Care Quality Commission (Reviews and Performance Assessments) Regulations 2014

Lord Hunt of Kings Heath Excerpts

Monday 27th October 2014 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the Care Quality Commission (Reviews and Performance Assessments) Regulations 2014 include no provision for the regular assessment of performance by clinical commissioning groups and local authorities in the commissioning of health and social care and of the NHS Commissioning Board in relation to specialty commissioning (SI 2014/1788).

[Lord Hunt of Kings Heath (Lab)]

My Lords, the statutory instrument that we are debating tonight arises from an amendment that the Government sought parliamentary approval for during the passage of the Care Bill in 2013 and 2014. That amendment related to the scope of periodic performance assessments to be undertaken by the CQC and the method by which such reviews are to be devised and will allow an aggregate performance rating to summarise and compare the performance of organisations or the services provided. It is for the CQC to devise such quality standards and methodology in consultation with the Secretary of State and those key stakeholders that the CQC considers appropriate. The scope of those performance assessments is set out in these regulations, which by virtue of Regulation 1 will come into force on 1 October this year. That means that the CQC will be under a duty to undertake performance ratings of those registered service providers and regulated activities that such providers carry out, as prescribed by Regulation 2 and the schedule to these regulations.

I remain somewhat sceptical of the ability of the CQC to place such huge organisations as hospitals in one of only four categories. The Explanatory Note to the SI refers to work commissioned by the Secretary of State on the use of aggregate ratings of providers. This is not the first attempt at performance ratings, but the fascinating piece of work produced by the Nuffield Trust and commissioned by the department has a number of warnings on this. The trust says in its report:

“A rating by itself is unlikely to be useful in spotting lapses in the quality of care”,

particularly for services which “complex providers like hospitals” give.

“It is here that the analogy with Ofsted’s ratings of schools breaks down. Hospitals are large, with many departments and different activities, seeing large numbers of different people every day, carrying out complex activities, many 24/7, and in which people are sick and can die. Put another way, the risks managed by hospitals vastly outweigh those managed in schools. For social care providers the risks may be lower, but many are still dealing with frail, ill and otherwise vulnerable individuals”.

Its conclusion is that,

“unless there is a ‘health warning’ on a rating to clarify to the public what it can and cannot say about the quality of care, there is an inevitable risk that the rating (and the rating organisation) will be discredited, as lapses occur in providers scored as ‘good’ or ‘excellent’”.

It says that it will be just a matter of time. In summary the Nuffield Trust concluded that,

“the overall approach to ratings should allow complex organisations to be assessed at different levels and to promote service-specific ratings where possible, particularly in the case of hospitals”.

I would be grateful if the noble Earl could comment on this, particularly on how he considers the rating outcomes of individual providers are to be communicated to the public in an understandable way that none the less pays due regard to the complexity of the ratings so well described by the Nuffield Trust.

My real objective in bringing these regulations before your Lordships’ House is not so much what is in the statutory instrument as what is not. I go back to our debates during the passages of both the Care Bill and the Health and Social Care Bill in 2012. The noble Earl will know that I have expressed considerable concerns about the fact that the way in which clinical commissioning groups and local authorities commission services is no longer to be subject to regular review, audit and, indeed, rating by the CQC. During the passage of the Care Bill only a few months ago we discussed concerns about the quality of local authority commissioning of care services in the context of the scandal of 15-minute visits and zero-hours contracts. We argued then that the CQC should undertake regular inspections of local authority commissioning performance.

I suggest that the same goes for clinical commissioning groups in the National Health Service. When we debate NHS issues the noble Earl frequently—indeed, consistently —refers to the importance of commissioning. Whenever he is pressed on problems or gaps in services he has put his trust in more effective commissioning. However, it is very difficult to see how the performance of commissioners is properly assessed and held to account in the current structure. The noble Earl has previously argued that we should rely on such things as CCG outcome indicators, backed up by scrutiny from local Healthwatch. I think that that is a pretty weak response. So far there is scant evidence to show that this is effective. I am sure we would acknowledge that often when things go wrong in a health system it is a failure of the system—of course of the providers giving the services, but also of commissioners and, indeed, local authorities. Let us take the four-hour A&E target, which is proving to be a major challenge up and down the country. There will of course be issues in the organisation of the hospital itself, but there will also be issues around the organisation of primary care, the way in which services are commissioned and the ability of local authorities to ensure that there are specific and sufficient facilities in the community for when patients are discharged from hospital.

