Health and Social Care Bill

Baroness Young of Old Scone Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Mawhinney]

My Lords, it would be very courageous for anyone in your Lordships’ House to argue that there was no benefit to the patient in trying to have as integrated a service as possible. I am not that courageous. It is a good place to start. Having said that, I do not believe that these amendments are the answer or that they move forward the argument for integration. I searched through these proposed new clauses and I find no mention of any legal responsibility on the local authority, the social care agencies or anyone else. They are entirely directed to health bodies. That imbalance struck me as being a pretty poor starting point if you are genuinely interested in trying to produce integrated services.

Your Lordships will know that, even before the introduction of the Bill, there were various attempts to integrate services in various parts of the country. I happen to be a reasonably well-informed individual in respect of one of those attempts. It is one thing to say to the PCT, the cluster, or whatever is the latest development in that area that it has responsibilities to integrate with the local authority, just as it will be a different thing to say that a local commissioning group has to integrate with the local authority if some attempt is being made legally to define the role of the health component but there is no commensurate attempt to deal with the legal framework with regard to the providers of social care. I know of one example of attempted integration in this country that is foundering because the health component is seeking to shift its deficit on to the local authority. Sometimes the quality of those who serve in one is so different from the quality of those who serve in the other that no right-minded person who was dealing with his or her own money would invest in a partnership that was as skewed as those that exist up and down the country.

I started where I did because I do not wish to be interpreted as being against useful, appropriate and constructive forms of integrated provision. I have taken a view throughout the Bill that it ought to be for the benefit of the patient. It would be courageous to suggest that some appropriate form of integration would not be of benefit to the patient. However, these skewed and flawed amendments are not helpful and certainly do not beat a path to the future for the benefit of patients.

[Baroness Young of Old Scone]

My Lords, I rise to support Amendment 38C and to disagree violently with the noble Lord, Lord Mawhinney. I think that the importance of integration applies not just between health and social care but also within health services. We have to start somewhere, and the Bill before us gives us the opportunity—now, today—to start with the important new bodies that will come into existence on the health service side of the partnership. It is fundamental and vital that they are properly tasked with responsibility for integration. Let me explain why.

I hope that many noble Lords listened last week to the interesting and powerful “File on 4” programme on the dreadful condition, in terms of lack of integration, of our diabetes services. Diabetes is a long-term condition and those who have it require each year that about 15 essential and different services are clustered around them in an integrated way; otherwise they run a high risk of suffering premature death or horrific and expensive complications. I emphasise the word expensive because those complications can include kidney failure, blindness and amputation, which are hugely expensive for the National Health Service to treat and could, at the current rate of increase in diabetes, financially wreck the NHS. I hope that at least some noble Lords heard that programme because it demonstrated that integration between health and social care and within healthcare is vital for long-term conditions—not just for diabetes but for other long-term conditions as well.

This is a disputed figure, but it is thought that long-term conditions now take up somewhere between 60 and 70 per cent of the NHS budget. If the Bill is about the future provision of healthcare in this country and how healthcare needs to be joined up internally and with social care, it will have to address that 60 or 70 per cent of NHS expenditure that relates to long-term conditions. Therefore, it is pretty important that the new institutions of the NHS Commissioning Board, the clinical commissioning groups and Monitor are clearly now tasked—while we have the opportunity to influence them—with incorporating integration into their annual plans and with reporting annually on how they have got on with fulfilling this obligation and important duty. I do not think it is too much to ask; I think it is pretty important. I hope the Minister will agree.

Monitor will also have a crucial role in the development of tariffs. At the moment we have tariffs which, unless properly constructed, get in the way of integration: they form a barrier to putting together sensible packages of services. In a competitive environment, that will be even more so. It is fundamental that tariffs are constructed in a way that supports the important integration—and I am not going to apologise for repeating this—which if not delivered results in premature deaths and horrific complications. I hope that the Minister will take this point and support the amendment.

Health and Social Care Bill

Baroness Young of Old Scone Excerpts

Monday 13th February 2012 Lords Chamber

[Earl Howe]

My Lords, I hope that the noble Lord will allow me to remind him very respectfully that we are on Report and not in Committee. I am trying to work through my arguments, which I hoped would have a flow to them, but my flow has been interrupted. I am getting to what I hope he wants me to get to.

I was saying that the amendment would effectively require you to prove a negative—in this case, that people were not told about something going wrong with their healthcare. If they were not aware of the error, they would not be aware that they had not been told about it, and the volume of incidents is such that a single national body could not possibly verify compliance with that requirement.

