Southern Health NHS Foundation Trust

Lord Hunt of Kings Heath Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, these are truly shocking revelations and reveal deep failures at the trust. I start by echoing his remarks about the families so grievously affected.

As the Minister said, only 195 of the 1,454 unexpected deaths were actually treated by the trust as serious incidents requiring investigation. Perhaps most worryingly, it appears that the likelihood of an unexpected death being investigated depends hugely on the patient. For those with a learning disability, just 1% of unexpected deaths were investigated. For older people with a mental health problem, just 0.3% of unexpected deaths were investigated.

Obviously, we will expect a full response from the Government when the report is published, but in the mean time, can the Minister say whether he judges services at the trust to be safe? What advice can he give patients currently in the care of this trust, and their families? He explained that NHS England first received the report in September. Can he say why it has not yet been published, and when a final report will be made available?

Finally, I want to raise an issue the Minister himself mentioned. I understand that the trust disputes the analysis by the audit company Mazars, which produced the report. NHS England needs to sort this out. When the report is published, it is clearly vital that there be no question about its methodology or the robustness of its conclusions. Is he absolutely confident that NHS England has got a grip of this?

[Baroness Walmsley (LD)]

My Lords, our hearts go out to the family of Connor Sparrowhawk and all the other families who have struggled so hard to get investigations of the unexpected deaths of their loved ones. On many occasions they have struggled to find the financial support required to make that investigation. That is quite wrong. In this particular hospital’s case, the percentage of unexpected deaths that was investigated is pretty scandalous. In fact, across the board, only 1% of unexpected deaths of those with learning disabilities are investigated.

I very much welcome the Minister’s saying that a light will be shone on this, but will the investigation bear in mind the possibility that it should not be the hospital trust itself that decides which of its unexpected deaths should be investigated? Police forces no longer investigate themselves—that is done by another police force. Should that not be the case with hospitals too? My second question is about timeliness. The report is not the first indication we have had of problems with this trust. The coroners have complained on numerous occasions, and over a long period, about the timeliness and quality of the reports received by them on cases that were investigated. Surely this indicates that there have been problems with the administration, the collection of evidence and the systems of this trust. Why was that not picked up earlier?

Residential Care: Cost Cap

Lord Hunt of Kings Heath Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to wind up for the Opposition and to thank my noble friend. It has been an excellent debate; a number of very challenging questions have been put to the Minister and we look forward to his response. There can be no doubt that the viability of the residential care home sector, the failure to implement Dilnot and the failure to raise the means test are causing great anxiety to thousands of people and their relatives throughout the country. As the noble Baroness, Lady Walmsley, said, the lack of viability of the residential care sector is but one part of what one has to say looks increasingly like a dysfunctional health and social care system.

When the Minister replies—because he has done it recently—he will no doubt talk about the Autumn Statement, ministerial vision and the potential of the new models of health and social care that the Government are putting an awful lot of eggs into, without, I have to say, any evidence that they will be able to enable a response to the challenges. The gap between ministerial rhetoric and reality is striking. There is no problem with a five-year forward view. This vision is described as empowering patients, their families and carers to take more control over their own care and treatment. It is a future that truly integrates health and social care, at last puts mental health on a par with the rest of the system and, crucially, prioritises prevention. That is a fine vision and, in the absence of any vision for social care, I assume it is the Government’s statement of social care policy as well.

However, it is impossible for me to see how that will happen in the context of a Government determined to bring the share of government spending down from 41% to 37% of GDP. It is always good to wait until a few days after an Autumn Statement to get the real analysis of what is happening in spending. The analysis I have seen from the King’s Fund is that for the next five years the actual growth in the health service will be 0.85% per annum. So we are just continuing the misery of the last five years. We know that the historic growth level in the NHS is 4%, and that is what is needed to meet these challenges. It is striking that, of the much-vaunted extra £8.4 billion, £4.6 billion has come from other parts of Department of Health expenditure, including Health Education England, the nurse bursaries, capital and public health. You also have to add in the £1.1 billion of pension costs due to the changes in the pension rules from next April, for which no additional money has gone into the health service.

The King’s Fund projection shows that in this five-year period social care will be left with an annual cut of 0.3% per annum. Therefore, even though it is back-loaded, it is starting off with a very challenging situation. There is then the cost of the living wage to be added to the negative growth. I cannot possibly see how the health and social care sector can meet the challenges of the demographics that it is facing, with the huge population growth that we have seen in the last 10 years projected to increase by another few million over the next 10 or 15 years, as the noble Lord, Lord Filkin, said.

When it comes to the residential care sector, there is no need for me to repeat the figures that other noble Lords have referred to, but I thought that the ResPublica report got it in a nutshell when it talked about the unsustainable combination of declining real-terms funding, rising demand, increasing financial liabilities, a funding gap of £1 billion by 2021, the potential loss of beds and, of course, the knock-back impact on our National Health Service. I had not seen the advice from Care England. That advice is very sobering indeed when it comes to the whole viability of the residential care home sector.

It seems to me that the result of all this will be that, far from the models being implemented, we will see the perverse incentives mentioned by the noble Baroness, Lady Brinton, getting worse and worse because of the tension between the free-at-the-point-of-use NHS and means-tested social care. That is why integration is so difficult. Until we get to grips with that divide, we will never achieve integration of services. As my noble friend Lord Turnberg said, NHS hospitals are the providers of last resort. If the residential care sector goes down, residents will end up in NHS hospitals. I remember those dreadful long-stay wards that NHS hospitals used to have, and I am afraid that they will be recreated unless we can sort this problem out. Many reports are coming out but one report produced today by the Nuffield Trust shows that 3.6% of patients took over a third of all bed capacity in acute hospitals, and the trust expects the position to worsen in the years ahead. That is the challenge that our system faces.

There are about 10 questions from my noble friends to which the noble Lord, Lord Prior, is being asked to respond. The first, on the positive side, was asked by my noble friends Lady Dean and Lord Lipsey. Can we increase public awareness of the importance and success of many parts of the residential care sector and the good work done by the staff? My noble friend Lady Dean gave a wonderful example of the sector working at its very best.

The second concerns the general view that, essentially, the care cap will never be implemented. Can the Minister say that it actually will be implemented, and when? Thirdly, does he agree with his noble friend Lord Lansley about the sense in going back to Dilnot’s original recommendation about the size of the cap? A number of noble Lords mentioned the £6 billion. Noble Lords look quizzical whenever it is mentioned, but that figure has appeared in government papers and projections. I think we are right to ask what on earth has happened to it.

The noble Lord, Lord Sutherland, asked what analysis the Government have made of the risk of closures. What are their contingency plans? How will we avoid the dreadful situation of very frail older people having to be moved from one home to another, which we know can have appalling effects on life outcomes? When will the means test limit be increased as promised? The Government made a deal. They made a deal with people that the care cap would come in in 2016 and that the means test would be increased. Many people made financial provision on that basis. Surely the Government have a moral responsibility here to deliver what was promised. Does anyone remember the Prime Minister saying no one would have to sell their home? What has happened to that?

