Health: Tuberculosis
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Earl Howe
My Lords, there are regulations covering ports and airports which provide a contingency for when a passenger on a ship or a plane enters the UK, is suspected of having a notifiable disease and perhaps refuses to seek medical attention. The regulations include provisions for notification of such a case to the destination port health authority and for the detention of that person for the purposes of a medical examination. There are also quite flexible powers for local authorities to deal with incidents or emergencies where infection or contamination presents or could present a significant risk to public health.
Lord Hunt of Kings Heath (Lab)
My Lords, I refer noble Lords to my health interests. The Minister referred to a number of strategies in London, Manchester and Birmingham. Will he confirm that the implementation, particularly of some preventive strategies, will depend on the work of TB specialist nurses? Is he aware that some budgets are under pressure and there is a risk that we will not have enough nurses to do the job? Will he guarantee that we will see an increase in the number of TB nurses?
Earl Howe
My Lords, as the noble Lord is aware, NHS England allocates funding to clinical commissioning groups which commission health services on behalf of their local populations. It is for CCGs to decide how best to use the funding that is allocated to them, underpinned by clinical insight and knowledge of local healthcare needs. We expect health and well-being boards to have a major say in those areas where TB is commonplace.
Children and Families Bill
Lord Hunt of Kings Heath Excerpts(12 years, 2 months ago)
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Baroness Tyler of Enfield (LD)
My Lords, I rise extremely briefly because I had my go on Monday. I want to add just one point to what my noble friend Lord Storey has said. Some people are saying, “Let’s start with an awareness-raising campaign. Let’s see what we can do there. We don’t need to go straight to legislation”. I do not agree with that. The most effective example that I can cite was the introduction of legislation for the wearing of seatbelts. Awareness-raising had been tried, but it achieved only 25% compliance rates, but soon after the legislation was introduced, alongside the awareness-raising effort—you need both; it is not one or the other—91% of adults started to wear seatbelts. As my noble friend said, it is clear that it has saved lives. I think that very few people in this country, and certainly the polls show it, now think that that is an infringement of civil liberties.
Lord Hunt of Kings Heath (Lab)
My Lords, I should perhaps declare an interest as chairman of an NHS foundation trust, as a consultant trainer to Cumberlege Connections and as president of GS1. I welcome this debate. I am delighted to see Amendments 263 and 264, and I have put my name, alongside that of my noble friend Lady Hughes, to Amendments 265 and 266, which are essentially amendments to Amendment 264.
As my noble friend Lady Hughes said on Monday, ever since the advertising ban came in, cigarette packaging has been the way in which tobacco companies have sought to market their products. That is why they spend millions on developing their packaging by testing its attractiveness to potential new customers, and that is why standardised packaging is such an important issue. Amendments 265 and 266 build on the excellent Amendment 264. Essentially, we seek to strengthen that amendment by requiring the Secretary of State to make regulations rather than by simply giving him the discretion to do so. It is important that Ministers are left in no doubt that they need to introduce standardised packaging, which is why I hope that those noble Lords who have proposed Amendment 264 and spoken so eloquently to it will accept our amendments to strengthen the provision. What has happened over the past two years or so would suggest that it is better not to give Ministers discretion in this area.
When the noble Earl comes to wind up, it would be helpful if he could explain the Government’s change of view on this matter. He will know that the former health Secretary, Andrew Lansley, said:
“The evidence is clear that packaging helps to recruit smokers, so it makes sense to consider having less attractive packaging”.
It was widely reported in March this year that legislation to enforce plain packaging for cigarettes would be included in the Queen’s Speech. In April, the then public health Minister, Anna Soubry, said that, having seen the evidence, she had been personally persuaded of the case for standardised plain packaging for cigarettes, but in July we heard the announcement that this was going to be postponed because we would wait and see what happened in Australia.
Will the Minister explain to us why the Government changed their mind and does he agree that the systematic review of all the evidence on standardised packaging commissioned by his department and published alongside the Government’s original consultation showed clearly the strong evidence that standardised packaging would help to reduce smoking rates by reducing the attractiveness and appeal of tobacco products and increasing the noticeability and effectiveness of health warnings and messages? Will he also acknowledge that two internal Philip Morris International corporate affairs documents from February and March 2012 showed that the top lobbying message for the world’s largest tobacco company was to use the strapline, “Wait and see what happens in Australia”? Why have the Government fallen for that attempt? Why on earth should we wait to see what happens in Australia? Cricket aside, I have great fondness for Australia and Australians, but why on earth are we waiting to see what happens there?
We have always been a world leader in this area with actions such as introducing smoking bans in pubs and enclosed spaces, ending tobacco companies’ sports sponsorship and billboard advertising, raising the legal age for purchasing cigarettes and the introduction of graphic warnings on cigarette packs. We have been a leader and our actions have had an impact. We have seen a dramatic reduction in the number of young smokers. Why on earth do we not want to continue in that vein? The Government will be in no doubt about the strength of feeling in your Lordships’ House and I have no doubt whatever that it wishes to see action taken on this issue. I hope that the noble Earl will be able to give us some comfort that the Government recognise that we should get on with tackling this issue.
Earl Howe
That indeed is my understanding. Noble Lords have taken the opportunity of this Bill to raise the dangers of smoking, particularly of passive smoking for children, and I have no issue with that. I merely point out that there are problems with the amendment as drafted. I am not saying that it would not be possible to draft another amendment which noble Lords might care to consider between now and Report. Being able to enforce these provisions as drafted is also a significant aspect. For example, it may be hard to judge whether a product could reasonably be expected to attract children, as the amendment would require, or to determine what might be aimed at or would attract 18 year-olds but not, let us say, 17 year-olds or 13 year-olds.
I am grateful to noble Lords for raising this important issue and for keeping this debate at the front of our minds. It is a debate that we need to continue. As I have said, the Government have yet to make a decision on this policy, but if we were to bring in such a measure, we would not want it to be circumscribed in the way that is proposed. We would not want to set up a situation in which both branded and standardised packs could be sold legally depending on where they were sold and what other products were sold alongside them. I therefore urge noble Lords not to press their amendments and respectfully suggest that they consider other avenues for bringing this matter before the House on Report.
