Maternity Services in Morecambe Bay
Lord Hunt of Kings Heath Excerpts(11 years, 4 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, I thank the noble Earl for his well-judged Statement and entirely echo the sentiments he expressed. Families in Barrow and the wider Cumbria area were badly let down by their local hospital and the NHS as a whole. He was right to apologise to them on behalf of both the Government and the NHS, and I do the same for the previous Government. It is hard to imagine what it must be like to lose a child or partner in these circumstances, but to have the suffering intensified by the actions of the NHS is inexcusable. Bereaved families should never again have to fight in the way that these families have had to fight to get answers. The fact that they found the strength and courage to do so will benefit others in years to come, and I pay tribute to them all, but particularly to James Titcombe. The report finally gives families the answers they should have had many years ago. It explains in detail both what went wrong and the opportunities missed to put it right.
I echo the noble Earl’s praise for Dr Bill Kirkup, the investigation team and the panel which assisted them. Our shared goal must now be to ensure that this report changes this hospital trust and the NHS as a whole for the better. Its recommendations are powerful but proportionate. We support them all, and the noble Earl can rely on our full support in introducing them at the earliest opportunity.
People’s first concern will be whether services are safe today. Clearly there are parts of this report where the alarm bell is being rung. It identifies the root cause of the failures as the dysfunctional local culture and the failure to follow national clinical guidance. There are suggestions in the report that this problem has not entirely disappeared. It says that,
“we also heard from some of the long-standing clinicians that relations with midwives had not improved and had possibly deteriorated over the last two to three years”.
It goes on,
“we saw and heard evidence that untoward incidents with worryingly similar features to those seen previously had occurred as recently as mid-2014”.
I am sure the fact that problems have been acknowledged means there is improvement. I very much take the latter point the noble Earl made in that regard, but can he say more about those findings and what steps are being taken to ensure that the trust now has the right staff and safety culture?
After safety, people will rightly want accountability, not just for the care failures but for the fact that problems were kept hidden from the regulators and the public for so long. When information did come to light it was not acted upon. Lessons were not learnt and problems were not corrected. The investigation recommends the trust formally admits the extent and nature of the problems and apologises to those affected. I am sure that this House, as well as the other place, will endorse that and want to see it done both appropriately and immediately.
Can I ask the noble Earl to ensure that any further referrals to the GMC and NMC are made without delay? Will he ensure that any managerial or administrative staff found guilty of wrongdoing are subject to appropriate action? I wonder whether it is time to revisit the issue of the regulation of managers and administrators because of this concern about staff moving on to another organisation and still being in the employ of the service, seemingly without being subject to accountability for their actions. We know a number of staff have left the trust in recent years, many with pay-offs. Will the noble Earl review those decisions in the light of the report and take whatever steps he can to ensure that those who have failed are not rewarded?
One of the central findings of the investigation is the particular challenges faced by geographically remote and isolated areas in providing health services. The investigation warns of the risks of a closed clinical culture, where,
“practice can ‘drift’ away from the standards and procedures found elsewhere”.
Given that, is not the report right to recommend a national review of maternity care and paediatrics in rural and isolated areas, and will he take that forward? Will the noble Earl comment on the concerns about the sustainability of the Cumbrian health economy? My honourable friend the Member for Copeland has today written to Simon Stevens, the chief executive of NHS England, to call for a review of the specific challenges it is facing. I hope that Ministers will be sympathetic to this call.
On the question of the CQC, the role of the regulator is to be a champion for patients, to expose poor care and to ensure that steps are taken to root it out. It is clear the regulator failed in that duty in this case. Given what was known, the decision to register the trust without conditions in April 2010 was inexplicable, as was the decision in 2012 to inspect emergency care pathways but not maternity services. In doing so, it failed to act on specific warnings. The report says there was, and remains, confusion in the system as to who has overall responsibility for monitoring standards, with overlapping regulatory responsibilities. We support the moves to makes the CQC more independent, but does the noble Earl agree that the journey of improvement at the regulator needs to continue and that there is a need for further reform, as recommended?
Will the noble Earl ensure that NHS England draws up the recommended protocol on the roles and responsibilities for all parts of the oversight system without delay and does he agree that the CQC should take prime responsibility? Does he also agree that the answer to a number of the problems identified is a much more rigorous system of review of deaths in the community and in hospitals than currently exists? Is it not the case that the reform of death certification and the introduction of a new system of independent medical examination are well overdue? We know Ministers have previously said that they are committed, in principle, to bringing this in but nothing has happened. I hope that the noble Earl will agree to bring this new system in without delay. It needs to go further, too. We need to look at mandatory reporting and investigation as serious incidents of all maternal deaths, stillbirths and unexpected neonatal deaths. We need to see how we can move to a mandatory review of case notes for every death in hospital. We have asked Professor Nick Black to advise us and inform a review which we want to conclude by the end of the month. I hope the noble Earl will support us in that review.
There are two other points I would like to raise with the noble Earl. I want to ask him about leadership of the profession nationally. He will know that maternity services are coming under great pressure at the moment. With the increase in the number of births, many maternity services are facing huge difficulties and challenges, particularly in recruiting midwives to work in those units and in making sure that they can respond to the pressures that are undoubtedly there. We do not have a chief midwifery officer, either at the Department of Health or at NHS England. I wonder whether we need a leader of the profession who can really start to raise the morale and tackle some of these issues which have been around for many years. There will be a head of profession within his department who will be working with the Chief Nursing Officer, but I wonder whether we need a more visible leadership of the profession.
The noble Earl also mentioned the work of the NMC and the King’s Fund review into midwifery supervision and regulation. I very much understand those recommendations and am very sympathetic to the need to look at this carefully. That clearly has major implications for the current supervisory role of midwives. I take the point he and, indeed, the King’s Fund report make, about that role needing to be independent of the employing authority. Can he confirm, though, that much of what supervisors do is of value and that, in moving to a new system, we would not want to lose the value of the work that current supervisors undertake? I echo the noble Earl’s views on the work of the NMC. Under the current leadership it has shown great signs of improvement, and it needs to be supported.
Finally, I pick up the point that the noble Earl made about the acceptance of honest mistakes as long as people and organisations are open. I agree with that, but could he reassure me that he believes that that philosophy is consistent with the Private Member’s Bill of the noble Lord, Lord Ribeiro, in relation to the issue of doing no avoidable harm? I believe that it is. Perhaps we will come back to this when we debate the noble Lord’s Bill, but if the noble Earl was able to say that it is consistent, it would provide considerable reassurance to those health organisations that have reservations at the moment.