There are two final things. First, my noble friend Lord Bhattacharyya asked about incentives to encourage people to build up funds for their care. What has happened to the much-vaunted insurance market? It was supposed to come to the rescue and be complementary, in a sense, to the introduction of the care cap. Finally, and overwhelmingly, my noble friends Lady Pitkeathley and Lord Turnberg and other noble Lords talked about the need for a coherent, long-term strategy. Either we go into absolute crisis in the next year or two, with huge knock-on impacts on the rest of the provision of health and social care, or the Government have to get a grip and actually start going for a long-term strategy. I hope the Minister will announce that tonight.

Health: Liver Disease

Lord Hunt of Kings Heath Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the recommendations in the report about a hub-and-spoke approach, to which my noble friend refers, with district general hospitals having some hepatology services but being linked into a specialist centre are absolutely right. It is the right model; I have no doubt about that. We have established 22 operational networks for hepatitis C treatment, which are all linked into specialist treatment centres. We believe that that may be a model for the future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the issue of specialist centres, has the Minister actually read the Lancet report, which points out that the north-west has the highest incidence of liver disease, yet does not have a transplant centre? In view of the very good outcomes from the transplant centres, are the Government making sure that the north-west gets such a centre?

[Lord Prior of Brampton]

I have read the Lancet report and I noted this rather unusual omission in the north-west. I do not understand why the north-west does not have a specialist liver facility. It is something that I will follow up and find out. I will write to the noble Lord if I can.

Health: Adult Pneumococcal Vaccination

Lord Hunt of Kings Heath Excerpts

Tuesday 8th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the report by the JCVI was very clear in its recommendation that the existing vaccination, PPV, was the most appropriate for those aged over 65 and that PCV 13, which is the vaccination used for young children, because it provides herd protection—that is, young people who are treated with it can no longer carry the disease—offered the best long-term protection for the elderly as well.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this year community pharmacists have been given the opportunity to provide NHS vaccinations. Can the Minister say something about how successful that has been? Does he think that there is much greater potential for community pharmacists to do more work for the NHS in this and other areas?

National Health Service (Licensing and Pricing) (Amendment) Regulations 2015

Lord Hunt of Kings Heath Excerpts

Tuesday 1st December 2015 Lords Chamber

This has been a long speech because it is an important issue and one which is somewhat arcane for some noble Lords. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for his detailed and careful explanation of the reason for this statutory instrument. I still regard it as a flawed set of regulations and I am not surprised that your Lordships’ Secondary Legislation Scrutiny Committee has reported it for the specific attention of the House on the grounds that the regulations may imperfectly achieve their policy objective. It is my contention that the regulations undermine a core part of the Health and Social Care Act 2012. They certainly run against the spirit, if not the letter, of what the noble Earl, Lord Howe, told the House during the passage of the Bill. Although the noble Lord has been very careful to differentiate between acute and non-acute trusts, the actual impact of what is being proposed is that NHS trusts and foundation trusts, which provide 96% of the tariff work for the NHS, are effectively disabled from using the tariff objection mechanism because it is mathematically impossible for them to trigger it alone. They would need some of the very small-scale, private providers to join in. The effective silencing of the voice of the NHS front line in the tariff-setting process displays a shocking degree of arrogance on the part of NHS England. It seems to be bent on punishing these providers for having the temerity to object, as they did in the last financial year.

The noble Lord has carefully described the national tariff. I suspect that noble Lords know more about it than they ever thought they wished to. As he says, it is very important in terms of the income going to most NHS providers. The 2012 Act provides for a statutory duty to consult on the proposals that NHS England and Monitor make. There is also a parallel right to object to the tariff proposal if they have insignificant numbers. The current threshold is 51% of commissioners or providers, either individually or based on the proportion of services they provide. This is called the share of supply. I do not think that 51% could be said to be not setting a pretty high threshold. I understand entirely that this mechanism is not meant to be used regularly, but current experience shows that it actually works. It was not used in the first year of its operation, but it was used in the 2014-15 financial year, with 75% of providers by share of supply making an objection. The reason they objected was that the tariff changes made, particularly for specialist services, would have an enormously negative impact on the providers of those services and, by definition, on the specialist services themselves.

--- Later in debate ---

We recognise the degree of consultation, engagement, openness and trust that was not there last year, and we are committed to rebuilding that. We note the comments made by NHS Providers and have taken them on board. I can tell the noble Lord that Simon Stevens, Jim Mackey, the Secretary of State and I are absolutely committed to rebuilding that confidence and to having a much higher degree of engagement and consultation in the tariff-setting process.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to all noble Lords who have taken part in this interesting debate. We perhaps went rather wider than the terms of the regulations. I agree with the Minister that payment by results was brought in essentially to drive through reductions in waiting times by providing the right incentives. By and large that has been very successful, but we are moving, and this is a very good thing, into thinking about systems and how they work. There is a clear need to develop a funding mechanism to ensure that there are proper incentives for system-wide working, and I absolutely agree with that.

However, I also agree with the noble Lord, Lord Warner, my fellow former Minister. Looking at the Five Year Forward View, it seems to me that essentially we are moving again to a planning model but we are still stuck with the 2012 Act, and the two do not seem to mesh together. The Minister is struggling with these regulations because they are trying to operate a system that is still based on payment by results, when in essence we are trying to incentivise people to work together to produce a much more effective system and that is very difficult. If he were to tell me that the NHS amendment Act was to be brought forward, I think he would find a warm welcome in your Lordships’ House, but perhaps I dream too far.

I say to the noble Lord, Lord Patel, that I do not disagree at all with his idea of an independent commission; the funding challenges facing health and social care warrant that kind of independent consideration. I say to him, though, that all the work done by the King’s Fund and the Nuffield Trust suggests that if you could maintain real-terms growth at 4% a year, which is the historic annual real-terms growth of the NHS, we would get a pretty good system without some of the pressures that we are facing at the moment. It is not a question of having to increase money to the NHS and social care hugely, but it needs some increase or we will be faced with the kind of problems that we have at the moment. The Barker commission, which was sponsored by the King’s Fund, shows some of the thinking that one might ask a royal commission to go into.

My noble friend Lord Turnberg mentioned the particular challenges of highly specialist providers, which of course are very much tied into the area that he knows so well: our whole R&D effort in this country and the link with the life sciences. While I understand the language of domination by specialist providers, we need to recognise that the link that these very same providers have with R&D and the life sciences is crucial to this country and to the lead that we often have in these areas. We have to be very careful not to undermine their financial viability because of the general financial challenge.

I am delighted that the noble Lord, Lord Warner, is working on, chairing or leading this work on specialised services, and I am sure he is right that we need to have much more effective commissioning. I certainly accept that that is likely to lead to a rationalisation of specialised services, which will not be universally popular. However, if we can show that by doing so we get more bang for our buck, getting better specialist services, and that they are a better investment, clearly, that has to be followed through. I hope that we will see the outcome of that work within the next few months.

I have no problem at all with putting more resources into mental health and community services—I entirely understand that. However, the regulations are a pretty poor show, and in effect disfranchising the providers, who get 96% of the tariff income, is not the way to go forward. However, I am very grateful to the noble Lord, Lord Prior, for what he said. I take his commitment to rebuilding the confidence, as he described it, of providers in the system, as a very strong one. He did not quite go as far as I would have wished with regard to endorsing the open book approach. Does that mean that that is still being considered, or has it been rejected? Can I take anything from that?