I know that the noble Baroness advocates that the CQC should not routinely monitor this duty and instead should require organisations only to provide evidence that they encourage openness through having appropriate procedures and policies in place. Unfortunately, what that creates—this point was made by my noble friend Lord Ribeiro—is a tick-box exercise. Organisations can provide all the assurances in the world that processes are in place and therefore they are considered to be compliant, when in actual fact it could be that patients were still not being told about errors in their care. That is not acceptable and would not deliver the culture change that we need. We must have a requirement that ensures that patients are told of errors, not one that pays lip service to this and allows organisations—

[Baroness Young of Old Scone]

I was not intending to speak on this amendment but, as the former chairman of the Care Quality Commission, I have to make a point.

[Baroness Northover]

I remind the noble Baroness that, as my noble friend said, we are on Report. If she is seeking clarification or questioning something, that is slightly different, but she should not make a speech at this point.

[Baroness Young of Old Scone]

I merely want to ask the noble Earl what the material difference is between this requirement being laid on organisations by the CQC and many of the other basic requirements that are laid on organisations by the CQC. Those organisations are not inspected in detail on an ongoing basis, but the requirement is intended to seek from providers of health or social care an outline of how they intend to deliver that requirement, without their being inspected regularly in all cases.

[Earl Howe]

My Lords, I hope I have already explained that. In our conversation with the CQC, it made very clear that this would not be like any other requirement placed upon it. A requirement to prove candour will require the CQC to engage in a much more continuous and intensive process of monitoring than some of its other requirements. That was the distinction that it made and that is why it said that it did not have the capacity to fulfil this duty if it were built into the Bill.

I am afraid that the amendment would not be effective in meeting our shared objective. That is my problem with it. I have listened to the arguments put across by noble Lords in relation to primary care. I want to see openness in primary care as much as I do in secondary care. However, we still need to consider which requirements would work best in primary care.

Health and Social Care Bill

Baroness Young of Old Scone Excerpts

Wednesday 8th February 2012 Lords Chamber

[Baroness Pitkeathley]

My Lords, far be it from me to cast a pall over the House of Lords at its best. I join others in being glad about the consensus and in congratulating the Constitution Committee. I also congratulate the Convenor on the part that he played in getting the consensus. It is a privilege to follow him.

I join the noble Baroness, Lady Williams, in hoping that the consensus can continue but I have to remind the House of how the Bill is viewed out there. It is deeply unpopular with many of the people who will be required to make it work. They will make it work because that is what the workforce of the health service does and always has done in the most difficult of situations. However, it is looking to us to make those difficulties as few as we possibly can. Therefore, in congratulating ourselves on reaching where we have on this issue, let us remember the task before us.

[Baroness Young of Old Scone]

My Lords, I am afraid that I will be even more discordant. I do not want to denigrate the congratulations that have been offered to the noble Baroness, Lady Jay, and her colleagues and the process that has been gone through to reach agreement on this amendment. However, I share the view of the noble Baroness, Lady Pitkeathley, that we must not forget not only how deeply unpopular the Bill is but that it is flawed.

I had not intended to speak on this amendment but I cannot let the moment pass as I think that the noble Baroness, Lady Jay, referred to a spirit of improvement that she was seeking in moving this amendment. However, we have to remember that the improvement is a bit like trying to paint the face of a harlot; at the end of the day, it is still the face of a harlot, no matter how improved. We are seeing real impacts on healthcare in this country as a result of the Bill, as we speak. I come from a background of having run health services for 20 years. I have also been the regulator for health and social care and am now part of a patients’ organisation. Patients are telling me that we are seeing the fragmentation of responsibility for the commissioning of healthcare and that services are suffering as a result of the financial squeeze; for example, diabetic specialist nurses are disappearing and patient education is being cut. The things that are important for the quality of care are being removed.

I am experiencing a huge loss of momentum in getting any change implemented in the care for people with diabetes. Whenever I speak to the Secretary of State, he tells me that it is no longer his responsibility and that I should talk to the NHS Commissioning Board. However, when I speak to the NHS Commissioning Board, staff say, “We are still working out how we do this”. When you talk to clinical commissioning groups, they are still not clear about the framework in which they are operating. Therefore, we are losing one, two or three years of headway on issues where there needs to be real improvement for patients.

Because of the preoccupation with reform, we are seeing a lack of real focus on the task in hand, which is how we make the health service more efficient. The Minister and the Secretary of State have repeatedly told me that these reforms will deliver that necessary improvement in care and efficiency. However, my experience over 40 years leads me to believe that that is not the case. In saying that, I am not making a political point; I speak from my knowledge of what is happening in healthcare. We will continue to try to improve the Bill because we are good and honest toilers in the House of Lords, but we are trying to improve something that is deeply flawed.