It is a matter of regret that the CQC, as the primary regulator on quality and standards, is no longer concerned on a regular basis with the performance of local authorities as commissioners, and with clinical commissioning groups. It is true that the CQC has the power to conduct special reviews where concerns have been raised about a particular commissioner. I do not know whether that has happened yet—maybe the noble Earl will be able to tell me—but it seems to me that that is not anywhere near sufficient.

I also want to discuss the position of NHS England. The noble Earl will know that, although the original changes brought about by Mr Lansley were designed to hand over nearly all the commissioning budget to clinical commissioning groups, a rather substantial amount of money was ultimately retained by NHS England for commissioning of specialist services. It would be fair to say that NHS England’s performance on that has given cause for concern. The noble Earl will be aware that the budget for specialist commissioning is hundreds of millions of pounds overspent. In essence, we had an out-of-control budget and the board of NHS England seemingly unaware of what was going on. If an NHS provider had performed so lamentably its board would have been sacked, and rightfully so. I ask the noble Earl how the board of NHS England has been held to account for its lamentable performance relating to specialist commissioning. Have sanctions been applied? At the very least, should the CQC not assess NHS England’s commissioning performance?

In our previous debate on NHS England, the noble Earl informed us:

“NHS England has its own governance processes in place, including the development of the direct commissioning assurance framework to demonstrate that it meets the standards required. As this is developed further, elements will be introduced to bring external scrutiny to its board and function”.

He also said:

“Ultimately, NHS England is held to account by the Department of Health for its commissioning activity against its delivery of the priorities set in the mandate”.—[Official Report, 21/10/13; col. 813.]

I am sure the noble Earl thought that they were comforting words, but how on earth does this apply to the debacle over specialised commissioning? To my knowledge, that has still not been properly resolved.

I am not convinced that the Government have the right approach to commissioning. If commissioning in the health service and in local government is as important as the Government say it is, surely it is in the public interest that the CQC should take a much stronger role in checking and rating the performance of commissioners, and indeed of health and care system performance generally. I hope that this leads to a good debate. I beg to move.

[Baroness Wall of New Barnet (Lab)]

My Lords, I support in principle the wording of the business that we are dealing with, particularly the emphasis on regular assessment of other than the provider trusts. I share with the House and the Minister why I now feel that that is even more important. I declare an interest as chairman of Milton Keynes Hospital NHS Foundation Trust. Just last week, we were inspected by the CQC. Obviously, we do not yet know the outcome of that. The CQC was with us for four days and there were 40-odd people there.

As the noble Earl is aware, I have been very supportive of the CQC and share his aspirations for it. To be honest, our inspection was extremely thorough. We have to wait with bated breath for the outcome, but the enthusiasm, what was described as the buzz around the hospital and the way that people felt strongly about the services that they were giving made a huge difference to the whole thing. I am only three months into that trust, but this was not about preparing for the CQC; it was about the culture of the organisation and wanting to improve. I hope that the CQC comes back with recognition of that, whatever the outcome might be.

The inspection was carried out under the new way of doing things, which I think is great. There were many more people across all the spectrums of our services, at a professional and clinical level. That was superb. The reporting back every night was very good and helpful to the chairman and chief executive. All that felt good and thorough, which is what it is all about. I agree with my noble friend’s view about extending that for the very reason that he just gave. The importance of that inspection to the outcome for our patients was absolutely paramount, regardless of what the outcome might be in terms of the grading or level of assessment we might be given. But without that thoroughness and rigour, particularly with the CCGs, who are the ones making decisions about our services, with the GPs who run them—unless there is a deep dive, as we would call it, into any other part of the health service—the gaps that are still a worry for us may remain.