Earl Howe
My Lords, I welcome the measured and constructive comments of the noble Lord, Lord Hunt. He asked me a series of questions and I shall answer as many as I can. First, on how things are today at the trust and the safety of its services, clearly the CQC is the body best placed to make judgments about the quality of services. At the last inspection of the university hospitals of Morecambe Bay in February last year, safety in the maternity service at Furness was rated as good but overall the maternity services were assessed as requiring improvement. As a whole, the trust has been rated as inadequate. This demonstrates that, while the trust is making progress, there is still a long way to go, and it is clear that embedding changes of this nature takes time. The CQC will reinspect the trust in May 2015 and will make a judgment on whether it has made the required improvements.
The noble Lord asked about referrals to the NMC and the GMC. Where there are failings by a member of staff, they must be held to account. If an allegation is made about a medical doctor, a nurse or midwife, who may not meet the professional standards required in the UK, the relevant professional regulator has a duty to investigate—and, where necessary, to take action to safeguard the health and well-being of the public. The Department of Health is aware that the NMC and the GMC have each received a number of fitness to practise referrals linked to maternity and neonatal services provided by the University Hospitals of Morecambe Bay NHS Foundation Trust. As an independent body, each of them is responsible for operational matters concerning the discharge of its statutory duties. I would hesitate—in fact, I think it would be wrong of me—to comment further on those fitness to practise cases. However, we are confident that the NMC will take account of the recommendations and findings in the report.
The noble Lord made a number of comments about managers. As he well knows, the NHS is a huge and complex service staffed by committed people who often work under a huge amount of stress. I believe that those tasked with leading our NHS organisations, whether in management positions or clinical ones, are committed to making good decisions on behalf of patients. When it becomes clear that they are not up to the job, they should be replaced. Many senior leaders at Morecambe Bay have now been replaced. The current leadership should be allowed a period of time to refocus the trust on those values that are so vital to good patient care—staff morale, sound governance, strong leadership, team working and a focus on delivering high-quality care.
On the issues that are particularly pertinent when you have NHS services that are geographically remote, NHS England has today announced details of a major review of the commissioning of NHS maternity services as promised in the five-year forward view. The review will assess current maternity care provision and consider how services should be developed to meet the changing needs of women and babies. Recent advances in maternity care, changes in the demographics of women having babies and preferences of where they want to give birth will form the key focus. This review, which is expected to report by the end of the year, will be led by an external chair, supported by a diverse panel, and will include a review of UK and international evidence on safe and efficient models of maternity services.
I listened with interest to the noble Lord’s comments on the Cumbrian health economy as a whole. I am not in a position to comment on that at the moment but, if I may do so in writing, I shall be happy to. As for further reform of the CQC, we will examine the recommendation on this score in detail and publish a full response in due course. Further consideration is needed to ensure that the overall responsibility for patient safety sits in the right part of the system and the department has already committed to consider with relevant organisations the options for transferring NHS England’s responsibilities for safety to a single national body. We will also continue to look for opportunities to improve both the operation of the oversight arrangements in place at present and the understanding of those arrangements by NHS organisations and the public.
On the matter of reviewing all deaths and picking up the recommendations around death certification, a number of the recommendations in Sir Robert Francis’s Mid Staffordshire inquiry report refer to our planned reform of the death certification system and the introduction of the role of medical examiner in England and Wales. A new system of medical examiners has been successfully trialled in a number of areas around the country. The work of the two flagship sites in Gloucestershire and Sheffield has been continued and extended to operate a medical examiner service on a city and county-wide basis on a scale that will be required for implementation by local authorities when legislation is introduced. We will publish shortly a report from the interim national medical examiner, setting out the lessons learnt from the pilot sites. I hope that that gives the noble Lord an indication that this is work very much in progress.
On mandatory reporting of maternal, stillbirth and neonatal deaths, the Government are committed to doing further work to review avoidable deaths. We are working with NHS England to introduce a national standard approach for undertaking case-note review. This has the potential to enable NHS trusts to develop a better understanding of avoidable deaths. However, a top-down approach to ensuring that every trust reviews every death is not, in our view, appropriate. Our aim is to ensure that trusts focus their efforts on improving patient safety through learning about the root causes that have led to avoidable death. A systematic, but not necessarily burdensome, approach is needed, which is why we are moving ahead to develop a national rate and produce an estimated number of avoidable deaths for each hospital. The numbers will be made public. Trusts will be expected to report annually to the Secretary of State for Health on their actions to reduce avoidable deaths.
The noble Lord made a very interesting suggestion about the possible appointment of a chief midwifery officer. I would be happy to consider that idea. Of course, he knows that there is a head of maternity in NHS England at the moment.
On the performance of the NMC, it is, as the noble Lord is well aware, an independent body accountable to Parliament, via the Privy Council, for the way in which it carries out its responsibilities. In addition, its performance is monitored by the PSA, and the Health Select Committee has also chosen in recent years to hold an annual accountability hearing with NMC leadership. So there are a variety of robust measures in place to hold the NMC to account. I am aware that the performance of the NMC has a troubled history, which is why Ministers commissioned the Professional Standards Authority’s predecessor body, the CHRE, to undertake a full strategic review in 2012. As noble Lords will remember, the final report of the strategic review was published, putting forward 15 high-level recommendations for improvement in delivering the NMC’s regulatory functions, with the expectation that demonstrable improvements should be seen within two years. We welcome the new NMC chair and we hope that, under Dame Janet’s leadership, it will continue to make improvements to become a confident and capable regulator.
Health: Rare Diseases
Lord Hunt of Kings Heath Excerpts(11 years, 4 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, my name was inadvertently missed off the list, so I am going to speak in the gap. I will give the noble Earl his full 12 minutes. Perhaps I may put two points to him.
First, will the noble Earl agree to my noble friend’s recommendation that the Ministers institute a thorough review? I stress that this should be done by Ministers. NHS England has shown itself incapable of doing the job properly. Ministers are much more accountable and much more aware of the rare disease issue and I really do think they need to take charge.
Secondly, in the new agreement with the drug industry, any increase in the cost of drugs over five years is being met by the industry through rebates. Why on earth are those rebates not being used to fund innovative new drugs for rare diseases? Can it just be that the NHS is under such financial pressure that this money has had to be raided, when it should have been used for innovative new drugs?
Human Fertilisation and Embryology (Mitochondrial Donation) Regulations 2015
Lord Hunt of Kings Heath Excerpts(11 years, 5 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, I sense that the House wants to come to a decision.
Just over 14 years ago, I asked the House to agree that embryology research could be extended to cover diseases such as Parkinson’s disease, Alzheimer’s disease, cancer and diabetes. This provision had been anticipated and included as a regulation-making power in the Human Fertilisation and Embryology Act 1990, which had allowed embryology research but only for conditions such as infertility and congenital diseases.
