Contracting Out (Local Authorities Social Services Functions) (England) Order 2014

Lord Hunt of Kings Heath Excerpts

Tuesday 11th March 2014 Grand Committee

[Baroness Brinton (LD)]

My Lords, it is encouraging that the results from the social work practices pilots are very positive. Phrases like “innovative”, “flexible” and “less bureaucratic” are very important to begin to change the culture in the way people work. It is also as important that the real personalisation of services is balanced by the job satisfaction of staff.

The Explanatory Notes that accompany the order are almost entirely positive. I picked up a slight nuance in the Minister’s comments. I wonder if there were any identifiable less positive or concerning features about which it might also be worth advising local authorities in how they are going to be commissioning work in the future. Apart from that, it is inevitably unfortunate that there is a short notice period that this is intended to cover, before the Care Bill comes in. At least there will not be a gap now, which is to be praised.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I should have declared on the previous order—and do on this order—my chairmanship of the Heart of England NHS Foundation Trust and that I am president of GS1 and a consultant and trainer with Cumberlege Connections. I am happy to support this order. I think it is the third time the noble Earl has been before the Committee to present such an order and, as I understand it, it is an interim measure until the Care Bill is enacted; the noble Earl has said that that is expected to be on 1 April 2015.

To pick up the point raised by the noble Baroness, Lady Brinton, I suppose it would have been helpful if we could have seen the draft of the final evaluation report at this point—it is now not going to be published until April. The noble Earl referred to some of the main findings of the draft final evaluation report from King’s College. He said that it was mainly positive although there were clearly some issues, which are identified in paragraph 7.6. Perhaps he might like to say a little more about that.

Perhaps I could also ask the noble Earl about right to control. This was considered in the previous order, and in this order a reference is made to the fact that decisions on the future of the right to control pilot scheme have yet to be made and hence no provisions are included in the new order in this regard. When we debated this on 20 November 2012, the noble Earl referred to the interim evaluation of the right to control programme, published in February 2012, which showed that disabled people were benefiting but there simply was not enough evidence to make a decision on a wider rollout. He went on to say:

“Clearly, an extension of the kind that we seek will give us more evidence. The early signs are positive but that does not provide the basis for a robust decision on permanent arrangements”.—[Official Report, 20/11/2012; col. GC 150.]

Has the department now given this further consideration? Can the noble Earl say why no decisions on the future of right to control have yet been made and when he thinks such decisions will be made?

[Earl Howe]

My Lords, I am grateful to both noble Lords for their comments and questions. They both asked whether in the draft report from King’s we found any negative advice about the results from the pilots. I think the answer is no but it is worth repeating what I alluded to in my initial remarks—that King’s commented that the success of the pilots critically depended on the quality of the contract and the relationship with the local authority. The pilots that worked best were those where those two things had been got right. However, there was nothing to negate our general policy intention to roll out the right of delegation more widely. When the evaluation is published—I, too, have not had the opportunity to have sight of it yet—I am confident that it will be helpful to local authorities looking to delegate functions and I am sure we can be grateful to the team who put the report together for a very thorough piece of work.

The noble Lord, Lord Hunt, asked me about the right to control pilots. As he will have noticed, the order before us does not cover the right to control them. The pilot finished in December 2013. It was considered that there was no need to continue the pilot, which is currently being evaluated. Unfortunately, I cannot tell him when an announcement will be made on that issue but as soon as I am made aware of the date I will be happy to inform him of it. However, we were clear that the order before the Committee today need confine itself only to the matters to which I have already referred.

Health: Midwives

Lord Hunt of Kings Heath Excerpts

Wednesday 5th March 2014 Lords Chamber

[Earl Howe]

My Lords, I hesitate to correct my noble friend but Independent Midwives UK submitted a business proposal to the department which would require the Government to provide a £10 million grant to support the inception of an insurance scheme for its members to provide full maternity care. We have considered two options, either of which would deliver that result. The creation of any government scheme specifically for Independent Midwives UK would effectively position the Government as the underwriter of the independent sector. That is something that we have hitherto found difficult to consider.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my health interests. It sounds to me as though the Government are perhaps going to come up with a positive outcome. Why have independent midwives been excluded from the NHS Litigation Authority’s clinical negligence scheme for trusts? Would that not be a very straightforward way of allowing independent midwives to continue and to be regulated? Clearly, one of the big issues at stake is that, without cover, it is likely that they will not receive proper registration in the future.

[Earl Howe]

Yes, my Lords, that would be a very simple solution but it was rejected by Independent Midwives UK when it was put to it.

NHS: NICE-appraised Medicines

Lord Hunt of Kings Heath Excerpts

Thursday 27th February 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what is their response to the report of the NHS Information Centre for Health and Social Care, Use of NICE appraised medicines in the NHS in England-2012, experimental statistics, which showed extensive variation in patients’ access to new innovative medicines.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and I refer noble Lords to my health interests.