Lord Hunt of Kings Heath
I always admire the noble Earl’s eloquence when defending the indefensible and he has done that par excellence today, but is not the reality that this is an opportunity for the Committee and the House to express a view in principle on the issue? It would then be up to the Government. As the noble Earl knows, when that happens, the Government simply come back with an amendment at Third Reading to deal with the technical issues. Surely the issue here is whether the House goes forward to a vote in principle, which I hope it might be able to do.
Earl Howe
Well, my Lords, if I could repay the compliment to the noble Lord, Lord Hunt, he has very eloquently presented the case for the Government to go away and think further about this, which indeed we will do. I come back to what I said at the beginning of this debate: the message from this Committee has been delivered loudly and clearly. I am grateful to noble Lords for that. I say again that the Government’s mind is not closed on this issue.
NHS: Mid Staffordshire NHS Foundation Trust
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Lord Hunt of Kings Heath (Lab)
My Lords, I remind the House of my interests as chairman of an NHS foundation trust, president of GS1 and a consultant and trainer with Cumberlege Connections. I thank the Minister for repeating the Statement. What happened at Mid Staffs was a betrayal of the NHS and its values. The previous Government rightly apologised, but now is the time to back our words with action. That is why, in welcoming much of what has been said, I would like to press the Minister on where we feel we would have gone further and question why, of the 290 recommendations from Francis, 86 are not being implemented in full.
First, I pay tribute to my right honourable friend Ann Clwyd, Professor Patricia Hart, Professor Sir Bruce Keogh, Camilla Cavendish, Professor Don Berwick and of course Sir Robert Francis. Between them they have given us proposals that will help to prevent a repeat and, more importantly, change the whole of the NHS for the better. Both Francis reports found three primary and fundamental causes of what went wrong: a failure to listen to patients; a lack of properly trained staff; and a dysfunctional culture. I shall turn to each of those.
First, I am sure that the Minister will agree with me that patients and their families must always, as Francis recommended, be the first priority for the NHS. Was Francis not right to recommend that the NHS constitution and the ethos that it sets out should be required reading for all NHS staff? I congratulate the Minister on agreeing to implement the Clwyd review in full and change the way that the NHS handles complaints.
Secondly, there is the issue of staffing numbers and training. The first Francis report found that Mid Staffs made dangerous cuts to staffing over a short period. I welcome the Government’s new focus on this issue, but is it not the case that nurse to patient ratios across the NHS have got significantly worse in the past three years, with nearly 6,000 fewer nurses, more older patients in hospital and bed occupancy running at record levels?
It is encouraging that the NHS plans to recruit more nurses and is introducing more monitoring and transparency. The Secretary of State says that things are already changing for the better, but is the Minister aware that Monitor, the economic regulator of the NHS, has warned that trusts are planning major nurse redundancies in the 2014-16 period, far outweighing any increase planned this year? Will the Government intervene to stop that? Further, why have the Government stopped short of requiring safe staffing levels? Is the Minister aware that nurse training places have been severely cut in recent years and that many NHS trusts and foundation trusts are now being forced to recruit from overseas?
Alongside nursing, more action is needed to raise standards across the caring workforce. As Robert Francis has said, it is unacceptable that the security guard at the door of the hospital is more regulated and subject to professional sanctions than the healthcare assistant attending to an elderly patient. The development of the care certificate, as proposed by Camilla Cavendish, is a step forward, but will it not work only alongside a register of those who hold it and with an ability to remove it if they fall short? What happens if a member of staff employed as a care assistant in an NHS hospital has indeed obtained a care certificate but is then found to be wholly unsatisfactory to carry out a care assistant’s work? What happens to the certificate? Surely we need to go back to the Robert Francis recommendation of a system of regulation for healthcare assistants. Will the Government reconsider this decision and at least commit to keeping it under review?
On culture change, Robert Francis’s central proposal is a new duty of candour on organisations and individuals. It is not entirely clear how an organisational duty alone will help individuals challenge an organisation where there is a dysfunctional culture. Is it not the case that an individual duty, as proposed by Francis, is needed? The point comes over very clearly from the evidence given to Francis from a senior, soon to be retired consultant. He said:
“I took the path of least resistance … There were also veiled threats at the time that I shouldn’t rock the boat at my stage in life”.
It is only when an individual is both required to speak out and protected in doing so that the House can say that it has done enough to safeguard patients.
The duty of openness and transparency should apply equally to all organisations providing NHS services, including, as Francis rightly recommended, contractors providing outsourced services. The Government are clearly bringing in more outside providers. Surely patients need reassurance that we do not have an uneven playing field where private providers face less scrutiny. Will the Government extend the duty of candour to all healthcare organisations as Francis proposes? The amendments to the Care Bill do not seem to make that clear. Should not the Minister commit to extending freedom of information law to any provider of NHS services and not allowing them to hide behind commercial confidentiality?
On openness, Francis made a direct call on the Government to set an example to the rest of the NHS. He said:
“risk assessments should be made public, and debated publically, before a proposal for any major structural change to the healthcare system is accepted”.
Given the Government’s claim to have accepted this recommendation, should they not show what they mean by finally publishing the risk register on the current reorganisation of the NHS?
Finally on openness, the NHS will be more accountable to families with a proper system of death certification. The House will recall that this was a core recommendation of Dame Janet Smith’s inquiry into the Shipman murders. The Francis recommendations on this are not all accepted in full. I hope that the Minister will be able to give me some reassurance on that.
I would also like to ask the Minister about the regulatory structure. I have raised with him before the question raised by Don Berwick in his very interesting report on patient safety, which the Government themselves commissioned. In that report he said:
“The current NHS regulatory system is bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies. It should be simplified”.
He went on to say:
“The regulatory complexity that Robert Francis identified as contributing to the problems at Mid Staffordshire is severe and endures, and the Government should end that complexity”.