The 2001 regulations were passed following a Motion moved by the noble Lord, Lord Alton, to whom I pay tribute for his integrity and perseverance. However, his Motion to establish a Select Committee prior to the regulations being approved was defeated by 212 votes to 92.
The 1990 Act followed the work of a committee led by the noble Baroness, Lady Warnock, which made recommendations on developments in science and medicine in relation to human fertilisation and embryology. I pay tribute to the noble Baroness for her outstanding work in helping us get the balance right between the respect owed to human embryos and the potential for the use of embryos in research and treatment for devastating illnesses.
The 1990 Act was a model in the regulation of certain infertility treatments and embryo research. It reflected the need to have a strict framework in which regulation could be conducted to take account of the advances in medicine anticipated by both the noble Baroness, Lady Warnock, and Parliament in 1990.
Since 1990, the science and research have developed, just as has the need for Parliament to keep up and anticipate further developments. Thus, in 2001, we passed emergency legislation to put it beyond doubt that human reproductive cloning could not take place in the UK. In 2004, we passed regulations in which the identity of the donor of eggs, sperm or embryos could be given to the adult donor-conceived person under certain circumstances.
We have heard about the 2008 Act, which amended the 1990 Act to include restrictions on the types of embryos that may be placed inside a woman. Importantly, the 2008 Act amended the 1990 Act to insert a regulation-making power to enable techniques which were under development at that time to be used in treatment to prevent a child being born with serious mitochondrial disease. Surely, the noble Viscount, Lord Ridley, and the noble Lord, Lord Walton, are right—at every significant stage of embryology research and potential treatment, Parliament has been asked to give its approval and thus ensure public confidence in our scrutiny of these most difficult decisions. My view is that Parliament has discharged that responsibility thoroughly and well. However, I am glad that the noble Lord, Lord Deben, has given us the opportunity to have this debate. Of course, we would have had a debate but the noble Lord has served a great purpose in encapsulating the core argument and I am grateful to him for so doing.
We find ourselves asked to make a crucially important decision, with powerful contributions having been made on both sides of the argument. On the one hand, we celebrate the triumph of science that these new techniques represent. We have within our reach the possibility of eradicating mitochondrial disease from families who have been blighted by it for generations. On the other hand, we are grappling with serious moral, legal and ethical questions that are raised by the proposed introduction of such techniques for treatment. We on this side of the House have a free vote. Speaking for myself, and myself alone, I will vote in favour of the regulations.
The noble Earl, Lord Howe, will respond to many important points that have been raised, but I ask him to focus on a number of very important considerations that have also been raised. On the question of continuing research and the comments of the expert panel, will he confirm that the panel said there was no evidence to suggest that the techniques proposed in the regulations are unsafe? Will he also confirm that the panel has agreed that further research and reviews could take place either before or after the regulations are approved?
As regards whether this matter is being rushed through Parliament and would benefit from further scrutiny by a Select Committee, the question here is: what would be gained by delay? Will the noble Earl confirm that the principles that we are discussing were approved by Parliament in 2008 after thorough debate? I do not need to go over the work of the Nuffield Council on Bioethics or that of the HFEA and its expert panel because noble Lords have mentioned that, but I should comment on the 90-minute debate that took place in the House of Commons. I agree with the noble Lord, Lord Alton, that 90 minutes is too short. However, I have read that debate and it seems to me that it was thorough and well informed and that the points on both sides were put forcefully and interventions were made. My honourable friend Luciana Berger was asked a number of very tough questions, as was the Minister. Could anyone say that at the end of those 90 minutes MPs were not in a position to come to a conclusion? Indeed, can anyone say that we are not in a position to come to a conclusion following a debate which has lasted at least three and a half hours?
We have heard from eminent lawyers on both sides of the argument on the legal questions. We have had written submissions from the Department of Health and the legal advice of the Wellcome Trust, and other legal propositions have been put to us. However, you reach a point when it is time to make a decision. I think that we are in a position to make such a judgment.
A number of noble Lords, including the noble Lord, Lord Alton, referred to the two techniques and how one should be considered in relation to the other. I understand the point that the noble Lord, Lord Alton, made. However, will the noble Earl, Lord Howe, confirm that the panel believes that at present there is insufficient evidence to choose between the two techniques? Does he consider that that is still the Government’s position? The noble Lord, Lord Deben, said that this was a question of resources. I have not seen evidence to suggest that that is the case. The important question is: can the Minister refute that? Can he say that the sole issue is that at the moment we are not in a position to judge which technique is likely to be more effective, and that it is solely for that reason that we are permitting the two techniques to be in the regulations?
Finally, we come to the position of the HFEA. At every point of our debates—this goes back to 2001—we have relied on the robustness of that body. The robustness of the HFEA is absolutely essential. There have been discussions and debates about how effective it is; my noble friend Lord Winston is a well known critic of some of its activities. Fair enough—but I believe that the HFEA has proved itself a highly effective and robust regulator over 20 years. I ask the Minister to confirm that it is the Government’s intention to continue to support the robustness of that regulatory approach.
As for the Chinese experience, will the Minister confirm that, although there are issues in connection with the techniques used, one big difference between the UK and the Chinese position is the regulatory framework and the robustness of the HFEA? I suspect that that was not the case in China years ago when those developments took place.
The question is whether the benefits of trying to eradicate this dreadful disease by preventing the transmission of mitochondrial disease, in view of the likelihood that otherwise children will continue to be born who will die in infancy, outweighs the risks of the techniques, which some noble Lords have described tonight. The scientific community—on the basis not of some kind of cosy consensus but of hard evidence—and the families experiencing this disease are clear that we are right to support the regulations. It is now up to us individually to decide whether we agree them. I, for one, am convinced that it is the right thing to do.
Francis Report: Update and Response
Lord Hunt of Kings Heath Excerpts(11 years, 5 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, I am very grateful to the noble Earl for referring to the Statement in the way that he did. We welcome the Statement and its commitment to improve the culture around tackling poor care in the NHS. The Opposition endorse the principles in Sir Robert Francis’s new report and we will work with the Government to get them on the statute book in the remainder of this Parliament.
In 1998, the previous Government introduced the first legal protection for whistleblowers in the public interest disclosure legislation, reinforced in the NHS constitution in 2008. We see Sir Robert’s new principles building on those foundations. Our shared aim should be to create a climate in which any NHS worker feels able to raise concerns and confident that they will be listened to, that appropriate action will be taken and that they will not face mistreatment as a result. Today’s report establishes a number of new principles to which all NHS organisations should work. We fully endorse these. The call for support for whistleblowers worried about losing their jobs or finding alternative employment, and training in whistleblowing for all staff, is long overdue. Can the noble Earl confirm that this will apply equally to all providers of NHS services, including voluntary and private providers?
