister this. In return, the Government must make as much time available as noble Lords need to give this huge and complex Bill the scrutiny that it deserves. The public and the NHS would not understand if we did anything less.

I pay tribute to the noble Baroness, Lady Williams, and others, such as Evan Harris, for their steadfast campaign and I hope that we can work together to improve this Bill. I promise that these Benches will be here to support sensible amendments to this Bill from wherever they come and I hope that noble Lords will do the same.

Perhaps I might gently remind my Liberal Democrat friends that for many years the NHS has been a toxic political issue for the Conservative Party and it never was for them. In fact, the Liberal Party was in at the birth of the NHS: you were part of its genesis. I would just ask: why would you put that legacy and that history in such jeopardy? As for the Conservative Party, people wanted to believe David Cameron when he promised before the election to protect the NHS. He promised to guarantee a real rise in funding and to stop top-down NHS reorganisation. I put it to noble Lords that every one of his promises is now being broken.

At a time of austerity, the NHS needs co-operation, collaboration and integration, not experiments with the extension of competition. So we are keen to scrutinise this Bill: we support the greater involvement of clinicians in commissioning; we support the devolvement of public health to local authorities with the right safeguards and financial support, and independence at a national level; and we support the creation of health and well-being boards and local accountability. We believe that the Bill needs to enhance the patient’s voice because we think that that is very inadequate at the moment. We believe that accountability and transparency need to be addressed from top to bottom of this Bill.

In addition, we believe there are matters concerning mental health, children’s safety and well-being, training and workforce planning, research and many other issues that will be raised by noble Lords across this House, which will need plenty of time in which to be debated and given the scrutiny that they deserve.

The wider context of this, of course, is the need for the NHS to deliver the Nicholson challenge and find the £20 billion of efficiency savings. We on these Benches believe that that is a priority and is enough in itself. Our concerns with this Bill are many and serious but the core of the Bill around regulation and the failure regime did not receive proper scrutiny in the other place. Indeed, the failure regime received no scrutiny whatever because it was introduced too late. We will be seeking major changes to Part 3, which we regard as dangerous as well as unnecessarily complex, bureaucratic and expensive. We do not support making our NHS into a regulated market, as advocated by some. Whatever the merits of competition and quasi-markets—we will hear a lot about these during the course of the Bill—they cannot be the basis for the delivery of healthcare. Indeed, there is a role for regulation, but the role and nature of the regulator has to be a lot clearer than it is in this Bill at the moment. I am giving noble Lords a very rapid summary of our major concerns and the areas of the Bill which we think need attention.

I now wish to address the procedural and constitutional challenges posed by the Bill. I would like to be very clear to the House: my right honourable friend Andy Burnham made a serious offer to the Secretary of State over the weekend. He asked the Government to withdraw the Bill and committed Labour to co-operating with the Government to implement the clinical commissioning agenda using existing powers, and doing it as quickly as possible. I repeat that offer to the Minister now. However, frankly the omens do not look good.

My party will support the amendment of my noble friend Lord Rea not to proceed any further with the Bill. We invite all those who love their NHS to join us. We do this with a heavy heart because it is this House’s job to scrutinise and improve legislation. However, we believe we have no option because there is no doubt that there is an overwhelming call for us to stop the Bill from the royal colleges, the professions, doctors, nurses, thousands of health workers, patients and, indeed, non-patients. However, there is an alternative before us today, and we think this offers a way forward if the Bill is not withdrawn or stopped. It is an alternative offered by the amendment in the name of the noble Lord, Lord Owen. The idea that we can have double the scrutiny going on at the same time is very attractive. We believe that it will expedite the process of scrutiny and we urge the Minister to accept this proposal. We know from previous experience that issues referred to a Select Committee help the House enormously in taking decisions.

Why did 100 noble Lords want to speak in this debate? Why did the noble Lord, Lord Owen, feel moved to put a significant amount of his time over the summer into working out a constructive way to maximise the scrutiny of the Bill? Why has the noble Baroness, Lady Williams, spent an enormous amount of her time since the spring trying to work out a way forward for the Bill? Why have dozens of noble Lords attended seminars and briefings since March better to understand this Bill? Why do we think thousands of people have written letters and sent e-mails to Peers across the House expressing their concern about the future of the NHS? Indeed, I pay tribute to the GPs, clinicians, nurses, midwives, physios and other ancillary therapists, mental health workers, care workers, trade unions, patient groups and health charities for the time and attention they have given to the detail in the Bill. The majority still do not like it. All of this has happened because our NHS is precious to every family and every person in the land, whether or not we use it. Everyone knows that whatever happens to them, wherever they are and however serious it may be, they can get healthcare. This is possible because we pay for it together and it is part of the social fabric of our nation. The NHS, in Bagehot’s terms, has a dignified as well as an efficient side and a specific role in the psyche of the nation as a symbolic guarantor of fundamental decencies. Any prospective reformer would have to respect those. I suggest that Andrew Lansley has not done so.

Our NHS was built on the principles of co-operation and integration as a genuinely national system with a properly accountable Secretary of State answerable to Parliament—a system working for the benefit of patients. This is where I end because the only real test of these reforms is their impact on patients. We are good in this House at hearing patients’ experiences and acting on them. We will have to listen very carefully indeed in the coming months. There is huge expertise in this House: medical, legal, organisational, charitable, and, often the most important, a great deal of common sense and practical experience. We will need to bring every bit of this wealth of talent to bear on this Health and Social Care Bill. I look forward to working with noble Lords across the House and with the Minister in the coming months.