Has the Minister picked up on the comment made by the chair of the CQC to the Health Select Committee in October, where he said that responsibility for patient safety in the health service should be transferred back from NHS England to the Care Quality Commission? Will the Minister agree that that is the right thing to do?
Can I also ask about the impact of competition on patient safety? The Minister may well have seen reports at the weekend that there are proposals to centralise cancer services in first-class treatment centres in order to enhance the efficiency, safety and effectiveness of the treatments being offered. Is he as shocked as I am that there has been a challenge to those proposals on the basis that they may run against the competition rules set out in the regulations that the Minister brought to this House in relation to Section 75 of the Health and Social Care Act 2012? Will the Minister look into those circumstances?
Finally, can I ask about the National Patient Safety Agency? In his Statement, the Minister referred to the fact that there will be a duty on staff to report near misses. He will be aware that the previous Government established the National Patient Safety Agency to allow staff to report those near misses. Is he as concerned as I am that the abolition of the NPSA and the transfer of the listening and reporting function to NHS England may, in itself, act as an inhibitor to staff feeling confident in reporting those safety incidents?
Finally, does the Minister believe—
Noble Lords
Lord Hunt of Kings Heath
My Lords, this does not eat into Back-Bench time. I think I am quite at liberty to ask as many questions as I like. Perhaps the party opposite would do me the courtesy of actually listening to the questions. Let me say finally—
Lord Hunt of Kings Heath
My Lords, I am very happy to carry on. We have 20 minutes for Front-Bench questions and answers, and I have not yet taken half that time. I am quite happy to go on but, of course, I want to give the Minister time to respond as well. Perhaps some noble Lords will read the Companion to see what the rules are.
Finally, is primary legislation needed to implement any of these recommendations? I say to the Minister that if that is so, we on this side will certainly co-operate on a cross-party basis to enable those recommendations to be implemented in full.
NHS: Urgent and Emergency Care Review
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Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the noble Lord, Earl Howe, for repeating the Answer. I declare my interests as chair of an NHS foundation trust, president of GS1 and a consultant trainer with Cumberlege Connections.
There is no question that A&E services are under pressure—in crisis, according to the College of Emergency Medicine. Earlier this year, the Health Secretary announced that Professor Sir Bruce Keogh would lead a major review of emergency care in the NHS. It is clearly a significant piece of work, which is why I would have expected the Government to come before your Lordships’ House and the other place to make a Statement. I object very strongly to this being briefed to journalists this morning, yet Ministers were not prepared to come to the House until the Speaker granted an Urgent Question in the other place.
The noble Lord has said, quite remarkably, that because this is to be published by NHS England, it is not appropriate for Ministers to come to Parliament. He says that the NHS is independent. He must be the only person who believes that the NHS is independent. It is a wholly owned subsidiary and quango of the department. Why does a Secretary of State insist on seeing the leader of NHS England on a weekly basis if it is an independent body? I hope that the noble Lord will reflect on that. The Government should have brought this to your Lordships’ House with a proper Statement.
When the Bruce Keogh report was commissioned, the Secretary of State said that it was intended that we would learn lessons for this winter. What are those lessons? What immediate actions are now being taken ahead of winter? Weekend briefings and leaks suggest that Sir Bruce emphasises alternatives to A&E, such as walk-in centres and the 111 service, yet we have had a report from Monitor saying that NHS England has overseen the closure of walk-in centres. He cannot pass that on to clinical commissioning groups as it is well known that NHS England put pressure on clinical commissioning groups to close those walk-in centres. Will that closure programme stop now? Will he put nurses back on the 111 helpline in order to make amends for the debacle of the launch of that inadequate service months ago? What will he do about the recruitment crisis in A&E?
Bearing in mind the Birmingham health system, can he assure me that the £250 million allocated to A&E hospitals under the most pressure will be spent to alleviate the pressure on those hospitals and not be filleted away for other purposes?
National Health Service (Approval of Licensing Criteria) Order 2013
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Lord Hunt of Kings Heath (Lab)
My Lords, first, I thank the noble Earl for that very full explanation of this order. In the context of the order, I should declare my chairmanship of an NHS foundation trust, which is subject both to Monitor and the Care Quality Commission.
I thought that the noble Earl’s full explanation of the order really reinforced concerns about the complexity of Monitor’s role and potentially the conflict between its licensing responsibilities, its independent regulation of pricing of NHS services and the general support that it gives for NHS foundation trusts. Now that Monitor has had time to consider these matters, since the passage of the 2012 Act, can he explain how it avoids conflicts of interest between these three separate roles? He will be aware that we discussed that issue when we debated the Bill.
Clearly, a lot of responsibility in Monitor rests on the leadership of Dr David Bennett. The noble Earl will be aware that in the pre-scrutiny hearing in the other place, the Health Select Committee—after examining Dominic Dodd, who had been proposed as chairman of Monitor—said of David Bennett that he,
“was appointed as interim Chief Executive in April 2010, and appointed as substantive Chair in March 2011. Since then he has filled the roles of both Chair and Chief Executive—effectively Executive Chair—and has led Monitor through the whole process of change brought about by the Health and Social Care Act 2012. This has been a period of great uncertainty for Monitor, with the nature of its role in the new system being unclear for most of the 18 months between the introduction of the Bill in January 2011 and its passing in 2012. Dr Bennett has both shaped and interpreted the role that Monitor now plays in the system which makes the transition to another individual taking on the Chair an especially difficult one. We do not think Mr Dodd is the right person to undertake that difficult transition”.
I understand that, following that, Mr Dodd withdrew his nomination, or at least his nomination was withdrawn.
In the context of this order, which sets the framework in which licensing will be undertaken by Monitor in future, can the Minister say a little more about the Government’s intention with regard to leadership, particularly the continuing role of Dr Bennett as both chairman and chief executive? As the Minister will know, in normal corporate governance terms that is not normally encouraged.