[Lord Prior of Brampton]

I will have to defer to Jim Mackey, the chief executive of NHS Improvement. It would not be fair for me to answer that question.

[Lord Hunt of Kings Heath]

I am sure of that, my Lords. I will just say to the Minister that I hope the spirit of this debate will be conveyed to him and NHS Improvement. I certainly have been very impressed by the chief executive’s words since his appointment, and of course the chairman, Ed Smith, commands great respect and authority, not least for the work he has done on behalf of Birmingham University, for which those of us in the city are very grateful.

With that, I thank all noble Lords who have spoken. The point has been made, we look forward to a better approach in the future, and I hope that the spirit of the proposal regarding early consultation and an open book process will be acceded to. I beg leave to withdraw my amendment to the Motion.

Amendment to the Motion withdrawn.

Accident and Emergency Departments

Lord Hunt of Kings Heath Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Prior of Brampton]

My noble friend makes a very important point. Many people go to A&E departments who need not go there. The review of Sir Bruce Keogh, the medical director of NHS England, concerning how we structure emergency care in this country will be very important. Clearly, we can make much more of NHS 111.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the point that Minister’s noble friend made was that the Government’s decision to phase out NHS Direct, which used qualified nurses, and replace it with call handlers who simply use algorithms on their screens means that those call handlers are risk-averse, which therefore leads to many more people being sent to A&E. Is it not time to get qualified nurses back behind those screens and talking to patients?

[Lord Prior of Brampton]

The noble Lord makes a good point. If qualified people take the call, the level of risk they are prepared to absorb will be greater, and that applies throughout the whole system.

Junior Doctors Contract

Lord Hunt of Kings Heath Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for repeating the Statement. My understanding is that since the Statement was read in the other place, progress has been made in the ACAS talks. Perhaps the Minister will update the House in response to my comments. I very much welcome the outcome of those ACAS discussions.

The Minister knows that the dispute has been very damaging to workforce morale. He also knows that many junior doctors have already voted with their feet, or are planning to over the coming months. What action is his department taking to stop the brain drain of our brightest medics to countries such as Australia and New Zealand? It is clear that the past few months have been very bruising to junior doctors and it is vital that this is turned around so that they come back to a positive view of working in our National Health Service. I hope that the progress that has been made this evening will mark a change in tone and approach on behalf of the Government.

No one disagrees that if you go to hospital in an emergency on a Sunday you should get the same treatment as you would on a Tuesday. But the Health Secretary has repeatedly failed to make the case for why reforming the junior doctors contract is essential to that aim. My honourable friend Mrs Heidi Alexander has made a genuine offer to the Health Secretary to work with him on a cross-party basis to do everything possible to eradicate the so-called weekend effect and to support any necessary reforms to achieve that aim. But in return, the Health Secretary needs to be absolutely clear about what needs to change in order to deliver that.

As many studies have concluded, there needs to be much more research into why there is a weekend effect so that we can make sure we focus efforts on the actual problem. We hope that the Health Secretary will commit to commissioning new independent research into how reforming staffing arrangements at the weekend might help improve the quality of weekend services. Will the Minister say what other steps are being taken to ensure that we have consistent seven-day services, including making sure that social care is available outside the working week?

We welcome the fact that the Health Secretary finally agreed to ACAS talks last week and I very much welcome the news from those talks tonight. Nobody wants patients to suffer and let us hope that we can put the whole sorry saga behind us.

[Baroness Walmsley (LD)]

My Lords, I, too, thank the Minister for repeating the Statement. I, too, understand that the junior doctors have now agreed to call off tomorrow’s strike. Will the Government therefore apologise to the 4,000 patients whose treatments tomorrow will have been delayed by this going right up to the wire and the Government being so reluctant to go to ACAS for negotiation?

I understand that more detailed negotiations will now take place. Will the Government be entering those negotiations without prejudice and with the well-being of patients—and the well-being of doctors, upon which the well-being of patients depends—in their minds as they negotiate? Will they take very seriously the concerns that have been put to them by conscientious junior doctors, who work very hard for us?

I, too, have some scepticism about the data in relation to the so-called weekend effect. I echo the call of the noble Lord, Lord Hunt, for some independent research into the causes of the less good outcomes that undoubtedly occur in some places—to what degree, we do not know. I am quite sure that the junior doctors and their contract are not the only cause of any such weekend effect.

Health

Lord Hunt of Kings Heath Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, as we have debated public health so much, I must remind the House of my presidency of the Royal Society for Public Health.

I pay tribute to the noble Lord, Lord Crisp. He was a very distinguished chief executive in the NHS and Permanent Secretary, and more recently he has led some incredibly important work on global health issues. I thought he made a very profound speech this afternoon.

I, too, congratulate our maiden speakers, the noble Baroness, Lady Redfern, and the noble Lords, Lord Foster and Lord Smith. They were excellent maiden speeches and we very much look forward to hearing them, I hope, in the not too distant future.

We have had some amazing contributions from speakers: my noble friend Lady Jay on cross-government working; the noble Baroness, Lady Campbell, on independent living; the noble Lord, Lord Best, on housing. I find it quite remarkable that so many health and well-being boards do not have the housing sector represented, given that they are meant to be driving forward public health in their locality. We heard from the noble Baroness, Lady Masham, on the really worrying issue of sexual health programmes and policies, which risk being decimated because of the transfer of responsibility to local government.

The noble Lord, Lord Alton, spoke about the very different health and social care scene that we face now compared with 1948, yet we are still trying to work with a 1948 model. In fact, a lot of the barriers to the integration that noble Lords want to see are built into the very architecture—the targets that separate government departments set. I take the point made by the noble Baroness, Lady Walmsley, about vanguards, but until we get Whitehall to change its own architecture, it will always be driving forward the type of change that she identified with a hand behind its back.

The noble Lord, Lord Foster, talked about personal responsibilities, and the right reverend Prelate the Bishop of Bristol talked about isolation, which a number of noble Lords referred to. The noble Baroness, Lady Lane-Fox, talked about the NHS and technology. I agree with her—finally, having dabbled in this and spent a few billion pounds on the issue as well, we are on the edge of a major change in healthcare, and there are positive signs now coming through.

The noble Lord, Lord Smith, talked about human contact and the role of clubs, which I fully accept. The noble Baroness, Lady Neuberger, spoke about children and isolation, and the noble Lord, Lord Rea, spoke about the role of government in regulation and taxation, dealing with poverty in particular. The noble Earl, Lord Listowel, talked about loneliness and mentioned housing security in particular.

I thought that the noble Lord, Lord Mawson, was very interesting. He described health as an outdated silo and wondered how you translate excellence using the example of Bromley-by-Bow. I take his point. You cannot just ordain this: you have to grow it locally.

Clearly, in essence all speakers support the general point made by the noble Lord, Lord Crisp, which is that we need a paradigm shift in the way that we think about health and the role of the National Health Service. However, I am very wary of the five-year forward plan on the basis that suddenly, if we build these new models, we can actually expect to see a shift of resources from the NHS in order to fund them. I do not believe that.