Let me turn to the recommendation for an external organisation which staff can approach for advice and support. In response to the first Francis report in February 2010, my right honourable friend Andy Burnham, when he was Secretary of State, established an expert group to update whistleblowing guidance. It reported in June 2010 and the then Secretary of State, Andrew Lansley, announced plans for a “safe and independent authority” to which staff can turn when their own organisations are not acting on concerns. Will the noble Earl say why little progress has been made since then and assure us that there will be no further delays now that Sir Robert has reinforced this recommendation?
Are the Government concerned by Sir Robert’s findings that the NHS culture might have got worse in recent years? As regards the cases he examined, he said:
“Many were relatively recent or current. This is not about a small number of historic high profile cases from a time when organisations might argue the culture was different. We had a significant number of contributions about cases in 2014”.
The report specifically references figures from the latest NHS staff survey, which shows that reports of bullying have increased from 14% of staff in 2011 to 22% in 2013. Over the same period, staff feeling unable to speak out about poor care, report errors or near misses has fallen from 98% in 2011 to 94% in 2013. Those figures suggest that things are getting worse and not better. Will the noble Earl comment on that and give the reasons?
This seems to underline the importance of any moves to improve culture being brought forward in the right sprit, supportive rather than punitive, so as not to reinforce the wrong culture and create a climate of fear. At the weekend, the Secretary of State proposed fines and jail sentences for failure to be open about poor care. We certainly support that zero tolerance approach but is the noble Earl not concerned that this might be perceived on the ground as creating such a climate of fear and therefore having the opposite effect?
I know that the Minister’s right honourable friend frequently quotes the airline industry as a model to be followed. I remind him that the experience in the airline industry has been to create a safe environment in which pilots can report near misses and untoward incidents so that the industry can learn from them. I urge the noble Earl to consider that whatever happens in the future, the encouragement to be open is not lost in this new approach.
Turning to Mid Staffordshire, we supported Sir Robert’s original recommendations and I certainly give credit to the Secretary of State for making progress on this since the report was produced and the recommendations were accepted. However, he will know that there are gaps where progress has not been made and that this is a concern when standards overall in the NHS are recorded to be falling and not rising. I particularly want to ask him about the long-standing need to reform the system of death certification. This goes back to Dame Janet Smith’s proposals which were embraced within the Coroners and Justice Act 2009 to make provision for the independent scrutiny by a medical examiner of all deaths that are not referred to by the coroner. Following successful pilots, Sir Robert Francis reinforced Dame Janet Smith’s recommendations. I was the chair of a trust which ran a pilot scheme, and I can testify to the effectiveness of having a senior consultant as the medical examiner looking at the case notes where deaths have occurred, informing patients, finding out where things have gone wrong and helping doctors to improve their practice. There is concern that the Government have shelved this proposal, and I hope to hear that that is not so.
Can the noble Earl set out a clear timetable for the introduction of medical examiners and comment on the arrangements in hospitals for reviewing case notes when patients have died? Over the weekend, the Government announced plans to introduce an annual review from a sample of patients. While that will definitely help us to develop a more accurate measure of avoidable deaths than the current mortality rates, does he think that it will go far enough? Should not the NHS learn from all serious failings, and will he give consideration to our suggestion that every death in hospital should be given an appropriate level of review?
We welcome the progress which has been made at some of the hospitals in special measures, but I want to ask the noble Earl about the use of mortality statistics. Is he aware that the graph on page 8 of the recent Dr Foster report shows that mortality rates at the Keogh trusts fell faster between 2006 and 2010 than between 2010 and 2014? Perhaps I may also refer him to the plans outlined by the Secretary of State to calculate the number of avoidable deaths for individual hospitals. They were described by Nick Black, a professor of health services research who has produced many of these ideas, as not having any meaning because of concerns about the robustness of the figures. Will he also acknowledge that a recent investigation by the Academy of Medical Royal Colleges into the use of hospital standardised mortality ratios as a means of comparing the quality of US and English hospitals has shown the method to be unreliable? He will know that Professor Jarman made a proposition that mortality rates between English and US hospitals were such as to cause concern about the UK position. The investigation demonstrates very clearly that the data are not comparable and cautions the use of a crude approach towards trying to judge institutions simply on the basis of HSMR statistics.
Finally, does the noble Earl agree that encouraging an open culture where whistleblowers feel secure in being able to raise issues of concern emanates from a culture that must apply throughout the system, starting at the top in his department and then through all the national regulators as well? If the national bodies feel that they are not able to raise concerns about government policy publicly and if the chief executives of NHS organisations know that if they make any public criticism, they will be penalised in one way or another by the system, is it any wonder that they then find it difficult to create a culture of openness? I urge the noble Earl to embrace fully what is being proposed today by acknowledging that if we are really going to grip the system, a culture of openness and of whistleblowing has to go right through the system and must include his own department, the regulators and NHS England.
In conclusion, we welcome the Statement today and we will do everything we can to ensure that the regulations the Government bring forward are able to go through Parliament before the election.
Earl Howe
My Lords, I am grateful for the welcome and support that the noble Lord, Lord Hunt, has given to the Statement. I do of course agree that Sir Robert’s recommendations, which we accept in principle, build on the current safeguards for whistleblowers. But, as the noble Lord knows, Sir Robert did identify some important gaps in those safeguards which we must now address.
The noble Lord asked me a number of questions. First, he asked whether these provisions would apply equally to all providers of NHS services, including to the voluntary and private sectors. Similar provisions will certainly apply to the voluntary and private sectors. We will expect such providers to reflect on how Francis’s recommendations might apply to them, but we will also use the NHS contract in an appropriate way.
The noble Lord asked whether the Government were concerned about an increase in the number of whistleblowing cases over the last few years. There is evidence that safety and compassionate care have in fact improved in recent years. It is also possible that the new emphasis on openness and transparency may lead to more concerns being raised, which is a slightly counterintuitive effect of a better culture. We want to examine Sir Robert’s findings carefully and would encourage NHS organisations to do the same. But it is important to emphasise that however much improvement we see, we must never be complacent about how good the system is.
The noble Lord asked about progress in identifying an authority to whom whistleblowers could turn. I refer him to Sir Robert’s recommendations, which provide for local “freedom to speak up” guardians, who will report directly to trust chief executives and, crucially, to whom members of staff in an organisation can speak if they have particular concerns. There will be a new independent national whistleblowing guardian as a full-time post within the CQC, as a further safeguard in this process—a person who can understand what has happened in a given local case and refer back to that local organisation in an appropriate fashion.
I agree with the noble Lord that we want to achieve, above all, a supportive and learning culture. That is something emphasised not only by Sir Robert but by Professor Don Berwick in his review of patient safety issues. He is also right that if we go too far with a punitive approach to these matters, it could deter people from wishing to step forward. That is why we hope that we have the balance right in the legal provisions that we put through in the Care Act so as to ensure that, while organisations must always be on the line for the extent to which they have complied with, for example, the duty of candour, we do not put employees in a state of excessive fear, lest they refrain from speaking up when appropriate.