My third question relates to the Explanatory Memorandum, rather than the order itself. I was interested to see that, under “Policy Background”, paragraph 7.2 sets out three key functions of Monitor. I have already referred to them as,
“working with NHS England to provide independent regulation of pricing … protecting patient choice and”,
addressing,
“anti-competitive behaviour … and … working with commissioners to secure continuity of services”.
I just wondered where integration had got to. Have the Minister’s officials forgotten that? We debated this at great length and the Bill was amended to ensure the importance of integration. The noble Earl will recall that Monitor was given that express role. I am very disappointed to see that it is not referenced in the policy background but I am not surprised because, frankly, we have seen very little work on integration coming out of the various bodies concerned with the health service.
There has, however, been an awful lot to do with competition. As the noble Earl will know, in evidence to the Health Select Committee—I think it was only two weeks ago—the chief executive of the NHS railed against the way in which competition was being introduced in the health service. He knows, as everyone working in the health service knows, that a huge amount of money is being spent because of the enforced tendering of services that is undoubtedly taking place. It is very important that the Government reconsider the architecture that they have now put in place.
In addition to Monitor, we have the CQC, the NHS Trust Development Authority, the NHS Executive—I am sorry, I meant NHS England; that was a Freudian slip—and Ministers. Compared to the previous Secretary of State, the current Secretary of State takes a very different view of his role, and so we have a very confusing architecture. We also have the Office of Fair Trading making extremely unhelpful and unwelcome interventions, which again seems to act against the appropriate integration of services. It really needs to be sorted out.
I have no doubt that we will talk about this in a few minutes, but after Monitor’s welcome report on walk-in centres—I do not know whether it was as welcome to the noble Earl as it was to me—we have a situation where NHS England has undoubtedly been encouraging clinical commissioning groups to close down walk-in centres to make savings. However, yet another part of the architecture has come out with a report essentially saying that this has been a big mistake and has added to the pressure on A&E departments. One is entitled to ask: who on earth is really driving the policy at the moment?
Although I welcome the Monitor report, I was interested to know why it has produced it. At paragraph 1.2 on page 9 of the report, Monitor says:
“Our decision to review walk-in centre provision is grounded in our main duty as health care sector regulator: to protect and promote the interests of patients by promoting the provision of health care services that is effective, efficient and economic and that maintains and improves the quality of services”.
Well, yes, but is Monitor’s role really to look at this area of service provision? Fine—it is a good and welcome report, but it is confusing as to where one regulator’s role stops and the other starts. I have this great impression of five or six large, powerful bodies, all with well paid executives and strong boards, vying for influence. What that does at a time of huge pressure in the health service is to create uncertainty about who is leading, who is setting the policy and who is responsible for its implementation.
Finally, I come back to the question raised by Don Berwick in his very interesting report on patient safety, which the Government commissioned. In that report, which was published only a few months ago, he said:
“The current NHS regulatory system is bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies. It should be simplified”.
It certainly should be simplified. He went on to say:
“The regulatory complexity that Robert Francis identified as contributing to the problems at Mid Staffordshire is severe and endures, and the Government should end that complexity”.
Does the noble Earl agree that the order he brings before us today is simply a sign of greater complexity? I do not think that we have had a response from the Government on this recommendation. I know that the noble Earl has a regulatory Bill up his sleeve for the next Session. Given what Don Berwick said and the evidence that Sir David Nicholson gave to the Health Select Committee, does he not agree that it might be sensible to go wider and look at this whole business again, to get much greater clarity into what is a complex situation?
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Hunt, for his questions. I start with the issue that he raised initially, which was about the role of Monitor and what he perceives as the conflicts within that role. I address that by saying that there is no fundamental conflict, although he is perfectly right to say that Monitor has distinct, separate functions. Different executives within Monitor lead on each of those areas. Monitor has a board, which functions to ensure that David Bennett’s dual role as chair and CEO works effectively. At the same time, the Department of Health, as the steward of the system, keeps Monitor’s performance under review. It does that through quarterly accountability meetings. I suggest that the conflicts that the noble Lord perceives are much more in the perception than the reality. There are mechanisms in place within Monitor to ensure that the functions are kept distinct and that, where appropriate, Chinese walls operate.
The noble Lord referred to the nomination of Dominic Dodd as the chair of Monitor and the Select Committee’s view that he was not the right person to lead the organisation. That was a view which Mr Dodd himself accepted, and he volunteered to step aside. In the light of that, we are currently considering options for a sustainable solution to Monitor’s leadership. We will make an announcement as soon as we can on that, but, meanwhile, I emphasise that we have complete confidence in David Bennett’s leadership of the organisation.
Lord Hunt of Kings Heath
I meant no criticism of Dr Bennett in his role. I just point out that if one goes back to Cadbury and all sorts of reports since then, the evidence is clear that it is undesirable to have the same person carrying out both roles.
Earl Howe
I completely take the noble Lord’s point. We will of course be looking carefully at how best to proceed. It was, of course, with a view to appointing a separate chair that Mr Dodd’s name was put forward.
The noble Lord referred to the importance of integration. He is of course right that we debated the issue extensively during the passage of the Health and Social Care Act and have done so since. The Health and Social Care Act established Monitor as the sector regulator of healthcare. That involves a duty placed on Monitor to protect and promote patients’ interests by promoting provision of NHS services which is economic, efficient and effective and which maintains or improves the quality of those services. Within those broad headings, integration fits neatly.
The provider licence is a key tool which Monitor will use in carrying out its duties and in influencing and regulating the provision of NHS services. Specifically, the licence enables Monitor not only to set prices for NHS-funded care, which it does in partnership with NHS England, but to enable integrated care. The fact that that is not explicitly referenced in the Explanatory Memorandum is not something to which noble Lords should attach particular significance. Integration is part and parcel of Monitor’s overall duties.
Professional Standards Authority
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Earl Howe
My Lords, the Francis recommendations made no reference to voluntary registers for healthcare support workers. The broad position is that the PSA has not received any applications from organisations holding voluntary registers for healthcare support workers, and therefore no voluntary registers for healthcare support workers have been approved. As accredited registers are voluntary, I am afraid that the Government are not in a position to predict how long it will take for all healthcare support workers to be registered.