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

My Lords, patients have a right to drugs and treatments that have been approved by the National Institute for Health and Care Excellence that their doctor decides are appropriate for them. There can be many reasons for variation in use but we are determined to tackle unjustified variation where it exists.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Earl for that response. Does he agree that one of the conclusions of the report is that there can be a tenfold variation in the take-up of innovative new medicines that have been approved under the NICE technology appraisal programme? Given that it is a legal requirement for clinical commissioning groups to fund those treatments, as I understand it, what sanctions can be taken against commissioning groups which do not fund those treatments? What can patients do in each area if they are refused such treatments? Is there a process of appeal that they can take their concerns to?

[Earl Howe]

My Lords, there is a process of appeal. Patients can go to their clinical commissioning group or, indeed, to NHS England and ask for the matter to be specially looked at. However, it is important to understand what these figures are and what they are not. They are not intended to be, and do not claim to be, a statement of whether certain drugs are being underprescribed or overprescribed in a particular area. One has to drill down into the reasons. In fact, when one does that, for most of the groups of medicines where it was possible to compare observed and predicted use, the report shows that use has increased over time, and we are introducing additional tools to allow the NHS to get to the heart of the reasons for variations in local areas.

NHS: General Practitioners

Lord Hunt of Kings Heath Excerpts

Wednesday 26th February 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they are taking to ensure that patients can get an appointment with their general practitioner.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and refer noble Lords to my health interests in the register.

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

My Lords, the GP patient survey showed that the vast majority of patients are satisfied with their GP and rated their experience of making an appointment as good. To improve access further we have announced a £50 million fund to support GP practices in improving services and access for their patients. We have also reduced the quality and outcomes framework, the QOF, by more than a third. This will free up space for GPs to provide more personalised care. In addition, by March 2015, all practices will have the facilities to offer online appointment booking and repeat prescription services, increasing ease of access to GP services.

[Lord Hunt of Kings Heath]

My Lords, the noble Earl will know that the analysis by the Royal College of General Practitioners at the weekend showed, according to its work, that 10% of patients were finding it difficult to find an appointment with their general practitioner. Can the noble Earl tell the House what the Government are going to do about that? Does he agree that as hospitals are now moving to full seven-day working, the accessibility of primary care must be improved?

[Earl Howe]

I do agree with the noble Lord’s final comment in particular. We know that GPs are hard pressed. GP consultation rates have risen by 40% since 1995. We therefore need to take several steps to address that. One is in the medium to longer term: we need more GPs, and we have tasked Health Education England to ensure that at least 50% of medical students move to the GP specialty. In the immediate term, there are the measures that I mentioned relating to the GP contract and the £50 million fund, both of which are designed to make the use of GPs’ time a lot more productive than it is at present.

Care: Financial Services Industry

Lord Hunt of Kings Heath Excerpts

Wednesday 26th February 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, thank my noble friend Lord Lipsey and the other noble Lords who have spoken in this highly informed debate. It takes us back to our debates on the Care Bill, which is still subject to deliberation in the other place.

My noble friend referred to the statement of intent and to the difficulties that the industry has encountered in producing policies, for the reasons that he set out. We have studied the statement of intent with care. I noted that the introduction refers to the following fact:

“In March 2013 the Department asked the major firms and trade associations in this field to undertake a review of how the market could develop. This reported back in July 2013 and is being published today”.

No one admires more than me the Department of Health but it does seem to have taken rather a long time for this to have been reported. I should have thought that it would have been more helpful to noble Lords if it had been reported when we were considering some aspects of the Care Bill.

The essential point of the review was that,

“there is currently a lack of demand for products and that new products might initially reach only a small market”.

Shock, horror in the Financial Times—but I do not think that my noble friend was surprised. As he said, he does not really hold out much hope that there will be a market in the future in the way that noble Lords have been talking about tonight: first, as he said, because of the difficulty of pricing products due to the uncertainties in the years ahead, and, secondly, because of the reluctance of most of us to buy those products even if the industry were certain of being able to put them on the market. I should be interested to know whether the noble Earl agrees with my noble friend’s analysis or whether he is more optimistic. If he is more optimistic, then why?

However, my noble friend pointed to what he described as two saleable products: first, point of use and, secondly, enhanced annuities. He felt that those were essential to underpin the Dilnot proposals. I do not want to go over old ground but I agree with my noble friend and other noble Lords that the real problem for us is that, while we obviously welcome the foundations laid in the Care Bill, the fact is that it does not really produce what we originally thought it would—a clear cap that people can understand. We have the £72,000 cap but, in reality, we know that it is much higher. There is the £12,000 per annum living cost and there is also the fact that the £72,000 cap is related to what the local authority will pay. We know that private funders pay more than that, and there are many suggestions that private funders are subsidising people funded by the local authority. Whether that will survive the transparency that will come in a few years’ time, I very much doubt. We argued and debated this when we discussed the Care Bill.