All the measures we have taken so far—the duty of candour, the new offence of wilful neglect, the fundamental standards that Sir Robert recommended, which will be coming in, and the fit and proper persons test—combine to shore up the system in a helpful way, without, we trust, making the NHS feel oppressed by regulation.
The noble Lord asked about death certificates. No, the policy has not by any means been shelved. The work is continuing. To be frank with him, progress has been slightly less fast than we would have wished, but the Government remain totally committed to the principle of these reforms. Further progress will be informed by reconsideration of the detail of the new system in the light of other positive developments on patient safety since 2010 and by a subsequent public consultation exercise. A number of recommendations in Sir Robert Francis’s Mid Staffordshire inquiry report refer to that reform of the death certification system. A new system of medical examiners has been trialled successfully in a number of areas across the country. The work of the two flagship sites in Gloucestershire and Sheffield has been continued and extended to operate a medical examiner service on a city- and countrywide basis at a scale that will be required for implementation by local authorities when legislation is introduced. We will be publishing shortly a report from the interim National Medical Examiner setting out the lessons learnt from the pilot sites.
The noble Lord, Lord Hunt, referred to the criticism voiced by Mr Nick Black on the way that we interpret statistics on avoidable deaths. The work that we have set in train builds on innovative work at the London School of Hygiene and Tropical Medicine, and we think it has the potential to enable NHS trusts to develop a better understanding of actually avoidable deaths. But we will continue to work with front-line clinicians, national organisations and academics to find ways to support trusts to understand better their levels of avoidable mortality and, crucially, to take effective action to reduce those levels.
The first Francis inquiry emphasised the importance of trusts looking carefully at their mortality rates as part of their overall scrutiny of safety measures. We believe that most, if not all, are now doing that but we want to do more to improve the data and their use to make improvements. I would just say to the noble Lord that we should not let the best be the enemy of the good. Imperfections in data should not get in the way of vigilant local scrutiny of those data, even though they may not be 100% accurate.
The noble Lord concluded his remarks with some questions about culture. In particular, he asked me whether I agreed that the culture of the system starts at the top. Of course, I agree with him fully on that. But I would just say to him that as a Government we have taken a conscious approach not to overemphasise poor care where it occurs but to expose it and to adopt a policy of transparency so that poor care as well as good care can be apparent to patients, the public and the system at large. We have given greater legal independence to the CQC. We want it to speak out without fear or favour, and it has indeed done that.
We believe it is right to confront poor practice where it occurs. The key, however, is to turn around those organisations that are found wanting, and the system of special measures has undoubtedly proved its worth, as the Dr Foster report recently made clear. There was an unequivocal finding in that report that the levels of avoidable mortality in most of the special measures trusts had gone down by a statistically significant percentage. There is undoubtedly a high degree of utility in the special measures process, painful as it may be to some organisations.
Health and Social Care (Safety and Quality) Bill
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Lord Hunt of Kings Heath (Lab)
My Lords, I declare an interest as president of GS1, which is the bar-coding association of the United Kingdom. I am sure that the suggestion made by the noble Lord, Lord Willis, will be given every consideration it deserves. I, too, congratulate the noble Lord, Lord Ribeiro, on bringing the Bill to your Lordships’ House. He knows that the Opposition support the Bill, and we will adopt a constructive approach to it.
However, I would like the noble Lord and the noble Earl, Lord Howe, to clear up this point about the remaining stages of the Bill in your Lordships’ House. My noble friend Lady Pitkeathley made a very important point. I do not understand why there is not time to give the Bill proper scrutiny. This is essentially a government Bill; it is therefore up to the Government to find the time. We know that this House has plenty of time until Prorogation on 26 March. At the moment, the noble Earl and I are enjoying many Questions for Short Debate, and I understand that there are many more to come. That is because there is virtually no legislation left. The Government say there is not time, but that is not so. I offer our good offices through the usual channels to see whether we cannot find time for a proper Committee and Report stage. That would be the right path. I understand what the noble Lord, Lord Elton, said—that in the past he has been very strong about the role of the House of Lords in the scrutiny of legislation, and has criticised the way in which Governments have tried to get legislation through. We have to be cautious about this. I want to see the noble Lord get his Bill by the end of this Parliament, and we will do everything we can to help, but the evidence that has come particularly from the Berwick committee shows that there should at least be some debate, especially on Clause 1, although there are other issues as well.
Some debate on Clause 1 would be helpful. Although we support the clause, it would be helpful to hear a little more from the noble Lord about what is meant by “zero harm”. The noble Lord, Lord Willis, says that those words are not actually used in the Bill. The problem is that those words were used in the briefing on the Bill, and now it has come to be known as “zero harm” in the health service. It may be that that is part of the issue around Clause 1—not so much what it contains as how it is perceived. I hope that we can clear that up as well as we go through the Bill.
I have one question for the noble Earl. As he knows, I and the noble Lord, Lord Patel—he cannot be here today but will be for later stages—have both chaired the National Patient Safety Agency. We encouraged NHS bodies to report near misses and patient safety incidents. I assume that many of those incidents would come within the definition of “avoidable harm”. Given that, can the noble Earl say whether that means that, once the legislation is passed, almost every NHS body in this country would fall foul of the provision? If that is so—and it might be argued that it should be so—does he think that there is a potential perversity in that people will try to hide these incidents in the future, whereas our whole learning experience, which came from the airline industry, is to encourage people to own up to mistakes? It is a very important point. I think it lies at the heart of what the noble Lord, Lord McColl, said earlier and, indeed, the evidence which we have received from the Berwick advisory group.
My noble friend Lord Young made a very important point about good practice, and I am not sure whether the Bill helps one way or another. He mentioned the WHO checklist in dealing with wrong-site surgery, which has a lot of support from various institutions, including the Royal College of Surgeons. We know that not every surgeon is prepared to do it; there is no question but that some surgeons refuse to take part in those checklists and that sometimes, if they do, they do not take part with wholehearted enthusiasm. Whether this Bill helps that or not, I would be interested in hearing from the Minister how he thinks we can encourage very powerful clinicians who, I suspect, think that it is beneath them to take part in what they call a box-ticking exercise. How can we encourage them to do so? My noble friend is absolutely right—one of the besetting sins of the health service is its inability to spread good practice quickly. That is why we invented NICE.
I find it really disappointing that, in relation to NICE technology appraisals, as an example, even now many clinical commissioning groups refuse to implement them, despite a legal requirement to do so, and have set up their own silly little committees to try to second-guess what NICE is doing. I know that that goes outside the Bill, but it does answer my noble friend on a really important issue that we need to tackle. We all know that we have excellence and we have problems in the health service, and the scale of transfer of excellence to the health service is just too slow.