Lord Hunt of Kings Heath (Lab)
My Lords, going back to the question raised by the noble Lord, Lord Taverne, is the Minister confident that every intervention by a doctor is actually based on robust clinical evidence?
Earl Howe
My Lords, as the noble Lord knows, it is the responsibility of local NHS organisations to make decisions on the commissioning and funding of any healthcare treatments for patients, taking account of issues to do with safety, clinical and cost effectiveness and the availability of appropriate practitioners. However, it is interesting to note that there are a number of complementary and alternative therapies referenced in NICE guidance, and I would expect any self-respecting doctor to take account of those.
NHS: London
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Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the noble Earl, Lord Howe, for repeating the Statement. I refer noble Lords to my interests, particularly as chair of a foundation trust.
Decisions on hospital reconfiguration should always be made on the basis of the best clinical evidence available. The noble Earl’s announcement today means the closure of a number of accident and emergency departments in London, with the centralisation of A&E services at five, rather than nine, hospitals. That is to happen at the same time as accident and emergency departments are under heavy pressure up and down the country, not least in London. Taking all major A&E units together, London as a whole has missed the Government’s A&E target in 48 out of the past 52 weeks. Is the noble Earl convinced that the system will be able to cope with the reduced number of A&E departments in London?
I note that the chief executives of the three major health regulators have been summoned to meet the Prime Minister to discuss the pressure that services are likely to come under this winter. These meetings are complementary to the weekly meetings that the Secretary of State has with these eminent people. Apparently these discussions are dominated by winter performance planning, particularly relating to accident and emergency departments. What measures are being taken to increase capacity in the community, to enable the flow of patients and their discharge at the right time?
What is being done about the accessibility of general practitioners? We heard much from the Prime Minister about a move to seven-day-a-week access, which the noble Earl will know has provoked a lot of opposition from primary care interests, citing cost at a time when the NHS is cash strapped and when there is a shortage of general practitioners. Does that mean the inevitable merger of smaller GP practices? Can the noble Earl spell out the Government’s intentions? In the Statement, we are told that there is to be seven-day access to GP surgeries throughout north-west London. Can the noble Earl confirm that that means that all surgeries will be open from 8 am to 8 pm, seven days a week? If that is not the case, what happens to patients in practices which are not prepared to open seven days a week?
I now turn to the noble Earl’s announcement about Charing Cross and Ealing hospitals. Very simply: is this a permanent reprieve? The report of the Independent Reconfiguration Panel says that the future of the proposed local hospitals at Ealing and Charing Cross, and the final decision about what might best be provided from each location must be the subject of a specific programme of work which should address the needs for in-patient services for the vulnerable and frail elderly, and that its outcome would determine whether there is a need for further consultation. In his Statement, the noble Earl has said that, whatever the outcome of that further work, Ministers have decided that Ealing and Charing Cross hospitals should continue to offer an A&E service, even if it is a “different shape or size” to that currently offered. Can the noble Earl spell out what, exactly is meant by that? Can he guarantee that both Charing Cross and Ealing hospitals will continue to run full, 24-hour A&E services in the long term?
The Statement is about hospitals in London. I was surprised that the noble Earl made no mention of Lewisham Hospital. The victory won by the people of Lewisham in the Court of Appeal yesterday will give hope to patients everywhere. Back in the summer, the Opposition explicitly warned the Secretary of State to accept the first court ruling. Instead, he ploughed on with a hopeless case, wasting taxpayers’ money in a cavalier fashion. Will the noble Earl confirm that there will be no further appeal to the Supreme Court? Will he give the people of Lewisham and the staff who work in Lewisham Hospital a commitment that their accident and emergency and maternity units will be protected in the long term? Given that the Lewisham clinical commissioning group opposed those changes, what does it say about the assurances that he gave during the passage of the Health and Social Care Act 2012 that the whole purpose of those misguided changes was actually to let local clinicians decide? What happened to that in Lewisham?
The noble Earl tabled an amendment to the Care Bill only a few days ago, which he described as making a small change, so he will of course know that the Government have sought, very rapidly and very quietly, to change the law so that what happened in Lewisham cannot happen again. My interpretation of that amendment is that in the future there is a risk of services being shut down without the agreement of local people, without extensive consultation and without agreement from local commissioners. We, on this side of the House, support reconfiguration of health services when supported by the clinical evidence, but it must be on the basis of a requirement to go through a properly defined and structured reconfiguration process with extensive consultation with the local community.
From all we have learnt, we know that successful reconfigurations need to take the form of open and honest leadership, a patient process of engagement and consultation and proper consideration of the wider impact. The changes that the Government seek to make in legislation will ensure that that does not happen in the future. I hope that the noble Earl will be able to say that, in the light of yesterday’s ruling, the Government are giving second thoughts to their intentions in this regard.
Care Bill [HL]
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Lord Elton (Con)
What the noble Baroness has just said prompts me to point out a difficulty. We are in an age when there is controversy about spirituality, when people can actually lose their jobs over issues of spirituality. If there were to be a case arising under this legislation in which such a matter arose and spirituality was not mentioned in the Bill, the position of those people would be a great deal weaker than if the Bill was amended as my noble friend suggests. Like the Chief Whip, I know that it is contrary to our normal custom to divide at this stage, but it seems that this is an issue of sufficient importance on the one hand and of narrowness of scope on the other to make it both necessary and painless.
Lord Hunt of Kings Heath (Lab)
My Lords, as this is a new stage I will just declare my interest as chairman of an NHS foundation trust, president of GS1, and a consultant and trainer with Cumberlege Connections. With the noble Baroness, Lady Barker, I, too, was very interested in this discussion at an earlier stage of the Bill. Our concern is that the original Government view is that spiritual issues would be embraced by Clause 1(2)(b) under the words “emotional well-being”. The noble Baroness, Lady Barker, and I did not feel that that was sufficient. Indeed, we had some worries that spiritual well-being could actually be subsumed under the terms “emotional well-being”.