In particular, my noble friend Lord Hunt said that there was an issue around local authorities. All trusts are struggling terribly with A&E. There are many reasons for that, as my noble friend has said. But one of the big reasons is the lack of rigour in social care and local authorities’ commitment to or understanding of the role that they play. From the experience that we have had over the past week, I believe that this is not a threat to people: it is empowering for them to have the CQC in there, ensuring that the rigour that they are supposed to apply to their work is there and that the role they play in patients’ experience really makes a difference. I urge the noble Earl to consider this opportunity yet again. We made a decision in the Care Act, which I think even more now is really a mistake from which we need to move on. I do not share the cynicism of my noble friend, but I share the concern about whether the CQC can embrace all that.

The investigation into my trust was supported, as I understand it, by far more clinicians than ever before and far more people had a much greater knowledge of the health service. If the CQC can continue to develop in that way, I believe it is in its interest—and, more importantly, in our patients’ interests—that those commissioning groups go wider and deeper into other than the provider trusts.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I am sure that the House is most grateful to the noble Earl for such a comprehensive description of the relationship between the department, NHS England and commissioners for health and social care. I congratulate my noble friend Lady Wall on her appointment to the chairmanship of the Milton Keynes Hospital NHS Foundation Trust. I echo her thoughts about the new inspection regime, which is a vast improvement on the old regime. I also acknowledge that the CQC has made some excellent appointments at senior level to help the inspection process.

That is a very good start, but there are gaps in relation to the commissioning of services. I would like to follow up the question asked by the noble Baroness, Lady Barker about prison health services. The Explanatory Memorandum states that regulated activities provided by prescribed service providers in prisons are excluded because:

“A performance rating might be helpful to the commissioners of these services, but only if it can be uniformly awarded to all providers in the sector and at present, not all prison healthcare is regulated by CQC”.

This is not the time to go into that in more detail, but I should be grateful if the noble Earl would be prepared to write to us about it—unless he wishes to intervene now. I am grateful that he indicates that he would be prepared to write to us, because it is an important point. There have been vast improvements in the health service within prisons in recent years and I would have thought that they would welcome some ratings from the CQC. I hope that the Government will look into that.

On the substantive point, I simply want to say to the noble Earl that many of the issues that the health service and care services face are very pressing and very challenging. Those services depend on all the people within a system—both commissioners and providers —working together. I still believe that there is a strong case for there to be assessment by the CQC to help systems generally to learn from others, to see where weaknesses are and to improve the whole system approach—something that is missing from the current regime. This has been a good debate. I beg leave to withdraw my Motion.

Motion withdrawn.

Medical Innovation Bill [HL]

Lord Hunt of Kings Heath Excerpts

Friday 24th October 2014 Lords Chamber

[Lord Turnberg]

As we have heard, my Lords, there is a degree of uncertainty surrounding certain aspects of the Bill that we have been trying to clarify. It is on that account that I have tabled Amendment 31, which sets out the need for a code of practice in which the Secretary of State describes in somewhat more detail what the Bill is about and how it should be enacted. I hope that it will be helpful to have that in the Bill.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this has been a fascinating debate, both in Committee and at Second Reading. We are all very grateful to the noble Lord, Lord Saatchi, for listening carefully and bringing the amendments that he has today, and for agreeing to a roundtable discussion between Committee and Report, which is a very constructive response to some of the issues that have been raised.

I say at once that I am absolutely with the noble Lord on the need to encourage innovation in our NHS, but the more that I have listened to the debate, the more convinced I am that it is not so much a question of the law but more one of actual practice within our NHS. I am afraid that we have to face up to the fact that there is a culture of regulatory processes and funding procedures that often get in the way of introducing innovation. For me, the Act that the Bill will become will be a signal to the NHS.

The noble Lord, Lord Blencathra, raised some interesting points about some of the problems that we have at the moment. He talked about off-label medicines. The Minister responded by saying that the Government are committed to innovation and gave a number of examples, which were welcome, but the point that I would put to him is that we now have a situation where NICE produces technology appraisals of new innovative procedures and drugs that clinical commissioning groups are essentially breaking the law by not implementing. He knows that they are under a requirement to fund the use of those procedures and medicines within three months of the technology appraisal being issued, yet we know from research by patient groups that the actual implementation is patchy. We could do an awful lot in relation to innovation if we insisted that people locally did what they were required to do.