On the subject of data-sharing, as the Minister knows, the Opposition are very supportive of the sharing of patient information, which is clearly in the best interests of patients. Indeed, we took through the original provision in, I think, the 2003 health Act, although there were many others that we might have taken it through in, to allow for this to happen. The care.data project ran into a few problems, as we know, and has now been rolled out in a kind of pilot way in order to secure public confidence. But I think that it would be fair to say that there are still concerns about whether, in the end, the public and GPs are going to be prepared to sign up to this. As he will know, we think that the National Data Guardian must be made a statutory post. It was the subject of amendments in the other place. I am delighted that Dame Fiona Caldicott has become the National Data Guardian; that is an excellent appointment, and the Government should be congratulated on making it. We know that the Secretary of State for Health has said that her appointment would be put on a legal footing at the earliest opportunity—and this is the earliest opportunity. Surely, this is the time to do it.
Noble Lords will have received briefing from Mencap —I certainly have—about the information-sharing clauses. Mencap wants Clause 4 amended so that the health information includes the person’s communication needs, which means that professionals are more aware of the ways in which people can communicate their health and care needs. Perhaps the noble Lord, Lord Ribeiro, could give some consideration to that.
On the issue of children and why they are not included in terms of a national identifier in the Bill, I assume this is because of the split in government responsibilities between the Minister’s department and that of another department. Perhaps that is not the case, but it would be interesting to know about that. On national insurance numbers, as my noble friend Lord Young whispered to me, children of course do not have national insurance numbers until I think the age of 16. That may be a problem.
I come back to Clause 5. A number of noble Lords have raised the issue of why provisions have not yet been brought forward relating to the Law Commission’s draft Bill. We all know why the Government was not prepared to bring forward a health Bill in the fifth Session—not even a draft Bill—which is why the noble Lord, Lord Ribeiro, has very kindly taken on a Private Member’s Bill. It has been very disappointing; at the very least we could have had pre-legislative scrutiny, which would have been very helpful. I am not going to suggest that we amend the noble Lord’s Bill with 300 clauses suggested by the Law Commission, but I hope that the noble Earl, Lord Howe, will be able to say something about what the Government are going to do with those clauses.
My noble friend Lady Pitkeathley raised some interesting points on the PSA and the new provisions. I take what the noble Lord, Lord Willis, said, but I hope that the noble Lord, Lord Ribeiro, will answer my noble friend’s point about whether there has been some misunderstanding of the PSA’s role. Next Wednesday we debate the Deregulation Bill. I have tabled an amendment that seeks to take a number of health regulators out of the economic growth provisions because I believe that they will inhibit the effectiveness of those health regulators. From meetings we have had with the Department of Health it has been made clear that the PSA is included, but not the regulators—the GMC, the NMC et cetera. I wonder whether there is some confusion in the noble Earl’s department about what the role of the PSA is. My noble friend Lady Pitkeathley pointed that out very well.
We support the principle of the Bill. I congratulate the noble Lord, Lord Ribeiro, on bringing it to your Lordships’ House. I wish to see it make progress, but we need to have proper scrutiny as well.
NHS: Maternity Care
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Lord Hunt of Kings Heath (Lab)
My Lords, I, too, very much welcome the initiative of my noble friend Lord Harrison in allowing us to debate these very interesting issues. I agree with many of the points that he made about the risk of fragmentation of services and the need for more prenatal and postnatal care. The noble Baroness, Lady Manzoor, made a very good point about mental health, and indeed it was raised at Oral Questions this morning by my noble friend Lady Royall in relation to postnatal depression. The role of fathers was given a great deal of emphasis by my noble friend and the noble Lord, Lord Farmer. Also recognised was the excellence of many maternity services. I agree with my noble friend that one of the roles of maternity services in this country is to share good practice globally.
On the question of choice, it is very clear that we have a problem at the moment. The Public Accounts Committee made some very important recommendations about choice in its report of January 2014. In particular, the National Federation of Women’s Institutes suggested that although many women wish to take advantage of midwifery-led units, not enough are given the choice. It is not always my experience that these units are used sufficiently once they are set up, and certainly, looking at the numbers in a lot of them, it is clear that they are bordering on viability. Despite the view that has come across from opinion polling, confidence in using those units needs to be built up among parents and mothers. That is something that the NHS may need to think about in the future. Often, the units are set up because the service has been downgraded. Services are now centralised and I am sure that that is appropriate, but it can lead to a loss of confidence among many members of the public about what is left of those midwifery-led units.
I want to ask the noble Earl, Lord Howe, something else that was raised by the PAC. It says that the NHS has persistently failed to deal with inequalities in maternity care. It adds that the latest data on women’s experiences show that black and minority ethic mothers are less positive than white mothers about the care they receive during labour and birth. What is the NHS doing about that? I also refer the noble Earl to Oxford University’s National Perinatal Epidemiology Unit, which found that the most deprived women in England were 38% less likely to be seen by a professional prior to 12 weeks’ gestation and 40% less likely to report being able to see one as early as they would have desired. Presumably they are the people who most ought to take advantage of those services. What can we do about that?
Can the noble Earl respond to the point raised by the PAC concerning confusion around the department’s policy on maternity services, what it wants to achieve and who is accountable for its delivery? Of course, this is partly a product of the arrangements resulting from the 2012 Act, but clearly it is very unsatisfactory in terms of having a cohesive policy at local level and then ensuring that it delivers. I point out to the Minister that, prior to the PAC report, the NAO inquiry found that the department did not fully consider the implications of delivering the ambitions that it had set out in its strategy for maternity services. It went on to say that it was unclear how local commissioners were monitoring the performance of the providers of maternity services and holding them to account. The noble Baroness, Lady Cumberlege, pointed to the ability of mothers to take advantage of home births. How can we make sure that the enunciated policy is implemented unless there is proper monitoring? I very much agree with what she had to say about that.
My noble friends Lady Wall and Lord Harrison referred to training commissions and training in general. There is a concern that with a huge increase in the number of births in recent years, the number of training commissions is not keeping pace with need and demand. That is one reason why so many midwives have left the profession and why it is such a challenge to bring them back into the service. I should just like the noble Earl to say a little more about how convinced he is that we have got the number of training commissions correct.
Is the noble Earl prepared to say something about the relationship between midwives and consultant obstetricians? My noble friend referred to Morecambe Bay, where I think one of the issues was a very poor relationship. We know that there are tensions up and down the country. I wonder whether there is a leadership role within the department to try to bring the professions together at a national level and to resolve some of those tensions. They cannot be good for the safety and quality of care within midwifery units. Yet this issue is being raised in a number of areas.