The noble Earl, Lord Howe, has, I think, met our concerns. As he said in his letter to us, adding “beliefs” to Clause 1(3)(b) enables spiritual beliefs to be encompassed within that term without excluding any other forms of belief that may not be described as spiritual. I think that meets the concerns that I had about this matter. I would like the noble Baroness, Lady Barker, to draw a distinction between that and the specific issue that noble Lords have raised in relation to the health service, which is clearly designed to ensure that the NHS employs a chaplaincy service and which I absolutely subscribe to. Indeed, I pay tribute to the chaplaincy service up and down the country. However, this Bill is about a different set of circumstances. To the noble Lord, Lord Elton, I say that employment issues do not arise in this regard. We are talking about Clause 1 of the Bill, which is about promoting the individual well-being within the context of the Care Bill. I understand the point that he raised, but I do not think it arises in this context.
I would, though, say to the noble Lords, Lord Hamilton and Lord Cormack, that, reading the Companion, they are definitely right to bring this issue up on Third Reading. It is quite clear that an issue was raised in the debate on Report and the noble Earl agreed to look into it. He has now brought forth an amendment, and the Companion is absolutely clear that amendments on Third Reading are,
“to enable the government to fulfil undertakings given at earlier stages of the bill”.
Lord Elton
My Lords, on the noble Lord’s response to me, if an employee is able to point to statute and say that they are carrying out a requirement of statute, that has a very considerable bearing on tribunal cases and should not be brushed aside.
Lord Hunt of Kings Heath
My Lords, I do not seek to brush it aside. However, this clause relates to the responsibility,
“of a local authority, in exercising a function under this Part … to promote that individual’s well-being”.
Spiritual issues are subsumed under the amendment moved by the noble Earl, Lord Howe. With the greatest of respect, this does not relate to an employment law issue between an employer and an individual. This is very much around the kind of support that should be given to an individual by the local authority. There is a distinction between the situation that the noble Lord raised, and the issue that is set out in this clause.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, before I move to the matter in hand, I thank noble Lords for the tremendous dedication that they have shown to the scrutiny of the Bill during its passage through the House. It is a landmark piece of legislation, and I hope that the House will agree that the changes that the Government have made in response to the debates that we have had have strengthened the Bill so that it will pass to the other place in an even better state. Many noble Lords across this House have dedicated impressive time and energy to improving the provisions in all parts of the Bill, but time does not permit me to thank all noble Lords individually, as I would like to. However, I thank again those noble Lords who played such an important role in improving the Bill as members of the pre-legislative scrutiny committee.
I turn to my noble friend’s amendment. Under Clause 1, local authorities must promote individuals’ well-being and must also have regard to individuals’ views, wishes and feelings. As I set out during our debate on Report, we consider that these provisions mean that a local authority would take a person’s spiritual views, wishes and feelings into account in promoting their well-being. However, in response to concerns raised by a number of noble Lords on Report, I have now tabled an amendment to make it absolutely clear that these matters should be considered where they are of importance to the individual.
My amendment adds “beliefs” to the matters to which a local authority must have regard when exercising care and support functions. Having regard to someone’s beliefs includes their spiritual beliefs; for example, ensuring access to an appropriate figure of religious authority during palliative care. This approach achieves the same aim as Amendment 1 in the name of my noble friend Lord Hamilton, but I suggest to him and to the House that the government amendment is preferable, for two reasons.
First, my amendment quite deliberately does not refer specifically to “spiritual” well-being, but applies instead more widely to beliefs, which was the point made very effectively by my noble friend Lady Barker. That is because we do not wish to exclude those who may not consider themselves to have “spiritual” beliefs. That issue was raised by the noble Lord, Lord Warner, on Report, in relation to humanists.
Secondly, despite the comments of the noble Baroness, Lady Warnock—to whom I listened as always with great attention—spiritual well-being is not a well understood or defined concept. It carries a risk because it may confuse the practical application of the well-being principle on an individual level. There is another problem here. My noble friend’s amendment would effectively mean that local authorities had a duty to promote an individual’s spiritual well-being or beliefs. It is not appropriate to require a local authority to promote spiritual matters, except in so far as they affect the emotional well-being of a person.
Lord Best (CB)
My Lords, speaking as president of the Local Government Association, I can confirm that the LGA supports this amendment and underlines the importance of sound professional advice before people, particularly elder people with care needs, make major financial decisions, not least in relation to the use of their homes as a source of finance for meeting care costs.
Facilitating access to such advice, of course, will add to the duties and burdens on local authorities. That must be recognised, as with the implementation costs for the so-called Dilnot arrangements, in the financial settlement that central government makes with local government. The costs involved for local authorities may not be very great but they should nevertheless be acknowledged. With that point in mind, I am delighted to give firm support to the amendment. I am sure that, as always, the noble Earl will respond helpfully and wisely.
Lord Hunt of Kings Heath
My Lords, perhaps I may raise a couple of points with the noble Earl, Lord Howe, on this. First, to reinforce the point made by the noble Lord, Lord Best, about the cost falling on local authorities in providing facilitation to independent, regulated financial advice, there is a much more general point about the capacity of local authorities to implement the measures in this Bill. The Bill leaves us, albeit with many amendments, with an underlying concern about whether local authorities will have the wherewithal to implement a raft of new responsibilities over the next few years.
Secondly when the noble Earl argued against similar amendments on Report, he spoke of the concerns of local authorities that they might be held liable if they referred a person who comes under the Act to a financial adviser who subsequently gave poor financial advice. We have heard from the noble Lord, Lord Best, that the LGA supports the general thrust of my noble friend’s amendment. Can the noble Earl confirm, first, that a regulated financial adviser will be subject to FCA requirements and come under its disciplinary and regulatory codes? Secondly, can he reassure local authorities that they can offer names of regulated financial advisers in the way that I understand a number of local authorities do at the moment without fear of subsequent action being taken against them? I was puzzled by the argument put forward on Report and it would be good to have this cleared up at this stage.