My second point relates to the drug budget, an issue that the noble Lord raised. A few months ago the Government concluded an extremely interesting agreement with the branded drug companies, so that for five years the cost of branded drugs in England, apart from modest rises in inflation, will be fully met by the pharmaceutical industry. This is a very good agreement and one that I very much welcome. We still hear people in the NHS saying that they cannot afford the new drugs, yet the industry has promised to pay back any increase in the cost of those drugs over what they are paying now plus a modest increase in inflation. Here is a wonderful opportunity at last for the NHS to move quickly in widely adopting new medicines, but somewhere in the system someone is stopping it. I have read the NHS England five-year plan and it says nothing about the introduction of innovative new medicines.

I am sorry that this is a little outside the noble Lord’s Bill and I hope that he will forgive me, but this is about innovation. I am genuinely puzzled, and we will come back to this point, about why the Government did not rush to insist that the NHS took advantage of the agreement. In fact very few people in the NHS know about the agreement. My concern is that the rebates that the drug industry is going to give will be used for other purposes, which would be a very big mistake.

I hope that the Minister will agree to the amendment; I strongly advise him to do so, or at least to consider it. It is clear from the speeches that have been made that there is some confusion about the circumstances in which the noble Lord’s provisions are going to be made. Earlier in our debates, the noble Earl essentially said that doctors would have a choice when it came to whether, in relation to a given medical treatment, they would use this Bill’s provisions or rely on the traditional approach, the Bolam test. The noble and learned Lord, Lord Woolf, said that they are not alternatives and, in the circumstances raised by one noble Lord where there was not time to get the advice of the clinicians that is provided for in the noble Lord’s Bill, you would rely on the Bolam test. I am only a lay person, but I suspect that there is a risk of doctors not catching the nuance of that distinction. It is clear from the various letters that we have had from many of the medical bodies that there is some concern about this. I know that the noble Lord will speak and I strongly endorse his amendment on the regulation-making power, but I strongly advise the Government to agree to issuing guidance to the medical profession in this regard. There is a danger of some confusion and such guidance would be useful. If the noble Lord is not able to accept this amendment today, perhaps he will give it some further consideration.

NHS: Health and Social Care Act 2012 Reforms

Lord Hunt of Kings Heath Excerpts

Wednesday 22nd October 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, let us come back to the Question, which is about funding. If the picture was so rosy, why is it that a record number of NHS trusts and NHS foundation trusts are in deficit? If the picture was so rosy, what does the Minister have to say about the report a couple of weeks ago by the Nuffield Trust? It states:

“Prompt access to services has declined … In mental health services, demand”,

is,

“outstripping capacity for urgent care and for younger people. The wellbeing of frontline staff in both health and social care is”,

deteriorating. When he says that the Government are not ashamed of what they did, who is he speaking for? Is he really speaking for the Prime Minister and the leadership of his party?

[Earl Howe]

I am indeed and the NHS is under pressure for the reason that the noble Lord has just quoted—demand has risen dramatically. However, productivity has also risen dramatically, which it failed to do under the previous Administration.

NHS: Cancer Diagnosis and Treatment

Lord Hunt of Kings Heath Excerpts

Monday 13th October 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what is their assessment of the report by Cancer UK highlighting gaps in the provision of National Health Service cancer diagnostic and treatment services.

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

My Lords, there has been significant growth in the provision of cancer diagnostic tests and treatment over the course of this Government. For example, urgent GP referrals for suspected cancer have increased by more than 50% since October 2009. NHS England is taking action to support the NHS to improve performance, including establishing a cancer waiting times task force. We are investing an additional £750 million over four years to improve diagnosis and treatment of cancer.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the question of waiting times, can the noble Earl confirm that the 62-day target for cancer treatment has been breached in the last two quarters? Can he say why that is and can he confirm that it is really a result of the shambles that Mr Lansley’s changes have brought to the NHS?