If we look at the international comparisons, we spend so little on health and social care in this country. The recent OECD report showed that, of the OECD countries, we are 19th in terms of health expenditure per capita. In terms of doctors, we are 24th, nurses 19th, and hospital beds 26th, yet we know that the population will rise hugely. It has risen by 10 million in the past 10 years and it will rise hugely in the next 10 years. We have to be very careful not to think that suddenly we can turn off the tap of NHS provision by adopting this approach. All we can do is to slow down the growth.

I am very wary of people who think that the NHS can lose acute capacity. The idea that we could actually reduce the number of beds in the health service is ill-thought-out and ill-considered. It just does not accord with the reality of the pressure on the system. When I look at the five-year forward plan and the models, I can see that they are very good models, but the reason why no one believes we can reach the efficiency savings of £22 billion is that it is built on the fantasy of being able to transfer money from NHS acute care.

The other point made by the noble Lord, Lord Crisp, was about the huge range of inequalities in this country. The noble Baroness, Lady Walmsley, referred to the Commonwealth Fund, which gave us a great rating except in health outcomes. The OECD report does not give us such a good rating. Where it agrees with the Commonwealth Fund is about our appalling health status. Again, if we look at the OECD statistics for life expectancy at birth for men, we are 14th and for women we are 24th. It is the same when you look at life expectancy at 65. In terms of smoking among adults, we are 20th; we are 19th on alcohol consumption; and on obesity, where levels are appalling, we are 27th.^.There are 26 countries with a better record on obesity that this country.

We could also have mentioned mental health—again there is a huge worry about the scale of mental health issues. I have seen recent research suggesting that common mental disorders are twice as frequent in carers who care for more than 20 hours a week than in the general population. We know, simply from looking at population statistics, that the number of carers will have to grow hugely in the next few years.

The challenge is immense. I have to say to the noble Lord, Lord Prior, that the great thing in the five-year forward plan was the reference in a managerial document to the importance of health. That is the first time I have seen it so explicitly expressed. Yet, we see the public health budget being cut. It is so hard to fathom how a Government could do that. I hope that the noble Lord, Lord Prior, will address that in his response.

On the issue of Whitehall working, I agree with my noble friend Lady Jay. We used to have public service agreement targets which tied in different government departments into a common goal. I know that we can overdo targets, and I suspect we did, but there is no doubt that if different departments can be tied into a target that is enforced either by the Treasury, the Cabinet Office, or often by Downing Street, something does get done. This Government do not really do that.

We can see that in relation to the Department for Education. The Department for Education seems to be totally isolated from anything else in public policy in Whitehall. We debated a Bill on education recently. It is bizarre that, in respect of the Cities and Local Government Devolution Bill, which is all about the devolution of powers from Whitehall to the combined authorities, the Department for Education seems to know nothing about it and wants to have nothing to do with it. If we take the issue of obesity and the points raised by noble Lords on the lack of activity in PE, again the Department for Education is oblivious to this and its outcomes.

The DCMS is another example of a government department that does not understand Whitehall working at all. I have read its recent sports strategy. It is true that the Department of Health has a half-page in it, but why on earth is DCMS not doing, along with the Department of Health, a sports and health strategy?

In conclusion, this has been a great debate, but I would say to the noble Lord, Lord Prior, that the Government can do much; they cannot do everything. They can give leadership, and in this regard that is what this debate is asking for.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I shall try to do this without hesitation, repetition or deviation, but I fear I shall fail on all three counts.

First, I echo what all noble Lords have said and thank the noble Lord, Lord Crisp, for introducing this debate, which has been fascinating. He brings to it a lifetime of experience in healthcare, both in the NHS in the UK and, of course, globally. He mentioned two quotes in his speech. The first was:

“Modern societies actively market unhealthy life styles”.

In a sense, that lies at the heart of much of what he said.

He also referred to the African saying: health is made at home, hospitals are for repairs. That is something we should take to heart. He has always said that we have much to learn from other countries, and perhaps we can learn a great deal from that particular saying.

I want to pick up some of the important issues raised by noble Lords in this debate. The noble Baroness, Lady Jay, talked about localism, about which she has some reservations. I suspect that that is an issue we will come to many times over the next few years. While I do not regard her as “a centralised dinosaur”, as she put it, the thrust of much of government policy over the course of this Parliament will be very much towards accountable localism.

The noble Baroness, Lady Williams, started her speech by almost praying for a whole-party approach to healthcare. It is probably unlikely, but it would be nice. She talked about prevention and education. I think that the curriculum for those aged up to 14 now has more time for nutrition and healthy eating, but she and other noble Lords mentioned the lack of time for PE. She also talked about mental health, domestic violence and equality of treatment for those suffering from mental health issues, something we all support in this House.

The noble Baroness, Lady Campbell, spoke movingly about what she called the empowerment model of putting patients—service users, or clients—much more in charge. We should not be so hamstrung by the medical model that has dominated healthcare for so long.

I congratulate my noble friend Lady Redfern on her wonderful maiden speech. She talked about nutrition—perhaps not surprisingly, as she said that she comes from a place where beetroot and celery are much talked about. She also talked about rehabilitation and reablement. Acute hospitals need to do a lot in the field of rehabilitation and reablement so that we can get much earlier discharge of care.

The noble Lord, Lord Best, reminded us that housing and health used to be part of the same department. I do not know how many years ago that was, but it is an interesting observation. He reminded us that home can become a trap, a prison—indeed, a fridge if the temperature is not right. Those were very important observations.

The noble Baroness, Lady Masham, talked very powerfully about the Paralympics and the power of sport. However, she also reminded us that there is no room for complacency about infectious disease and the treatment of people with drug and alcohol problems, and, of course, about the importance of hospital food.

I congratulate the noble Lord, Lord Foster, on his maiden speech. Like many of us, he was once a young rising star, but sadly those days are behind most of us. What he had to say about personal responsibility is very important. We can look to the state and to government institutions, but we need to take responsibility for ourselves as well, wherever possible.

The noble Lord, Lord Alton, made some very interesting comments about variation across the system. It is patchy. We talk about a National Health Service, but it is very different depending on where you live. It was interesting to hear him say that 660 million antidepressants have been prescribed where the underlying problem is loneliness, and that medicine is not a remedy for that. The right reverend Prelate the Bishop of Bristol quoted John Donne:

“No man is an island”.

We are all “part of the main”. I fear that the bell might be tolling for myself this evening, but he again made a very strong point. Social isolation and loneliness were common themes from many of your Lordships.

The noble Baroness, Lady Lane-Fox, knows a great deal about the internet. When she said that the organising principle of our age is the internet, she made a profound point. I have absolutely no doubt that the power of the mobile phone and of the various apps being developed will reshape healthcare. It will shift power away from medical professionals towards individual users. I believe that there is now an app that can monitor your life signs from a drop of blood taken once a month. That is hugely powerful. She warned us of the risk that so much of this technology is concentrated in a small number of highly successful technology firms based in California. We need to be well aware of that.

My noble friend Lord Smith talked about the importance of clubs, participation and social interaction. He reminded me of Burke’s “little platoons”, which are such an important part of society. He also reminded us that in 1666, the average life expectancy was 35, so we have come a long way since then.