Earl Howe
My Lords, Amendment 3 brings us once again to the important matter of financial advice. As we have covered this subject at some length previously, and in the interests of time, I will endeavour to keep my response reasonably short. At the same time, I do not intend to make brevity a substitute for substance.
My discussions with the noble Lord, Lord Lipsey, my noble friend Lord Sharkey and the noble Baroness, Lady Greengross, and my officials’ discussions with the financial services industry have persuaded me that we are all seeking the same end point for financial information and advice. I believe that any apparent distance between the positions of the Government and noble Lords on this issue reflects only the way that I have expressed our intentions thus far. We want to ensure that when people take decisions about how to fund their care it is done in a considered and informed way. We agree that the local authority has a pivotal role to play in ensuring that this happens. I want to set out what I see that role as being in the hope that noble Lords will agree that we are indeed in concordance.
We believe that the local authority should take a proactive role. What does that mean in practice? Under the new system we expect many more people, a large number of them self-funders, to approach the local authority to start their meter running. This provides an invaluable opportunity for local authorities to reach out to these people and tell them about the support that is out there to help them better plan, prepare and provide for the costs of their care. It is particularly important for self-funders that this includes the relevance and the availability of regulated independent financial advice. To pick up the word in the noble Lords’ amendment, this should be a facilitative role for the local authority, providing a nudge in an appropriate direction.
In trying to define what we mean by facilitation, I wholeheartedly agree that handing out a leaflet or placing a page on a website is not sufficient. Instead, local authorities should talk to people and use the opportunity of contact with self-funders and others to give them individually tailored advice that suits their personal circumstances. They are likely to know something about a person’s financial situation and so will be able to tell them about the range of information and advice that might be most relevant to them in considering their care options, whether that is light-touch budget planning or advice from a regulated organisation. It would not be sufficient for local authorities just to tell a person about the types of information and advice available. They will also have to explain how it could be accessed and provide information to enable them to do so.
There is more work to be done before we can finalise what the guidance will say. To get it right, we will need to work collaboratively with stakeholders, including the financial services industry. We have begun to do that already and have had initial discussions and workshops involving representatives from the finance industry. They have confirmed what we all know of some of the necessary complexity in the system, so how and at what stage a person or their family is facilitated to take up regulated financial advice will depend on how and where they have made contact to obtain information and advice. We will gather examples of best practice to inform statutory guidance to help local authorities identify the types of information and advice that different people may need, inform them of those options at the right time and help them to access them.
In addition to the call for evidence and responses to the consultation on funding reform, background work has already been undertaken over the summer that supports the development of statutory guidance. Work commissioned through the Think Local Act Personal partnership has resulted in two publications on information and advice, principles for the provision of information and advice and an interactive map evidencing the difficult pinch points in people’s typical journey through the care system.
We have commissioned detailed work with six local authorities chosen from 40 examples of current practice collected earlier this year to draw together evidence on benefits and effectiveness in developing information and advice services. A number of those examples, including West Sussex, involve directing people to regulated independent financial advice. Helpfully, the ABI has invited my officials to participate in a workshop on access to financial advice being held on 14 November, which we expect further to support the development of guidance.
I am confident that no further amendments are needed to effect what I believe is a shared ambition. The Bill sets out the framework, the skeleton if you like, but it is the statutory guidance and implementation support that will put meat on those bones. What I have set out today is what we will put into practice through guidance. This guidance will be developed in co-operation with all interests, including the Association of British Insurers and the Society of Later Life Advisers, SOLLA, which will build on the good practice that already exists in many areas. We really want this to be the product of co-development which achieves the aims that I firmly believe that the noble Lord and I share.
The noble Lord, Lord Hunt of Kings Heath, expressed concern about what I said on Report about the possibility that local authorities could be held liable in the event that a regulated financial adviser gives poor advice. He pointed out, quite rightly, that such an adviser would be covered under FCA codes, and so on. The issue here is about the local authority making a recommendation to an individual adviser. We do not consider that there is any problem with local authorities providing a list of advisers from whom a person could choose.
On the impact of local authority responsibilities, we have established a partnership with the Local Government Association and the Association of Directors of Adult Social Services and have set up a joint programme and implementation board. We have a lot of ground to cover, and I think that no one would deny that we have our work cut out over the next few months, but I can tell the noble Lord that, together, we are absolutely committed to providing the support that is needed by local government to enable it to fulfil its functions. I hope that we have achieved a meeting of minds on this matter and that what I have said today will give the noble Lord, Lord Lipsey, sufficient reassurance to withdraw his amendment.
Lord Hunt of Kings Heath
My Lords, I am looking forward to the response of the noble Earl, Lord Howe, and hope that he can reassure the House on this point. It is important that the House should be reminded that the universal deferred payment scheme was discussed on pages 65 and 66 of the Dilnot commission report, which set out an analysis and evidence supporting its recommendations. It explained why the current arrangements and deferred payment schemes were not widely used, and why in the main report the commission recommended extending the current system to a full universal offer across the country.
In its arguments, the commission accepted that local authorities should be able to charge interest and recover their costs and that a scheme would be cost-neutral to the state, although it might require an initial cash injection. Dilnot also made it clear that the Government needed to strengthen and standardise the deferred payment scheme in the light of their decision on the level of the cap, means-testing and the contribution to general living costs.
I accept that the scheme was not intended to be generally available to the very wealthy and asset-rich. As my noble friend Lord Lipsey has so convincingly argued, though, being required to spend your assets down to £23,250 seems far too restrictive to deliver a viable scheme. Indeed, as it would be of no use whatever to people of middle income, it is very difficult to see if anyone at all is going to use the scheme. My question is: why have the Government been consulting on such a figure? Does that actually mean that they do not want the scheme to succeed? Do they recognise that it cannot possibly succeed if you have to get down to such a low figure before the scheme can apply?