[Earl Howe]

My Lords, the noble Lord is correct that although most waiting time standards are being maintained there has been a dip in the 62-day pathway standard in the last two quarters. However, survival rates are improving and we are treating a record number of NHS patients for cancer. Last year, 450,000 more patients were referred with suspected cancer than in 2009-10. That is an increase of 51%. In addition, campaigns such as Be Clear on Cancer have been exceptionally successful in raising awareness of symptoms. In large part, that is what has accounted for the pressure on the waiting time standards: in a way, the campaigns are a victim of their own success.

Ebola

Lord Hunt of Kings Heath Excerpts

Monday 13th October 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I thank the noble Earl for repeating the Statement. I start by echoing his words by paying tribute to NHS staff members and members of the Armed Forces and of the Diplomatic Service who have been heavily involved in the Ebola response both at home and in West Africa for many months. I am sure that we have all been horrified by the devastating scenes reported on TV as the virus has spread. People will also be worried by reports of a second case of Ebola in Dallas. There will be particular concern that that second case has occurred in a health worker. We look to the Government for reassurance.

The noble Earl repeated the point that the Chief Medical Officer expects there to be a handful of cases. Perhaps he could say a little about what modelling has been undertaken to estimate the potential number of cases. What is the range of those estimates? Is a handful of cases the worst-case scenario? He will be aware of the independent review of the Government’s response to the swine flu pandemic by Dame Deirdre Hine, who said that the only predictable thing about such events is their unpredictability. Can the Minister confirm that the Government are planning for the worst-case scenario so that there can be no sense of complacency?

It is also right that we should consider further measures to ensure that we are fully prepared should an Ebola case be identified here. I would like to ask the noble Earl about the Government’s position, as there seems to have been some confusion. Last Thursday, a statement on the Department of Health’s website read:

“Entry screening in the UK is not recommended by the World Health Organisation, and there are no plans to introduce entry screening for Ebola in the UK”.

Just 24 hours later the Department of Health changed its position. Will the Minister say what official advice on screening his right honourable friend received from the Chief Medical Officer and from Public Health England? Did screening have the support of the Chief Medical Officer? In interviews over the last 48 hours the Chief Medical Officer seemed to be saying that there is no evidence to support the effectiveness of the screening programme that the Government are putting in place. Can the Minister confirm that?

Can the Minister also say who is in charge? He will remember concerns as the 2012 Health and Social Care Bill went through the House about the fragmentation of public health and about responsibility for it seeming to be split between Ministers, the Chief Medical Officer, Public Health England, local authorities and the NHS at local level. There will be questions about who is in charge and who is accountable.

The preparation exercise undertaken this weekend was of course extremely welcome. The Minister will know that a patient was transferred from Newcastle, where they have negative pressure beds, to the Royal Free, where they have what are called Trexler beds. The current advice—which has recently been revised—from the Advisory Committee on Dangerous Pathogens is that patients can be handled in either type of bed. Can the Minister comment on that? If only Trexler beds are recommended, is he satisfied that the NHS currently has only two such beds, both at the Royal Free? Can the Minister update us about progress on the proposed second unit planned in Newcastle, which he mentioned when he repeated the Statement?

While border checks and preparation exercises are important, the public will want to be reassured on three key issues. The first is that treatment is available, and that all necessary steps are being taken to develop a vaccine. The second is that the NHS is prepared and that staff are sufficiently aware of the symptoms. The third is that public information is readily available. I will take each in turn.

On treatment, although there is currently no specific treatment for Ebola, there is an experimental medication called ZMapp which the British nurse who was treated here was offered and took. Will it be standard practice to offer that medication to patients, and are the Government satisfied with the current supply of it in the NHS? The best assurance we could give people is that there will be a vaccine which will be made easily accessible to those who need it most. Can he update the House a little more on progress in its preparation?