Finally, on midwifery leadership, it is essential that we have visible, strong leaders locally and nationally. Is the noble Earl satisfied that at his department’s level and at NHS England there are sufficient midwifery-led professionals and a visible head of profession, perhaps a chief midwifery officer? Often, midwives are subsumed within the nursing profession. They are a separate profession but they often come under the management and leadership of a chief nurse. Sometimes midwifery does not get a fair shot when it comes to issues about arguing for resources and priorities. I wonder whether the noble Earl is able to comment on how we can enhance leadership nationally and locally.
NHS: Financial Tariff for 2015-16
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what is their response to the rejection by National Health Service Trusts of the financial tariff proposals drawn up by Monitor for 2015–16.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we recognise the frustration and uncertainty this delay will cause providers and commissioners. My department is working closely with Monitor and NHS England to consider which option to pursue that provides the fairest settlement for different NHS organisations while ensuring that patients continue to receive the best possible care.
Lord Hunt of Kings Heath (Lab)
My Lords, I thank the noble Earl for that reply. Can he confirm that this is the first time that NHS trusts have rejected the tariff on the grounds that they can no longer provide safe and quality care and meet financial targets next year on the basis of the tariff laid down by Monitor? Can he also confirm that the finance director of the NHS Trust Development Authority told Monitor that he does not consider that the efficiency requirement for next year can be met without risking quality of care? When will the Government take responsibility for the financial disaster coming upon the NHS?
Earl Howe
My Lords, it should not cause us any surprise that, at a time of financial stringency in the NHS and increasing demand, it should have proved more difficult than usual to arrive at a settled position on the tariff. The process is undoubtedly complex and challenging but we will continue to work with and support Monitor and NHS England in managing this in a way that attempts to be as fair as possible to all parts of the system.
Smoking: E-Cigarettes
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Earl Howe
My Lords, e-cigarettes are undoubtedly helpful to some people in enabling them to cut down on, or quit, smoking. The evidence is encouraging and we would not want to stop smokers trying out e-cigarettes as an alternative, particularly if other remedies have failed. Equally, we need to be cautious as regards the long-term health effects of using e-cigarettes. That is why the Chief Medical Officer is currently not able to recommend their use.
Lord Hunt of Kings Heath (Lab)
My Lords, does the noble Earl agree that the noble Viscount is perhaps guilty of a little bit of journalistic licence on this issue? The Cochrane review undoubtedly produces encouraging results, but its research contains a big “but”, in that it cautions that only two studies, covering just over 600 smokers, were reflected in the review. The Cochrane review says that we should await the outcome of further studies. Does the noble Earl agree, and can he inform the House when we are likely to see the outcome of those further studies?
Earl Howe
My Lords, the noble Lord is correct. The Cochrane review concluded that the quality of the evidence overall is low because it is based on only a small number of studies. The National Institute for Health Research has recently commissioned a large randomised control trial to examine the efficacy of e-cigarettes compared with nicotine replacement therapy when used within the UK’s stop smoking services. That project is due to end in 2018 and will certainly improve our current understanding.
Smoke-free (Private Vehicles) Regulations 2015
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Viscount Simon (Lab)
My Lords, the Minister knows—I suppose I should declare it as an interest—that in January 1995 I developed severe brittle asthma. On a motorway with my car windows closed, I probably will have an asthma attack if someone is smoking a cigar in another car. Children are particularly vulnerable to second-hand smoke as they have smaller lungs and breathe faster, and their immune system is not as developed as that of adults. This leaves them more open to ear and lung conditions triggered by passive smoking.
It has not been mentioned this afternoon and it is not generally known or acknowledged, but the concentration of tobacco smoke in a car with the windows half down is much higher than the amount of smoke that there used to be in pubs in the old days, and it increases to 11 times more in a stationary car with the windows closed. If parents knew of this, I suspect that they would stop smoking in their cars, but they do not know. We therefore have these regulations before us today. The Minister has given us an excellent description of how the regulations will work, and I support them.
Lord Hunt of Kings Heath (Lab)
My Lords, I, too, welcome the regulations. They follow on from my amendment at Report to the Children and Families Bill, which was agreed by 222 votes to 197, to ban smoking in cars when children are present. I am very proud of that amendment and I express my thanks to organisations such as ASH, the British Lung Foundation, the BMA and others who lent their support to it. I echo the tributes to the noble Lord, Lord Ribeiro, and to other noble Lords who have been campaigning on this matter for some years, including the noble Baroness, Lady Finlay, my noble friend Lord Faulkner, and the noble Baroness, Lady Tyler. My noble friend Lord Simon persuasively and eloquently illustrated the issues that we are dealing with. I am confident that these regulations, if they come to be successfully implemented, will do a lot on those issues.
My noble friend Lord Foulkes was very brave, a long time ago, to pioneer the proposal. What he had to say about the tactics and activities of the tobacco companies was a point very well taken. I welcome the Government’s decision to go ahead with standardised packaging regulations but we know that many of those companies will do their best, through representative bodies, to sabotage them—as I think they have attempted to do in Australia. We must be ever watchful about that.
I agree with the noble Baroness, Lady Tyler, that it is interesting how much public support there is for this measure. She may well have seen the work by the British Lung Foundation which has shown, in survey after survey, that a huge majority of children wanted action to be taken. We have also had the ASH poll conducted last March by YouGov, which showed that 77% of all adults—including 64% of smokers—agreed that action should be taken. Does the noble Earl agree that that shows that there is public support for measures such as this, particularly when it comes to the protection of children? I wonder whether he shares our ambition on this side of the Committee to reduce smoking prevalence to 10% by 2025 and, over the longer term, our goal that all children born in 2015 and beyond will become the first smoke-free generation in hundreds of years.
I noted that the regulations come into force on 1 October 2015. The noble Earl explained why 1 April is not appropriate but I wonder whether 1 July could not have been chosen instead. The noble Baroness, Lady Finlay, raised the experience in Wales. Is the noble Earl confident that the provisions for Wales will come in at the same time as those for England? Could he say a little more about the public marketing plan being developed by Public Health England? That very much relates to the questions asked by my noble friend Lord Foulkes about enforceability, which is so important. I am confident that a great majority of the members of the public will in fact respect the change in the law. The evidence is pretty strong on that. None the less, we need an effective public health campaign and the support of the police in being prepared to take action against those who transgress the law.
Earl Howe
My Lords, I am very grateful to all noble Lords who have spoken and I am grateful for their universal welcome for these regulations. I begin by referring to the remarks of my noble friends Lady Tyler and Lord Ribeiro and the noble Viscount, Lord Simon, all of whom reminded us why we are doing this—the noble Viscount from a very personal perspective. Three million children are exposed to second-hand smoke every year and we want to protect them. Existing smoke-free legislation is popular, as has been said, and has a very high rate of compliance. Personally, I credit the public with more willingness to follow the law and therefore protect their children from second-hand smoke, rather than thinking of elaborate ways to break the law.