The noble Baroness, Lady Neuberger, talked about loneliness and how hugging a young baby or child actually helps develop their brain. It is not just about the very young, but the old as well. Lonely people suffer both physically and mentally. We all love human interaction and know that it is not just the elderly who suffer from isolation; many parts of society suffer from loneliness. I fear that computers have not done us proud when it comes to interacting as individuals with others.

The noble Lord, Lord Rea, talked about the importance of primary prevention. He quoted from Sir Michael Marmot’s book on health inequalities, which of, course, is very powerful. I will write to him, if I may, on Sure Start centres after this debate. The noble Earl, Lord Listowel, talked before to me about loneliness and isolation, in particular the importance of relationships for looked-after children, adolescents and those in their early years. I am not familiar with the Bromley-by-Bow model raised by the noble Lord, Lord Mawson, but I would like to learn about it. I was fascinated by his strictures about replication: you cannot just pick up a model in Bromley and dump it in Birmingham, or probably in any other part of London. There are aspects, however, that can be translated. He said it is always better to start small, rather than trying to start big. In the NHS, we perhaps get ahead of ourselves sometimes.

I turn to the comments made by the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt. This has been an important debate that reaches across a wide part of government. It raises issues that are not just pertinent to this country, but global. At their base, they reflect the fact that our population is increasingly elderly and people are suffering from many chronic long-term conditions. Lifestyles are causing a growing disease burden, particularly from obesity but also from alcohol and smoking. People’s expectations are changing all the time, and, of course, the cost of new surgical and pharmaceutical developments is huge. I suspect that genomic development and genomics will only add to those costs.

At the moment, however you measure how we fund these things—whether it is 16% of national wealth in America or more like 8.5% in this country or 11% in Germany—healthcare is consuming a vast amount of our GNP. Whatever health system you are in, there is an issue of sustainability. I believe that a strong economy is fundamental to any strategy that any of our parties would wish to have. We must have a strong economy, but that is not just so that we can afford better healthcare: it is actually more profound than that. It is because we have a strong economy that we will have high levels of employment. Work is a critical part of addressing some of the concerns of my noble friend Lord Crisp. If people have decent employment, they will tend to have higher levels of physical and mental health.

Education is also fundamental. It was Sir Michael Marmot, I think—or somebody else—who said that you could pretty much predict people’s future lifestyles from the age of 11. If their educational attainment is well below average at the age of 11, the outlook for the rest of their lives is not good. We also need to consider that the transition from adolescence into adulthood is also a critically important time. So I welcome the last Government’s and this Government’s increased commitment to apprenticeships.

The life expectancy of people living in Kensington and Chelsea was referred to earlier in the debate. I think I am right in saying that the life expectancy of people living in Salford is something like 25 years less than that of people living in Kensington. That cannot be explained just by reference to healthcare. Healthcare is demonstrably a very small explanatory component of such a difference in life expectancy. The differences are much more profound than just those associated with the NHS. When we talk about the health of the nation, it is tempting to focus just on the NHS, but it is only a very small part of it.

I wish to expand on devolution a little more because the driving force for devolution, particularly in Manchester but increasingly in the Black Country and other parts of the country, is to try to get greater economic regeneration. I believe that that, together with devolving more power to local authorities, will help to build a healthier society. I do not want to make a party-political point on this at all but I congratulate the principles underlying the work that Iain Duncan Smith has done in developing the universal benefit to try to make it easier for people to move from welfare into work. It is my fundamental belief that work is a crucial part of building a healthier society.

I wish to give noble Lords two quotes. Having said that the NHS is not a big part of this, I want to dwell briefly on it. The first quote is from the NHS Plan 2000. Perhaps the noble Lord, Lord Hunt, was a member of the Government in 2000. The NHS Plan states:

“The NHS is a 1940s system operating in a 21st century world”.

I believe that that comment, made in 2000, was profound. Now here we are in 2015 and the NHS Five Year Forward View states that,

“there is broad consensus on what that future needs to be. … It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment. One that no longer sees expertise locked into often out-dated buildings, with services fragmented, patients having to visit multiple professionals for multiple appointments, endlessly repeating their details because they use separate paper records. One organised to support people with multiple health conditions, not just single diseases”.

So we all know what the issue is and yet getting change in the NHS has proved extremely difficult. I take issue with the noble Lord, Lord Hunt: I think that we have to push these new models of care and treat more people outside hospital settings, not because it is lower cost but because it is better care.

[Lord Hunt of Kings Heath]

I am not arguing against the models; all I am saying is that I think there is a simplistic view that, if you develop the models, you can reduce the pressure on your acute care capacity. I, and I think many commentators, are doubtful about that, given that our acute care capacity is so much less than that of most comparable countries. That is the point I was making.

[Lord Prior of Brampton]

I understand that fully. To be clear, at the heart of the Five Year Forward View are both the new care models—the vanguards referred to by the noble Baroness, Lady Walmsley—and a change in productivity. I wish to dwell on productivity for a minute because the NHS is a lean system. I do not argue against that at all. It is a very high-value system. I was at a meeting with people from the Mayo clinic very recently and they said that they felt the NHS was the highest value healthcare system in the world. That does not mean that it is perfect. However, although we are always highly critical of it, by world standards it is a very good system.

We are going to address productivity through using much greater transparency—using the work of the noble Lord, Lord Carter—as well as trying to get a much higher degree of clinical engagement so that we get real traction. In the past we have had a top-down approach to try to drive through productivity improvements. This time we hope to have a much more bottom-up approach, with a much higher degree of clinical engagement.

The noble Lord, Lord Crisp, divided this issue into three, and the third aspect was the most important. The message is that it can be done. For example, the number of teenage pregnancies has been reduced by half. The number of people who die in fires has been reduced by half. Smoking prevalence has come down from 40% to 18%. Health-acquired infections such as MRSA and C. diff have come down very significantly. We can do it, if people work together.

Some of your Lordships may have read the McKinsey Global Institute report into obesity. It is a very good report. Obesity is a global problem: 2.1 billion people in the world are overweight—30% of the global population. It is going to rise to 50% by 2030. It costs billions of pounds and wrecks millions of lives. The McKinsey analysis makes three good points. First, there is no single intervention—no silver bullet. It is not just passing a sugar tax or a new regulation. In its view, when it comes to tackling obesity there are 74 separate interventions that must be done: housing, education, personal responsibility—it is a combination of all these things. Secondly, no part of society can do it on its own. It cannot just be top-down from government. It cannot just be bottom-up from individuals or the community. It has to be top-down, bottom-up and in between. Thirdly, you can never have all the evidence. If we wait until we have all the evidence about every single intervention, we will end up doing nothing. That is quite a good illustration of what the noble Lord, Lord Crisp, is aiming at. If we are going to have an effective strategy for obesity, which we will be revealing early in the new year, it has to be multifaceted. There is no silver bullet.

Treating illness is the tip of the iceberg that we all focus on but the much greater part of the iceberg is below the water. Improving and reducing health inequalities will require an effort that goes way beyond the NHS. Of course, the NHS has a big part to play but there is a much bigger and wider role for society as a whole. I thank the noble Lord, Lord Crisp, for raising this issue. It has been a fascinating debate and I look forward to pursuing discussions with him and others outside the Chamber.