With regard to preparation, is the Minister satisfied that all relevant NHS staff, including GPs, know how to identify Ebola, the precautions to be taken in any presentation and the protocols for handling it once it has been identified? Can he give an assurance that safety equipment is of the standard stipulated by the WHO? He will be aware that it is a cause for concern that breaches of protocol and the quality of safety equipment have been cited as potential causes of the infections in Spain and the US.

What plans do the Government have in the area of public awareness? Has the Minister considered introducing a telephone advice line? Does he consider that it would be wise to temporarily increase the number of clinicians available to answer NHS 111 calls?

The UK has, rightly, pledged £125 million to assist Sierra Leone in fighting the outbreak. However, with cases doubling every three to four weeks there is widespread agreement that the response of the international community in general has to date been slow and inadequate. The window of opportunity to halt Ebola will close very shortly, and I ask the Minister what extra steps the Government are taking to help the affected countries with resources and clinical expertise? What are they doing to mobilise action by the international community?

Finally, do the Health Secretary and the noble Earl accept that improving global health systems is the best way to prevent these outbreaks, or at least to ensure that such outbreaks are caught before they get out of control? It is indeed shocking that the index case for this outbreak was identified 10 months ago. My own party, along with the Governments of France, Germany and Senegal, among others, has called for universal health coverage to be placed at the centre of global development, yet the UK is currently opposing such plans at the UN. Can the Minister explain the Government’s opposition to this?

NHS: Cottage Hospitals

Lord Hunt of Kings Heath Excerpts

Monday 13th October 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that we are all grateful to the noble Lord, Lord Naseby, for raising this interesting Question. I enjoyed his heroic defence of the 2012 Act and the remarkable—and really quite dangerous—changes it brought about. I thought that today’s Times was an interesting read, and I recommend it to the noble Lord.

The role of cottage hospitals in the National Health Service is a very interesting question. We do not really call them that now; we call them community hospitals. It would be fair to say that they have had a mixed experience in the past few years. They are valued by the local community but are often at risk from the centralisation of services, and have tended to see their role downgraded over the past few years. Like the noble Lord, Lord Naseby, I was interested in the comments of Simon Stevens, the NHS chief executive, when he spoke about the experience of what he called running smaller, viable hospitals in other countries. I should be interested to know from the noble Earl, Lord Howe, what he thinks about that. Does he think that clinical commissioning groups should be encouraged to reverse the flow of services away from community hospitals into larger, centralised services? If he agrees, what attitude does he think that the regulatory bodies are likely to take? I am thinking here particularly of the Care Quality Commission, which has the responsibility of regulating all hospitals and care institutions.

I take it from the comments of the noble Lords, Lord Naseby and Lord Framlingham, that they would like to see an expansion in the services provided by community hospitals. However, that is unlikely to take place unless the regulator believes that it is safe to do so. I would be interested in the noble Earl’s comments on that. I have no doubt whatever that in terms of the current pressure on acute hospitals in particular, the more rehabilitative services and respite care that can be provided locally the better. Perhaps this could be an exciting role for smaller hospitals in the future.

As far as mutuals are concerned, I do not know if either noble Lord has read a report, sponsored by the Department of Health, called Improving NHS Care by Engaging Staff and Devolving Decision-Making: Report of the Review of Staff Engagement and Empowerment in the NHS. I do not know whether the noble Earl will refer to it but it is interesting because, on the one hand, it makes the point that,

“there should be greater freedom for organisations to become staff owned and governed, on a strictly voluntary basis, following detailed consultation with staff and staff-side trade unions”.

Clearly, some thinking is going on, which suggests at the very least that staff ownership—I know a mutual goes much wider than that—is one building block in the establishment of mutual organisations. On the other hand, I put to the noble Earl the comment made by the UNISON head of health—I should declare my interest as a member of UNISON—stating that there was,

“a very real danger that bringing the mutual model into hospitals will be a Trojan horse for privatisation”.

I did not take it from the comments of both noble Lords that that was what they had in mind. I took it that they both saw mutuals as being a support to the National Health Service and that they would not envisage patients paying money to go to those hospitals, which would very much be seen as being part of the NHS—although perhaps not run as other NHS bodies are. I thought that I should raise that issue.