I know the nursing home that my noble friend referred to because my mother has instructed me that, if she has to go into a nursing home, that will be the one to which she goes. She sized it up and everyone in Oxford knows that it is a very good nursing home. However, £50,000 a year—£1,000 a week—is much higher than the local authority will be paying for the people for whom it will be responsible. Therefore, in essence, the cap will be much higher than £72,000. I agree with my noble friend that the Government need to come clean on this. We will not get the certainty that is required or achieve the required literacy among ourselves and other people unless it is clear what the likely liability is going to be for many of us and our relatives.

My noble friend raised two further points. The first concerned regulation. He is not convinced that the standards required of independent financial advisers are sufficient. This is worrying. Noble Lords will have received very interesting briefings for this debate from the Equity Release Council and the Just Retirement organisation. The Just Retirement briefing refers to polling that it commissioned, conducted by YouGov. It found that when individuals were asked where they would go for information or advice on how best to pay if they needed to organise professional care, one in five chose their local council, a similar number chose a CAB and almost a fifth said that they would go to the National Health Service—I am not sure whether that is advised, but there we go.

However, interestingly, the poll also revealed that when people were informed that they would face a large care bill before reaching the cap, almost two-thirds recognised the need for professional financial advice. That is encouraging as long as we can be sure that the independent professional advice is of a high order. I share my noble friend’s concerns that this is very variable, and I am not sure that the regulatory context in which those providing the advice operate will deliver the goods.

The second point that my noble friend raised comes back to being clear about what people are liable for. There are continuing concerns about the role of local authorities in this and their capacity to deliver. I am still concerned about their ability to undertake assessments when the new clock starts, and I have not been convinced that local authorities really do have the capacity to do the job effectively. However, that then raises the question of the nature of the very welcome campaign that the Government, as a result of our debates, have agreed to.

A national public awareness campaign is very important, but it has to be done with effectiveness and vigour. I wonder whether the noble Earl will be able to say a little more about how the campaign is going to be organised, what the budget will be, when it will be launched, how long it will run for and what partner organisations his department will work with. I refer him again to a poll by Just Retirement, which found that nearly one-third of those aged 55 and over believe that councils pay most of the cost, with individuals topping up the rest, while 40% believe that individuals pay most, with councils topping up the remainder. Many, many people do not understand the liabilities that they will face. We need to do everything that we can to ensure that people understand and can get proper advice, and we need to ensure that where the insurance market has a role to play, that role will be as effective as possible. This debate, although very short, is very important if we are to go forward with confidence in terms of Dilnot and the many liabilities that people are going to have to face in the future.

NHS: Patient Data

Lord Hunt of Kings Heath Excerpts

Tuesday 25th February 2014 Lords Chamber

[Earl Howe]

My Lords, I am aware of concerns around the leaflet. Many people have said that they have not received it, which is clearly a concern. NHS England, which is leading on the development of the programme, will consider how to ensure that it engages fully with stakeholders and the public over the coming weeks and months and respond to the concerns that have been raised. The Government will also be engaging with stakeholders to see what we can do from a broader perspective.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my health interests. Is not one of the problems that if a patient wants to opt out of the system they have to go to or communicate with their general practitioner? I am sure the noble Earl will have seen the report at the weekend from the Royal College of General Practitioners that GPs are sometimes rather difficult to find. Would it not give the public more confidence if they could opt out in a straightforward way rather than have to go to see their GP and then depend on the GP to enact that in practice?

[Earl Howe]

My Lords, I cannot agree with that. The GP surgery is where the records are kept and would seem to be the natural place for patients to go. They do not have to make an appointment to do that. If they are concerned, they can write a letter or send an e-mail to the GP practice and then have a conversation later if they would like to. I do not think this is a difficult process.

Drug Companies: Medical Trials

Lord Hunt of Kings Heath Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My Lords, I readily acknowledge the work done by the previous Government, which makes this country probably the best prepared in the world for a flu pandemic.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I come back to the question raised by the noble Baroness, Lady Brinton. Once a medicine goes off patent it can, through generic production, remain available to members of the public for many years. The evidence seems to be that trials that give a favourable verdict are twice as likely to be published as trials giving unfavourable results. Could the noble Earl focus a little more on whether the industry can be encouraged to produce evidence around those trials in relation to current medicines as well as future ones? I also refer noble Lords to my health interest in the register.