Health and Care Professions Council (Registration and Fees) (Amendment) (No. 2) Rules Order of Council 2015

Lord Hunt of Kings Heath Excerpts

Tuesday 24th November 2015 Grand Committee

Moved by

[Lord Hunt of Kings Heath]

That the Grand Committee takes note of the Health and Care Professions Council (Registration and Fees) (Amendment) (No. 2) Rules Order of Council 2015 and of the increase in mandatory registration renewal fees for health and social work professionals (SI 2015/1337).

[Lord Hunt of Kings Heath (Lab)]

My Lords, this order concerns the Health and Care Professions Council and its fee raise, which is in relation to 330,000 health and social care professionals. They include paramedics, occupational therapists, biomedical scientists, chiropodists, dieticians, physiotherapists, radiographers, prosthetists, orthotists, speech therapists and social workers. That list brings home the importance of this group of professionals. Parliament, through various pieces of legislation, has seen fit to ensure that they are subject to mandatory regulation in the interests of public protection. Parliament also has a role, therefore, in overseeing the performance of the regulatory bodies.

On 1 August, the annual registration fee for members of the professions covered by the HCPC went up by 12.5% overnight as a result of the order that we debate today. The order was passed in the face of cross-party concern, including 100 Members who signed up to an Early Day Motion and indeed the tabling of a Motion to annul in committee at Holyrood. The 12.5% increase in fees followed on the heels of a 5% rise the previous year and in the face of assurances given by the HCPC in 2014 that it would not look to raise fees again until 2016. This is not being done in isolation. I know that we are not discussing other regulatory bodies, but I would mention to the Minister the NMC, which raised fees for nurses in 2013 from £76 to £100 and in 2015 from £100 to £120. The points that I want to raise in principle relate to a number of these regulatory bodies.

The contrast that I want to make is between the regulator’s demand for an increase in fees alongside what is essentially the sixth year of pay freeze and pay restraint and the Government’s policy on austerity generally. It is a puzzle as to how, when the public sector in general is under tight financial control, the one area that seems to be able to raise its fees willy-nilly is that of the professional regulatory bodies and the Care Quality Commission. The Minister will know that the CQC proposes to raise fees hugely, at some financial risk, particularly in the care sector. That is not for debate today, but there is an issue of principle here: in contrast to the issue of pay restraint and restraint generally on the public sector, a group of regulators seems to be able to put forward proposals, which the Government accept, for large fee increases.

I read the consultation paper issued by the HCPC, which said that the unexpected fee rise was prompted by the levy that it now has to pay to fund the Professional Standards Authority for Health and Social Care, the regulators’ regulator. I understand that and it was fully discussed in a debate in the other place in March. However, it subsequently emerged that the levy that it said had to be paid because of the Professional Standards Authority actually accounted for only 30% of the fee rise, and the remaining 70% was so that the HCPC could buy new accommodation for hearings, IT and quality assurance systems. In the consultation document, as far as I can see, that was not made clear. There was no breakdown or detailed justification of the fee increase.

That is particularly striking in light of the judicial review proceedings brought by the British Dental Association against the increase proposed by the General Dental Council whereas I understand that the High Court said that a regulator’s consultation on fee increase must set out a clear and detailed breakdown of the financial case for proposed increases. My point to the Minister is that that did not happen in relation to the HCPC consultation. There are three areas that I want to touch on. The first is that the consultation itself was extremely short. It covered the Easter holidays, May Day bank holiday and the purdah period. It closed on 6 May, the day before the general election. It totalled just 26 working days, leading many to suspect that it was designed to be buried away from scrutiny.

My second point is about accountability. Of those who did respond to the consultation, 86% of individual respondents objected to the increase, as did three-quarters of organisations. Their objections made not one iota of difference.

I come now to the role of the PSA, the regulators’ regulator. One of the problems is that while in a sense it can ask for a levy in order to fund itself, it does not seem to have a role to intervene on how regulators set fees or consult on them. In the light of experience with the HCPC, it would be good for the PSA to take a more proactive role. We know from submissions that I have received from staff organisations—I particularly refer the Minister to a survey by UNISON of nearly 5,000 registrants across the professions—that the fee rise was commonly referred to as a stealth tax. If you have no choice but to pay to practise your profession then it feels like a form of taxation. Yet registrants have little representation in the decision-making process that sets that fee.

Will the Minister also comment on the issue of the HCPC? Does it represent value for money? I know that the HCPC has done very good work, and I do not deny that it has absorbed a number of professions over the years successfully. However, these large fee increases bring concerns about whether the overall operation of the HCPC—and the other regulated bodies—is as efficient as it could be.

I want to raise with the Minister an issue that has been presented to me: although the fee might not be considered large in absolute terms, it is, none the less, a consideration for part-time staff in their choice of profession. The Minister may be aware that, as I understand it, the HCPC has declined to introduce a pro-rata structure, or differentiated fee structure, for part-time workers. That is a pity, given the need for us to attract staff and the fact that part-time staff have a lot to offer.

I understand that nine trade unions and professional associations representing registrants in HCPC fitness-to-practise processes have written to advise the HCPC that more could be done to control its costs, improve its efficiency and reduce the number of unnecessary hearings. They also made detailed recommendations on how the investigating process could be improved in order to root out unnecessary investigations, reduce the number of lengthy hearings and facilitate consensual resolutions. Seeing the noble Lord, Lord Lansley, here of course brings great joy to us all, but I cannot help commenting on the draft Bill drawn up by the Law Commission, which he would have received some time ago. Well, he may have commissioned it, I do not know whether he received it.

[Lord Lansley (Con)]

If I remember correctly, it was commissioned in 2011 and received by my successors in April 2014.

[Lord Hunt of Kings Heath]

My Lords, if he had still been in place I have no doubt that he would have acted on it. The point is, however, that a lot of the problems with the current fitness-to-practise procedures among health regulators generally derive from the fact that we have not implemented the Law Commission’s Bill, which would have allowed for a much more streamlined process.

The HCPC has, as I say, earned a great deal of credit for the way in which it has absorbed new professions over the years. I hope, however, that in this short debate the Minister will agree to look at some of the general principles raised. Does he agree that in any future proposal for a fee increase there needs to be a full breakdown and detailed justification for it? Does he also agree that it is not a good thing for Ministers to entertain fee rises that are higher than the percentage fee rises that are going to be given to NHS staff? There is an issue about pay restraint on the one hand and what seems to be the regulator’s ability to raise fees well above that rate on the other. Will he consider discussing with the PSA whether it will take a more proactive role in monitoring and evaluating any proposed increases by the regulator it oversees? Will he also look at whether the HCPC should be required to introduce a pro rata, or differentiated, fee structure for part-time workers?

Lastly, and I am sure the noble Lord will say yes to this, will he say that the Government will make it a priority to bring in primary legislation as soon as possible to implement the Law Commission proposals? The alternative is that the Minister will have to go through a succession of Section 60 orders when as a general principle he would find widespread support for the Law Commission proposals—there are one or two issues that we will debate—for a streamlined process that would apply consistency across all the regulated bodies. I am sure that it would reduce the cost of the regulators and, if the Government are not able to bring this in as a full Bill, at the very least it lends itself to pre-legislative scrutiny. However, there is enough consensus around the proposal to allow the Government to introduce a Bill. This short debate is a good opportunity to raise the issue of transparency of the regulators, and I hope that the Government are prepared to give this further consideration when a proposal comes up in the future. I beg to move.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I thank the noble Lord for introducing this short debate on the HCPC. It raises other issues beyond the HCPC that are of great interest to us.