The noble Lord, Lord Hunt, asked about public attitudes in relation to these regulations. We know from the responses to the consultation that there is widespread support for protecting children from the harms of second-hand smoke. I do not expect people to go to great lengths to carry on smoking in cars when they know that it is an offence to do so. As has been said, legislation can be instrumental in driving behavioural and cultural change. That has certainly been true in other areas of regulation in the past. Of course, we have to inform the public in a reasonable way before these regulations come into force.
More generally, we agree that education is essential in informing people of the harms of second-hand smoke, particularly to children, and we recognise the importance of social marketing campaigns. The department and Public Health England will continue to protect children from the harms of exposure to second-hand smoke by encouraging voluntary action through social marketing. Previous campaign results illustrate that such campaigns have been effective both in changing behaviour and in driving quit attempts. Of course, I agree with the noble Lord, Lord Hunt, that our ambition as a nation should be to drive down the prevalence of smoking to the maximum extent that we can. We are going to monitor progress in respect of these regulations by assessing the reduction in the number of children who are exposed to second-hand smoke in cars from the current level of 26%, and it is possible to do that.
As I said, I agree with my noble friend Lord Ribeiro about the importance of building public awareness of these health harms. Once again, I pay tribute to all his efforts in this sphere of activity. I also add my thanks to the noble Lord, Lord Foulkes, for his welcome for these regulations, and I acknowledge his far-sightedness in this context, even if he felt like a voice in the wilderness for a number of years. He expressed concern about the enforcement of the regulations—in particular, in view of his perception that the police do not go to great lengths to enforce the mobile phone laws. In fact, my advice is that the police assure us that they endeavour to enforce mobile phone legislation, as they would any law. In fact, in 2012 more than 90,000 fixed penalty notices were issued for mobile phone offences. We estimate that considerably fewer fixed penalty notices will be issued for smoking in private vehicles—possibly around or slightly above 2,000 each year.
The noble Lord, Lord Foulkes, also questioned whether the £50 figure was sufficient. The regulations were drafted following discussions with the police and others to provide for effective enforcement. As I said, the police have confirmed that they will enforce these regulations in the same way as they enforce other laws, such as those relating to seat belts and the use of mobile phones. It is for individual police forces to decide how enforcement will be carried out locally. They have advised that this can be taken forward by local police officers in conjunction with their wider functions on road safety. For example, when running an operation to check compliance with the laws on seat belts or child car seats, the police would also check for anyone smoking or discuss the offences with the driver if there was tobacco in the car. A fine of £50 is consistent with the existing smoke-free legislation, but that level of fine could certainly be subject to review when the regulations as a whole are reviewed.
Mental Health Services: Sign Language Users
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Lord Hunt of Kings Heath (Lab)
My Lords, I, too, thank my noble friend for instituting this debate and Sign Health for its valuable briefing. I welcome the input of the noble Lord, Lord Borwick, but my noble friend’s Question was quite specific. I fully accept that however widely you define deafness, the scale of mental health problems is serious and deserving of attention. I thought that the noble Lord, Lord Addington, put it well. The focus on British Sign Language users is valuable in itself, but it is also a signal of more general problems.
Interesting work published recently in the British Medical Journal has shown, first, as is well known, that deaf adults in the UK occupy poorer socioeconomic positions, have poor literacy and have limited access to communicate through speech. Their health is generally poorer than that of the general population, with probable underdiagnosis and undertreatment of chronic conditions. As for mental health, other research shows that 40% of deaf people are likely to experience a mental health problem. Although the incidence rate of schizophrenia is probably similar to that of the hearing population, the rate of common mental health problems is much higher. Going back to the BMJ research published only a week ago, the rates of depression self-reported by deaf participants was 24% overall—32% for women and 14% for men.
In any response to the mental health issues facing many deaf people, it is abundantly clear, as the noble Baroness, Lady Tyler, said, that there is no national strategy to which one can turn to describe what services deaf people could expect from the NHS. That is related to confusion about what should be commissioned at national and local level. We see lots of indications that clinical commissioning groups find it very difficult to commission services for what inevitably will be a small population in their area.
Equally, I fully accept that not all of that can be commissioned at the national level. We need to find a way that will help clinical commissioning groups to commission services locally for these smaller population groups so that there is much more of a cohesive approach. I do not think that CCGs will do it if left to themselves. That is the real problem that we face, alongside the funding issues around commissioning at a national level for speciality services. This is not an easy issue, but we have to do better than at the moment.
A number of noble Lords referred to the position facing speciality services, and I want to add to the points that my noble friend made about this. I want in particular to raise the question of the Deafness Cognition and Language Research Centre at University College London, which I understand is putting together a costed business case for a national neurological service for British Sign Language deaf users. I understand that it has met Norman Lamb; it has also met my colleague Andrew Gwynne. This has clear cross-party support. The centre is putting a business case forward to secure the presence of a clinic beyond 2015; I do not know if the Minister will be able to update me on progress in that area.
My noble friend and other noble Lords have mentioned the Improving Access to Psychological Therapies service, which showed very promising results from the date of its introduction. Other noble Lords referred to the outcome measures. This has clearly fallen foul of the problem of being delegated to CCGs to commission; they are clearly not going to do so. I had the privilege of meeting SignHealth with Mr Norman Lamb. We had a very good hearing and I was left with considerable optimism that some way would be found to fund this. Again, if the Minister were able to give us some updates on the progress of that, I would be very grateful.
We come back to the point that, if this is left to local CCGs, there is no hope for services that need a contribution from each CCG to make it viable. One way or another, we have to find a way for there to be some kind of national leadership. Indeed, if I were to ask for one thing above all else, it is that the Minister would see if his department was prepared to produce some kind of cohesive strategy around deaf issues and mental health issues for deaf people. That would then give us some encouragement that we would be able to tackle these issues in a coherent way. I always thought that national service frameworks were a very good idea; I am not sure that the current Government think so but, if we are not to have them, we need something in their place.
I want to ask the Minister about the equality duty in relation to deaf people. Is he satisfied that the NHS understands its responsibilities under the equality duty? The noble Baroness, Lady Hollins, suggested that many staff in the health service are very much unaware of the issues for deaf people and the barriers that they face. The issue here is that we lack national standards against which local NHS bodies could judge their performance. The noble Baroness raised the question of reception and waiting room experience. The fact is that work has been done showing that 90% of deaf people have missed many GP appointments through not hearing their name called out in the surgery. That is just one example of the kind of communication problems that they face. At this point it would probably be better if I sat down and gave the Minister even more time to answer the questions.