I should also like to ask the noble Earl, Lord Howe, whether another approach could be to extend the foundation trust model. I have just given up chairing a foundation trust where we had 100,000 members, consisting mainly of members of the public but also 11,000 staff members. As members, they elect the governing body of the organisation. The governing body in turn appoints a board of directors. I have found that to be a useful mechanism whereby the board of the organisation is locally accountable. I have found the regular meetings of the governing body to be one of the most challenging experiences as chairman because there was a sense of accountability to the governing body, which represented both the locality and the members of staff.

I wonder whether the noble Earl, Lord Howe, thinks that perhaps we need to refresh the governance of NHS institutions in a way that allows much more mutual ownership. If he agrees, does he not think that clinical commissioning groups are an area where we should start? In our debates on the Health and Social Care Bill, one of my concerns about clinical commissioning groups was that essentially they have no accountability to their local population. One way around this would have been to adopt the foundation trust governorship model. Although the CCG is essentially a membership organisation of general practitioners, it could have a much wider responsibility and accountability as well.

We are all interested to hear the noble Earl’s comments on this interesting issue. I hope that, at the least, we get a sense of where the Government stand in relation to the role of community hospitals in the future.

Learning Disabilities: Premature Deaths

Lord Hunt of Kings Heath Excerpts

Wednesday 30th July 2014 Lords Chamber

[Earl Howe]

My Lords, I can assure the noble Lord that there is currently a whole-system response to the recommendations in the review. As I said earlier, this is a response from NHS England, Public Health England, local organisations and, indeed, Ministers overseeing the Learning Disability Programme Board. I shall take away the noble Lord’s question about a formal annual review, consider it carefully, and write to him.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Earl recognise that the confidential inquiry showed that there are great failings in the health treatment given to many people with learning disabilities, which probably contributes to their very poor life expectancy? He will be aware that my own former trust, Heart of England, appointed specialist liaison nurses who could help people with learning disabilities find a pathway through their healthcare. Would he advise other NHS trusts to follow that example?

[Earl Howe]

My Lords, the noble Lord makes a good point. Following the recommendations of the UK review of learning disabilities nursing, we have set up an independent collaborative to address that workforce’s needs. We are also working with Health Education England’s 13 local education training boards to develop greater links with the independent and voluntary sector which will help with workforce planning. This year Health Education England increased its national commissions for student learning disability nurses by 4.5%. We are working on a number of initiatives to raise the profile of learning disabilities nursing and promote the profession as an attractive career choice.

Health: Dental Implants

Lord Hunt of Kings Heath Excerpts

Wednesday 23rd July 2014 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Baroness, Lady Gardner of Parkes, is one of our most active Members and I am sure we all owe her a great debt in bringing this matter to our attention tonight. I declare an interest as a member of the Faculty of Dental Surgery at the Royal College of Surgeons. Last Friday, I attended a celebration of the 50th anniversary of the fluoridation of the water supply in Birmingham. Will the noble Earl join me in congratulating the great city of Birmingham on this achievement? It is interesting that, when one looks at health outcomes, Birmingham is often towards the lower end of the table, but it is way up in the top 10 in oral health. Whatever one’s views on fluoridation—and I also declare my presidency of the British Fluoridation Society—there is no question that it has had a very positive impact in Birmingham and the West Midlands in terms of the number of children who have to go into hospital because of oral issues, which was a point raised by the noble Baroness.

As the noble Baroness said, the use of dental implants has grown rapidly across the UK in the last few years. That has been very welcome to many patients but we know that, on the other hand, alongside this rise, the General Dental Council has seen an increasing number of complaints, particularly regarding the lack of informed consent for treatment, damage to the tissue and bone surrounding the implant, and failures. The noble Baroness was very explicit about some of the health issues that can arise. I have looked very carefully at the briefing provided by the Faculty of Dental Surgery at the Royal College of Surgeons. It makes four points that I will put to the noble Earl, alongside the questions raised by the noble Baroness.