[Baroness Thornton]

My Lords, we must be thankful to my noble friend Lady Jay and the Constitution Committee for their initial work and their second report, which has enabled us to reach the point that we have. I am grateful to my noble friend Lady Pitkeathley and the noble Baroness, Lady Young, for saving us from the gloopy treacle of self-satisfaction into which we were sinking, to which my noble friend Lady Jay referred.

I, too, thank the noble Lord, Lord Laming, the Convenor of the Cross Benches, for chairing the seminars that have been referred to. We all know that chairing seminars attended by opinionated Members of this House and lawyers is not an easy task. He did an excellent job and led us gently towards the consensus that has resulted in the amendments being tabled that we are discussing. I pay tribute to the noble Baroness, Lady Williams, the noble Lords, Lord Hennessy and Lord Owen, whose wisdom brought the great importance of this issue to the attention of the House.

We support this amendment as it is clearly an improvement on what was in the Bill originally. We are still perplexed as to why we could not simply have kept the 2006 wording, but we are where we are. However, I wish to repeat the question that I have already put to the Minister. The Secretary of State has let it be known that he does not think that this measure makes a difference. That shows no respect for the work that we have undertaken and the place in which we find ourselves. Therefore, I should like clarification on that point. We need to know why that is the case. This measure constitutes a significant change because, as I think the noble Baroness, Lady Williams, said, it will have repercussions on other parts of the Bill. I welcome that and hope that it is the case. We need to look at the changes proposed in this and the following amendments as they should make easier our job of testing other parts of the Bill against them.

I say to the noble Lord, Lord Mawhinney, that this is still a very political Bill. The noble Lord’s party and the Liberal Democrats pushed the original drafting on the Secretary of State’s powers through the Commons. I have tried to keep my remarks about the highly politicised nature of the Bill separate from this debate because I thought it was important that we should also recognise the work that has gone on and the consensus that we have reached in this House. That is due to a combination of clarity, wisdom and our consideration of the Constitution Committee’s report. I compliment noble Lords on my own Benches because we were determined not to accept the well meaning and imaginative original proposal of the noble and learned Lord, Lord Mackay of Clashfern. We had very trenchant support from noble Lords such as the noble Lord, Lord Owen. The Minister, in his wisdom, took these clauses off the Floor of the House and we are now where we are. That is a great credit to everybody concerned, including my own party. Therefore, we are very happy to welcome this amendment and hope that it bodes well for our future discussions on Report.

Health and Social Care Bill

Baroness Young of Old Scone Excerpts

Tuesday 22nd November 2011 Lords Chamber

[Earl Howe]

I could not agree more with the noble Lord. We want to get closer to the question of what represents value for money in primary care. There are perhaps two principal ingredients of that equation. The first is the money we put into primary care, which we will know through the resource allocation formula, with which the noble Lord is familiar; the second is through highlighting the results achieved through primary care. Primary care clinicians will be accountable as never before by reference to the outcomes that they achieve for their patients. The other ingredient, overarching all that, is transparency. The more measures of performance that we can devise and place into the public domain the better in my view, and in the next few weeks, we will be announcing measures that I hope will be welcome in that regard. However, we are starting from a low base—not much information is currently published. We want to change that, and ensure not only that clinical commissioning groups and the NHS board are aware of all this but that patients and the public are aware of how well or badly a practice is performing. All these things such as prescribing rates and referral rates are key measures of performance, which we have to get closer to. If we can ensure that practices themselves are more able to compare their own performance with those of their peers, that too will be an advance. I am sure that this is a rich seam, as the noble Lord put it, and we very much hope to advance on that front over the coming months.

[Baroness Young of Old Scone]

Can I just press the noble Earl on that point? We have a situation at the moment that I think is not in patients’ interests. If you want to find out about the quality of diabetes care by provider, hospital or trust in this country, you can find out about it perfectly well; if you want to find out about the quality of diabetes care commissioned by a PCT, you can find out about it perfectly well. The quality of care being delivered to people with diabetes by general practitioners is available and can be seen by general practitioners—who can compare their performance with each other—but it is not available for people with diabetes. Quite frankly, I think that is outrageous and I would urge the Minister to do something about that now.

Health: Diabetes

Baroness Young of Old Scone Excerpts

Thursday 4th November 2010 Lords Chamber

[Baroness Young of Old Scone]

My Lords, I add to the thanks expressed to the noble Lord, Lord Harrison, for giving us this opportunity to talk about a subject as important as diabetes and foot care. I also thank other noble Lords for the broad sweep of diabetic issues that they have raised today. I did not quite expect chocolate to come into it, but the sweep was wide. I should declare an interest as the new chief executive of Diabetes UK. This is day four, so noble Lords should not expect too much of me at the moment.