The HCPC is a statutory regulator established to protect the public. To do this, it keeps a register of professionals who meet its standards for professional skills and behaviour. The noble Lord knows all that, but this is a preamble. There are 330,000 professionals across 16 health, psychological and social work professions. It is a very large regulator. It is self-financing, with funding coming entirely from registrant fees. It does not receive any regular funding from the Government.

The HCPC’s registration fees are the lowest, and have consistently been so, of all the UK statutory regulators of health and care professionals overseen by the Professional Standards Authority. Its fees are £90 a year. The next lowest regulator, the NMC, charges £120 per year. By way of comparison, the GMC is £420 a year. However, as a self-funding regulator, like all the professional regulators, its needs to keep its fees under regular review so that it can respond to demands on finances and resources, and to continue its role of delivering effective public protection.

As noble Lords will know, from 27 March 2015 to 6 May 2015 the HCPC consulted on raising its fees by an average of 12%, or £10 a year. That is 26 days. I appreciate that it was over an election period but that decision on consultation had to be with the council of the HCPC and the decision to formally review and consult on an increase to its fees was the result of three factors: first, as the noble Lord mentioned, because the PSA fee regulations came into effect, as a result of the Government deciding that the PSA should be funded by the regulators that it oversees, rather than the public purse; secondly, to improve how fitness-to -practise hearings are run; and thirdly, to invest in essential IT systems.

In relation to the first point, the Professional Standards Authority for Health and Social Care (Fees) Regulations 2015 came into force on 1 April 2015. This marked the realisation of the previous Administration’s commitment, set out in the Department of Health’s report Liberating the NHS: Report of the arm’s-length bodies review, to move the PSA away from government funding, to becoming funded by a fee on the nine regulatory bodies that it oversees. As required by those regulations, the PSA’s fee is calculated on each regulatory body’s registrant numbers. The HCPC is the second largest regulator by registrant numbers and will contribute to around 22% of the PSA’s funding. The PSA fee will be determined each year.

This methodology was considered fair because available evidence suggests that the level of PSA resource given to each regulatory body is very much influenced by the number of registrants as this critically informs the level of Section 29 work that the PSA undertakes for each regulator. Section 29 work is where a fitness-to-practise case is heard in court.

While around one-third of the 2015 fee increase was to meet the PSA’s fees, as I have said, the HCPC is also making improvements in the way it works. The HCPC is also looking to improve its fitness-to-practise processes. In doing so, the HCPC plans to introduce dedicated facilities for fitness-to-practise hearings. The HCPC’s existing office space was not purpose built for holding public fitness-to-practise hearings, which affects its ability to run a high-quality and modern adjudication service. It believes that introducing dedicated space will be consistent with the modern adjudication facilities provided by other regulators.

The HCPC also says that that the number and length of hearings are key cost drivers of the fitness-to-practise process. It has said that it aims to keep the cost of hearings low—for example, by proactively looking to conclude cases with the consent of the registrant involved, where appropriate. This avoids the need to have a contested hearing, with all the costs this involves. However, the HCPC says that it has seen an increase in the complexity of the cases since 2012. This has meant that the average length of a hearing has increased over time. The average number of witnesses required for each hearing has also increased to between three and four for each hearing. The HCPC’s primary objective is public protection, and it says that every allegation it receives must therefore be considered on its merits.

On the third point, the HCPC says that the new IT system it is looking to introduce will make its work more efficient by replacing a number of other legacy systems, by driving and delivering time and resource savings. Additionally, a project looking at redesigning the HCPC’s registration processes and systems should improve the level of service that it is able to provide to applicants and registrants by allowing them to carry out many more tasks online.

Finally, in determining budget forecasts for future years and the level of fees, the HCPC says that it had to make assumptions about costs and activity level—in particular, the volume of fitness-to-practise cases. It says that these forecasts indicated that despite generating a surplus in previous years, without the 2015 fee increase it would make operating deficits in 2015-16 and 2016-17. This would not be sustainable and would threaten its ability to fulfil its role of protecting the public. Additionally, the HCPC registers each profession on a two-year cycle, so it will take two full financial years before any increase in the renewal fee has full effect.

The HCPC says that it has not changed its ongoing commitment to the principle of small, regular increases in the fees where possible and necessary. Its latest five-year plan does not forecast any further increase in fees until 2019-2020. That said, in the past the Government have expressed a view on registration fees and the expectation that they should not increase beyond their current levels unless there is a clear and robust business case that any increase is essential to ensure the exercise of statutory duties.

The noble Lord raised a number of issues. First, he asked that in a consultation exercise there should be a detailed breakdown of the reason for a fee increase, which strikes me as a reasonable request, which I will draw to the attention of the PSA. He said that the fees should not increase by greater than the amount of the increase paid to NHS staff. All I can say is that the fee increase must be kept to an absolute minimum. I entirely appreciate that we live in a very difficult world, and fees must be kept to an absolute minimum. I do not think that we can make any commitment that they should be kept to the absolute level of increases of salaries paid to NHS staff.

The noble Lord asked that the PSA should take a more proactive role. Of course, the PSA undertakes an annual assessment of all the organisations that it is responsible for, which is tabled before Parliament. It is of course up to the Health Select Committee, if it wishes to do so, to have any individual regulator before it.

The noble Lord also asked about part-time workers; I hope that it will be all right if I write to him about part-time workers, as I am not sure of my answer on that. As regards the work the Law Commission has done, I think we all accept that it has done an outstanding job and made some extremely important and what could be very useful recommendations. The Government are currently reviewing how to take forward the work of the Law Commission.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to the noble Lord, Lord Prior. He is right to acknowledge the issue of pay restraint. However, I have three points. On consultation, I hope that the HCPC and the PSA will take note that it is reasonable to have a proper consultation in relation to fee increases in the future. Secondly, I noted what the Minister had to say about the introduction of IT and new systems and that it would lead to resource savings in the future. I have some experience of IT systems in the health service, and I certainly hope that that comes true. I noted the expectation of no further increase until 2019-20. Given the expected resource savings from new IT systems, it would be very disappointing if the HCPC came forward with any other proposal in the next Parliament.

Thirdly, I understand the Government’s reluctance to bring health legislation through Parliament, but one has received so many representations from the regulatory bodies. Given the extensive work of the Law Commission, I hope that the Government will give further consideration to bringing a Bill before Parliament before too long. The debate has been very helpful and I am most grateful.

Motion agreed.

National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) (No. 2) Regulations 2015

Lord Hunt of Kings Heath Excerpts

Tuesday 24th November 2015 Grand Committee

Moved by

[Lord Hunt of Kings Heath]

That the Grand Committee takes note of the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) (No. 2) Regulations 2015 and of the simplification of the assessment of the maximum waiting time for NHS treatment for elective patients, in the light of the review by Sir Bruce Keogh, and the risk that the current more complex standards could provide a perverse incentive to commissioning bodies to deal with those recently added to the waiting list before those who have already been waiting for more than 18 weeks (SI 2015/1430).