Essentially, the briefing says that it is very important for patients to be given adequate information about the risks and alternative options for treatment. Secondly, patients should be aware that periodontal and peri-implant checks are essential to ensure that problems are detected early. The stability of the implant is threatened by diseases such as the one mentioned by the noble Baroness. I do not dare attempt to repeat its name, although I believe that the noble Earl, Lord Howe, is perhaps braver than me on that. However, this is why checks are essential.

Thirdly, the GDC should consider ensuring that peri-implant assessment and maintenance is part of the normal undergraduate course. Fourthly, I would like to mention the Law Commission draft Bill. We are not to see the Bill, but it contains proposals to give regulators the power to annotate their registrar and indicate specialisms or other qualifications. Given that we are not going to have the Bill—I know that there will be some Section 60 orders—perhaps I could make a plea that this might be considered if a dental order is to be brought forward.

Finally, I refer to a very interesting note I received from the Faculty of General Dental Practice about the standards of training in implant dentistry. This is available from a wide variety of providers in the UK, including universities, royal colleges and hospitals. These standards have been developed to ensure patient safety and protection, and I understand that they also serve as a reference point for the GDC in consideration of patient complaints. The only question I wanted to put to the noble Earl about this is that, although this seems to be absolutely fine, how can we ensure that more dental teams take up these training opportunities?

Clearly, we have a good system where standards are very much developed. The providers have to provide training in line with those standards, and the General Dental Council is there to follow up complaints when there are indications that dentists are not practising according to those standards. I wonder whether the noble Earl thinks that there is an issue of some dental practitioners not doing that, which then has an impact on their provision of clinical services.

Health: Midwives

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd July 2014 Lords Chamber

[Earl Howe]

My Lords, I do not have information on the confidential enquiry in my brief but, according to international statistics, the NHS remains one of the safest places in the world to give birth. The latest independent CQC survey found that maternity care in England has improved, with women reporting a high level of trust and confidence in the staff caring for them. I shall gladly let my noble friend know the latest that my department has on the issues she has raised.

[Lord Hunt of Kings Heath (Lab)]

My Lords, did the noble Earl see the report in the Times this morning that the Nottingham University Hospitals NHS Trust maternity unit closed 97 times in a period of 12 months due to pressure? Freedom of information requests have shown that some 62 maternity units were forced to close because of pressures in 2013. Is that not a firm indication of a shortage of midwives? Does it not show that the Government are less than active in seeking to put this right?

[Earl Howe]

It is up to commissioners to ensure that facilities are available to meet the needs of women who are due to give birth. There may be limited occasions when a maternity unit cannot safely accept more women into their care. That is why we have seen some temporary closures of units. Any decision to redirect women is made by a clinician as part of a carefully managed process. It is not something that suddenly happens. However, commissioners need to be alert to the risks for provider facilities that a bulge in births can create.

Learning Disabilities: Community-Based Support

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd July 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they are taking in the light of the events at Winterbourne View hospital to ensure that people with learning disabilities inappropriately placed in hospital are able to move to community-based support.

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

My Lords, the Government are working with health and care system partners, self-advocates, family carers and other stakeholders to improve safety, quality of care and outcomes for people with learning disabilities, including reducing significantly reliance on in-patient care, by reviewing people’s care and moving them to alternative, community-based support where appropriate.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Earl for that. Can he confirm that the Government set a deadline of 1 June for the transfer of thousands of people with learning disabilities out of institutions such as Winterbourne View? The latest figures show that only one in 10 such residents has actually been so moved. Will the noble Earl accept responsibility for this and tell the House what the Government intend to do about it?

[Earl Howe]

My Lords, the Government’s mandate for NHS England in the current year includes an objective which covers Winterbourne View concordat commitments. He is right that the deadline was missed. We are not satisfied with that and we are working very hard with NHS England to set out our expectations for progress and improved rates of discharge from in-patient settings. NHS England is going to produce an action plan this August but, in the mean time, it is doing three things. It is complying with the transforming care and Winterbourne View concordat commitments, which we have tasked it to do. It will set out what progress it expects to make and by when, with milestones, and it will provide real clarity on what success looks like—an important issue if we are trying to hold it to account—and how progress will be measured.