When I was swotting for the interview for the job, one of the heart-stopping statistics that I learnt was that, every week, 100 people have a foot amputated as a result of diabetic complications. Even worse, 85 of those amputations are entirely preventable. The report and the issue that we are debating today are therefore extremely important for a variety of reasons.

Rather than go through the report’s recommendations, I shall highlight some of the principles. It is clear that early detection of potential foot complications, not only in patients with diabetes but in other patients where diabetes may as yet be undiagnosed, is vital on admission to hospital and throughout a hospital stay. It needs a proper history to be taken and a proper examination.

We also need to make sure that the threat of diseases of the foot is recognised by some of the key, non-specialist healthcare professionals. As the rise in the number of people with diabetes or potential diabetes is truly epidemic, we need to make sure that health professionals across the piece, not just the specialists, are capable of recognising complications before they get active. Once there is active foot disease, there needs to be a referral to a specialist team or to a professional with specialist skills. Last but not least, the noble Viscount, Lord Falkland, rightly said that this is a disease where the patient needs to be in the driving seat. People need to be at the centre of their own care and to have access to information and support from specialist teams. One in three people with diabetes is currently unaware of the potential problems that they could have with foot complications, which is a poor performance figure.

Those are the sorts of things we need to bear in mind, but I will talk about that particular complication of diabetes as just one of those indicative of a much wider issue in the care and management of diabetic problems in this country. As many noble Lords have said, diabetes is a big problem. It consumes 10 per cent of the National Health Service budget; that is, £9 billion. It is also a growing problem, as we have 2.8 million people with diabetes and a large number of people as yet undiagnosed. There is the potential for it to rise very shortly to 4 million people with diabetes in this country. Foot problems and amputations are only some of the complications. Others, which have been referred to, are blindness, stroke and heart disease. Those represent a huge cost, not just to the NHS but to the economy, because people with severe complications may be less able to work and more dependent on benefits and social care, apart from the huge human cost and misery that we are talking about.

We need to ensure that we somehow enable that 10 per cent of the NHS budget, which might have to become more, to be spent at an early stage in the pathway for diabetes—at a point where the prevention of type 2 diabetes and of complications in all types of diabetes can take place, avoiding the complications further down the line that are such a huge cost economically, socially and in terms of heartache. That needs collaboration between the commissioners of services, the providers of services and patients and their families but there is lots of guidance around; we are not short of guidance on what good practice might look like.

There is, for example, NICE guidance on the prevention of foot complications. Their subsequent management is currently being consulted on. NICE is going to work on quality standards for diabetes as one of the 150 quality standards that the coalition Government have asked it to develop. I gather that the diabetes standard will be an early one among those. Guidance for commissioners already exists, which Diabetes UK worked on some years ago. We are currently working on a kind of checklist for what an integrated quality diabetic service would look like. There is plenty of advice around and nobody is in any doubt about what the standard of the service should be. The problem is that its implementation is very patchy.

Diabetes UK, in the context of the NHS reforms, is very much going to put its shoulder to the wheel, as it were. Many things which the charity currently does will fit well with the principles of the health service reforms. There is considerable information and support for patients and their families and guidance for commissioners, as I said—we will be inputting very actively to the national standard-setting process. There is also our volunteer network, which will be active locally in fora where advice and decision-making about diabetes is taking place, both at the commissioner and provider level. We will very much want to work locally with the commissioners as the GP consortia emerge. I share the views of other noble Lords; we need to have larger commissioning consortia rather than smaller. I hope that we can learn from history, as the primary care trusts had to be clumped up and merged because they were too small to do a decent job. Let us not forget that lesson by having consortia that are too small. Another job that Diabetes UK will willingly turn to is monitoring the quality of services being received locally and their implementation nationally. We are very much there to play our part.

I want to ask the Minister two questions. First, how can the Government ensure that there is a change in the pattern of investment in diabetes care, to make sure that the services for early detection and for preventing complications are up front, as it were, and that the huge downstream costs of complications are not using up the NHS budget for diabetes inappropriately as well as generating the social costs and the personal heartache of complications?

Secondly—this reiterates the point made by the noble Lord, Lord Rennard—can the Minister let us know how the new arrangements with GP commissioning consortia will be able to ensure that people across the country with diabetes get the recommended standard of care, irrespective of where they live? We hear about localism and less central direction being very much a principle of the reformed NHS. I will not talk about the postcode lottery as a risk, although I have heard the phrase “postcode democracy”. We ought to hold the Minister’s feet to the fire to explain that before long.

I look forward very much to my new role and to hearing what the Minister has to say about this topic, which is hugely important not just for people with diabetes and their families but for the national economy.