[Lord Hunt of Kings Heath (Lab)]

My Lords, this is another fascinating measure that the noble Lord has brought before the Committee, for which we are all very grateful. I do not want to extend the time of Grand Committee. I am having this debate not so much because I oppose the regulations, but because I want to understand the thinking. Clearly, these targets are important.

Obviously, I have read the Explanatory Memorandum, which makes it clear that the reason for removing the two referral to treatment waiting time standards related to the completed pathways of patients who started treatment is to focus solely on the standard for the incomplete pathways of patients waiting to start treatment. This is because of the confusion of the previous set of standards that had the potential to give rise to perverse incentives. I understand that. But I wondered whether the Minister could tell me what evidence he, Bruce Keogh or Simon Stevens had for how these perverse incentives were being used. Rather than introducing new standards, this is consolidating existing standards, but does the Minister think that there is a risk of new perverse incentives being introduced as a result of the regulations?

The regulations also relate to NHS-funded nursing care, which, given the vulnerability of the care sector as a whole, is of some considerable interest. Is the Minister satisfied that the current eligibility criteria for NHS-funded nursing care are being observed properly by the NHS and not being reinterpreted? The obvious temptation for the NHS is to ensure that little NHS-funded nursing care is funded because it can then transfer to means-tested social care. Given current budgetary pressures, I would have thought that that is an ever-present temptation for the NHS. Is the Minister able to provide information about NHS-funded nursing care and the extent to which there is consistency throughout the country in terms of ensuring that the eligibility criteria are observed? I beg to move.

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, once again I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this to the Committee. My noble friend Lord Lansley has pretty much done my job for me, but I think I had better go through with this to put it on the record. I thank my noble friend for that articulate and eloquent exposition of why we now have one incomplete standard and not the three that we had before.

We all accept that waiting times are critical. I should pay tribute to the Government of which the noble Lord was once a member. Bringing down waiting times was a huge success and there is no doubt that targets were one of the instruments used to do so. However, the noble Lord accepts that they are a blunt instrument and can lead to distorting clinical priorities. They can lead to gaming and extra cost, so they are not the whole answer. In particular, they can lead to perverse consequences. That is why the Secretary of State for Health and Simon Stevens accepted the recommendations made by Bruce Keogh earlier in the year. I will place a copy of his letter to the Secretary of State and Simon Stevens in the Library. The noble Lord may already have seen the letter but I will place it there.

Sir Bruce’s clinical advice on the standards used to measure the 18 weeks NHS constitution right was to remove the two standards that looked at how long people who have started treatment waited and to focus on the incomplete pathway standard—that is, the people who are still waiting. Perhaps I can explain that by using the analogy of a bus. The two earlier standards measured the people on the bus and the incomplete standard is designed to measure those who are left behind at the bus stop. As all three standards were written into the standing rules regulations, this statutory instrument, which took effect from 1 October, was required to make that change.

The change affects the metrics by which we measure the NHS’s performance on waiting times. It does not change the patient’s right. It is important that that is on the record. Patients can still expect to start treatment within a maximum of 18 weeks if they want to and it is clinically appropriate. If this is not possible, patients have the right to ask to be referred to an alternative provider that can see them more quickly, and the NHS must take all reasonable steps to meet patients’ requests. Sir Bruce Keogh recommended this change because having a set of three standards could be confusing and give rise to perverse incentives.

My noble friend described those perverse incentives. The perverse incentive was such that you could treat only one patient who had waited for more than 18 weeks as opposed to nine who had waited for less. There is no doubt that hospitals were managing their waiting lists on that basis. As a consequence, there were people waiting beyond 18 weeks for far too long. That was the wrong that the incomplete standard tried to address. As Sir Bruce said in June, while hospitals may be the ones penalised directly when they breached waiting time standards, the true penalty was laid on the patient who was waiting for much longer than he should have done. I wholly agree that that was not right.

In 2012—I think my noble friend was Secretary of State at the time—the Government introduced the incomplete pathway standard that a minimum of 92% of patients yet to start their treatment should have been waiting less than 18 weeks, to give NHS organisations a reason to prioritise patients who had been waiting a long time. The removal of the two completed pathway standards further minimises the potential for management of the waiting list to cut across clinical decision-making. Clinical priority should always be the main determinant of when patients should be treated. This clinical priority should not have been distorted because it should have been possible to meet all the clinical priorities and meet the waiting time standard, but in practice that was not always the case. Clinicians should make decisions about patients’ treatment and patients should not experience undue delay at any stage of their referral, diagnosis or treatment.

These changes will mean that there is a simplified, clearer focus on only one standard, covering all patients on the waiting list, and ensuring that those who have been waiting a long time are not left languishing. The noble Lord raised the issue, which was addressed by my noble friend, of whether having just the one standard will result in new and different perverse incentives. My noble friend made the important point that it could lead to priorities being skewed in favour of non-admitted, simpler, cases rather than admitted, more complex, cases. That is something we need to keep a very close eye on. NHS England will continue to measure trusts’ performance against all the standards except that there will be only the one measure in the contract.

I stress that changing the standards is not moving the goalposts in response to poor performance. This change has been made on the basis of clinical advice and in the best interests of patients, and has received widespread support, for example from the Nuffield Trust and the Patients Association. More than a million NHS patients start treatment with a consultant each month and the overwhelming majority are seen and treated within 18 weeks. However, the NHS is busier than ever, which is why we are investing the extra £8 billion that NHS leaders have asked for to support the five-year forward view. I hope that the noble Lord will accept that this was done in good faith and in the interests of patients and that it was a decision informed by clinicians, not by politicians. I have not addressed the concerns he raised about the eligibility criteria for nursing, because they are not strictly relevant to these regulations, but perhaps I could write to him on that matter.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful for that. I must say that the intervention from the noble Lord, Lord Lansley, was very helpful. It reminded me that in 2001 I was resplendent in the title of Minister for targets in the Department of Health. I remember asking officials to count up how many targets we had set. When we reached 450, we decided we ought to start again, first by trying to refine the targets and then by setting up foundation trusts, in order to take them out of a directly managed form of control from the centre. Whether that has been entirely successful, in light of today’s circumstances, is up for some debate, though I still maintain that the concept of foundation trusts, with separate governance and local accountability, is the right way forward. I hope that NHS Improvement will see the benefit of trying to protect foundation trusts, and the good bits of their governance—the role of governors, the accountability of the board to local people—from overmanagement from the centre. I know that the noble Lord also chaired a foundation trust; he will know what I mean.

There is no doubt whatever about the targets. The waiting time in 1997 was more than 18 months. It was brought down to 18 weeks, which was driven by a target that people had to meet. That is always justifiable. However, we know that in both the public and private sectors, people who have to meet targets are very clever and sometimes the temptation for perverse behaviour is all too apparent. I hope that we can continue to rely on NHS England to monitor behaviour closely and that if it needs to adjust targets to meet any perversity, it is important that that is done quickly and responds to problems that arise.

I do not oppose these regulations at all; I think it is a sensible approach. However, it would be helpful if we saw that NHS England was fleet of foot in responding very quickly when new problems arise with targets, as inevitably they will. This is a good example of that.

Motion agreed.