[Earl Howe]

My Lords, it is important to point out that the MHRA does not have evidence that there is systematic or large-scale withholding of data. However, it has investigated cases in the past where clinical trials and safety data were not properly reported. The Government believe that the proposals included in the new EU clinical trials regulation will, as I said, contribute to greater transparency in the area of clinical trials. It must be remembered that any company infringing even the current rules can lay itself open to some very severe penalties.

Health: Folic Acid

Lord Hunt of Kings Heath Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My Lords, I recognise that this is an extremely important decision for the Government to make, affecting many people’s lives. I do not accept the implication behind the noble Lord’s question that the numbers involved in the analysis were somehow statistically invalid. I am assured that they represent a valid statistical base. We welcome all robust new evidence around the issue of fortification, such as the study published last week by the Wolfson Institute, and I can assure the noble Lord that we will take a decision on this matter as soon as possible.

[Lord Hunt of Kings Heath (Lab)]

My Lords, could the noble Earl give a little more precision as to what “as soon as possible” actually means? He referred to the study produced by the Wolfson Institute last week. Is he aware of the comments of Sir Nicholas Wald of the Wolfson Institute that it will be a public health tragedy if this country does not follow the example of the many other countries that have introduced this in a mandatory way? Is it not time that the Government simply made a decision? Indeed, they are clearly briefing to the media that they are going to make a positive decision. Why do not they just come clean and say, “We’re going to do it”, and say which date it will start from?

[Earl Howe]

My Lords, as I have explained on earlier occasions, it is very important that we use the latest data to reach a robust and defensible view of the risks and benefits on this issue. We will take the new National Diet and Nutrition Survey data on folate status into account when we do reach a decision. As for the position taken in other countries, while a number of countries have introduced mandatory fortification of flour with folic acid, others notably have decided against it, including Ireland and New Zealand.

Health: Meningitis B Vaccine

Lord Hunt of Kings Heath Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

I can tell my noble friend that the JCVI has been considering both those issues: first, the possible need for a population-based evaluation of the MenB vaccine to address uncertainties in its effectiveness; and, secondly, what the possible effect of the MenB vaccine on the carriage of meningitis B bacteria might be. I say again that we need to wait for the JCVI’s final statement of advice to get clarity on either of those issues.

[Lord Hunt of Kings Heath (Lab)]

My Lords, of course I understand that we need to await the outcome of the Joint Committee’s further deliberations. However, following up the Question asked by my noble friend, if the committee sticks to the view that a vaccine would have a huge impact on an estimated 1,000 young people every year but still considers that that is not cost-effective, surely it calls into question the methodology that it is using. Will the noble Earl say a little more about how the Government can ensure that this methodology is put under full scrutiny?

[Earl Howe]

Last October, in recognition of concerns about the methodology currently used for assessing cost-effectiveness of vaccines, the JCVI agreed that a working group should be formed to consider two issues: first, how the impact of vaccination programmes to prevent rare diseases of high severity should be best assessed; and, secondly, whether there were aspects of cost-effectiveness in relation specifically to children that should be addressed. It is a complex issue both economically and, indeed, ethically. We should not expect a report from that group, once it has been established, until next year at the earliest.

NHS: Black and Minority Ethnic Nursing Directors

Lord Hunt of Kings Heath Excerpts

Monday 10th February 2014 Lords Chamber

[Earl Howe]

We have to be a little careful about doing anything that appears to look like positive discrimination or setting quotas, because we stray into areas of dubious legality if we do that. Having said that, as I have indicated, the priority of the Chief Nursing Officer is extremely clear and substantial resources have been put behind this. I pay tribute to the work that the noble Lord, Lord Crisp, did when he was NHS Chief Executive. We have picked up a lot of the ideas that he promoted at that time. I would be very disappointed if there were not progress within a few years but one has to set a realistic time horizon.

[Lord Hunt of Kings Heath]

My Lords, I refer noble Lords to my health interests. One answer to the question raised by the noble Lord, Lord Mawhinney, would be to point out that 18% of the NHS workforce in England is from a BME background and 14% of the population of England is from a BME background. As 2.6% of nursing directors comes from a BME background, that shows that there is a very long way to go. Is the Minister confident that NHS England is acting in accordance with the Equality Act? If he is not confident, what is he going to do about it?

[Earl Howe]

My Lords, just to correct the noble Lord, the latest figure I have from 2012 is that total ethnic minority groups in nursing, midwifery and health visiting comprise 19.7% of the nursing workforce. That underscores the basic point that he made. One cannot aspire to 19.7% of those ethnic nurses becoming nurse leaders because there is only a limited number of leadership posts. However, we are clear that this should be a priority for the NHS.

The answer to the noble Lord’s second question is that the Equality and Diversity Council has published some refreshed guidelines. One of its goals is to have a representative and supportive workforce throughout the NHS. It is putting that in train by asking NHS organisations to monitor their equality performance jointly with their patients, communities and staff.