My only reading of why the Government have consulted on this low figure is because of Treasury concern about the initial cash injection. Is that so? Will the Minister also acknowledge that there is a question about whether in the long term—or indeed in the short term, because the scheme will begin to pay for itself within a very short time—his department thinks that there is going to be a cost-neutral scheme? It will be interesting to hear from him about why the Government seem so cautious and have been consulting on what seems to be such a low figure.
For the reasons that my noble friend has persuasively put forward, although in the end the number of people who will use the scheme may be counted in their thousands rather than their tens of thousands, there is no doubt that having a scheme available will provide a great deal of comfort to many people and their families, and it would be a great pity if this was going to be stillborn. We need to see a scheme that will be practical and will not squeeze middle-income people. I hope that the Minister will be able to reassure the House that the Government are having second thoughts in this area.
Earl Howe
My Lords, Amendment 5 returns us to the issue of deferred payments. I begin by saying that I welcome the opportunity to debate this subject again. Unfortunately, the Government’s position on it has been fraught with misunderstandings, and I would like to take this opportunity to dispel at least some of those.
First, I remind the House that a consultation on funding reform has been running over the past three months, and it closed last Friday. During these three months, officials have travelled across the country explaining our proposals and seeking people’s views. What we have put forward so far are proposals—something for people to consider. These are not set in stone. We will listen to what we have heard through our consultation, and indeed in this Chamber, as we develop our policies over the next few months.
The purpose of this amendment, as the noble Lord, Lord Lipsey, has explained, is to ensure that anyone—even people with assets of great monetary worth in addition to their main home—can have a deferred payment agreement. I have to make it clear that if one takes this amendment literally, I disagree with that principle. I do not think the public purse should be helping people who do not need financial support to pay their care fees. This would seem a long way from the Dilnot commission’s view that deferred payments should be used to support people who,
“would be unable to afford care charges without selling their home”.
For a person with a substantial sum in their bank account or substantial liquid savings, a deferred payment agreement might be a cheap loan—a convenience, one might say—but it would not be serving its core purpose.
I hope that we can therefore agree that the principle of having an upper threshold for non-housing assets is a sound and a necessary one. If we agree that this is a sound principle, all that is left to do is agree on an amount. Our consultation sought views on that amount. The noble Lord, Lord Lipsey, asked what was wrong with an asset threshold of £118,000. From April 2016, we are extending means-tested support for people with up to £118,000 when the value of a person’s home is taken into account in the financial assessment. This determines when an individual may be eligible for local authority support with their care costs. Deferred payment agreements are designed to help people to pay for their care costs; their ability to meet these costs in the short term will be dependent on their liquid non-housing assets rather than housing wealth. I can say to the noble Lord that we are happy to consider using a threshold of £118,000 as we analyse the consultation responses. We are happy to consider a range of figures.
The noble Lord, Lord Hunt, asked why we proposed the £23,250 threshold. We were seeking to identify those people most at risk of having to sell their home to pay for their care. The reason we proposed £23,250 specifically is because it provides consistency with the threshold for means-tested support when the value of someone’s home is not taken into account, and with the principle that people with non-housing assets under that amount are likely to need state support to pay for their care costs. Indeed this is the same figure and the same reasoning that the previous Government applied in their White Paper. Therefore, from that point of view if no other, it is a little surprising to hear the noble Lord, Lord Hunt, arguing against it.
There is an interesting point about people with more than £23,250 in savings. About 60% of people entering residential care are state-supported, meaning that they have only limited assets. Of the remaining 40% who enter residential care as a self-funder, less than half have liquid savings of more than £23,250. This means that the proposed threshold of £23,250 excludes only the richest 15% of people entering residential care. By increasing the liquid savings threshold to £118,000, the scheme would be available to all but the richest 5% of people entering residential care. I hope that that is a helpful contextual analysis. However, I reiterate—particularly to the noble Lord, Lord Lipsey—that we are not wedded to the figure of £23,250. We will analyse the responses to the consultation before making any further decision.
To answer the question posed by the noble Lord, Lord Hunt, about whether the scheme will actually be cost-neutral, we intend and believe that in the long run the scheme will be cost-neutral. We have committed £330 million to fund the implementation of the cap cost system, and deferred payments to cover the initial set-up costs.
I hope that in the light of what I have said the noble Lord will, on reflection, agree that his amendment would be undesirable as drafted and that he will be content to withdraw it.
NHS: EU Legislation
Lord Hunt of Kings Heath Excerpts(12 years, 3 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, I refer noble Lords to my health interests in the register. The noble Earl will be aware that this country has introduced a strong process of revalidation of doctors and continuing professional development. Can he assure the House that doctors who come to practise in the UK from other European countries will have been subject to as strict a regime as that in the UK?
Earl Howe
My Lords, the noble Lord will know that doctors from the European Economic Area are deemed to have professional skills equivalent to those of doctors trained in this country. When doctors come from outside the European Economic Area, then, indeed, the GMC puts procedures in place to ensure that the skills of those professional people match those that we would wish to see in the National Health Service.
Care Bill [HL]
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the reason for this Motion is that the Government wish to give the House the opportunity to amend the order in which we take our Report stage debates today. Last week, I became aware of some concern that my Amendment 168A, relating to trust special administration, would have fallen for debate at a rather late hour this evening. I assure the House that this was not by design and that the Government are more than happy to facilitate an earlier debate. Clearly, the issue of trust special administration is an important one. I understand the wish of some noble Lords to debate it fully in prime time. Accordingly, the Motion in my name would allow the debate on Amendment 168A to be taken at the start of today’s proceedings on the Bill. I should also indicate to the House that in response to the request put to me last week by the noble Lord, Lord Hunt of Kings Heath, I would have no objection to relaxing the rules of debate that normally apply on Report so that this amendment can be debated in full if that, too, is the desire of the House. I beg to move.
Lord Hunt of Kings Heath (Lab)
My Lords, I am most grateful to the noble Earl, Lord Howe, following my intervention last week. I made a similar proposition to the usual channels last Thursday, only to be told that there would be dire consequences for everything that your Lordships hold dear. I am glad that sense has none the less prevailed. I very much welcome this and support the noble Earl in his Motion.