Health Bill [HL]

My Lords, I will be more than happy to come back to that. I cannot commit to a date while standing in the House addressing a Bill that does not specifically address this issue but, as I said earlier, we are fully committed to this. Last month the Secretary of State announced not just a commitment but a significant investment to support that commitment. We have also had an interesting and informative debate on the proposals in the Bill to introduce direct payments for healthcare. I am grateful to noble Lords for the range of experience that they have brought to these discussions, particularly the noble Baroness, Lady Campbell, for her powerful contribution. Many noble Lords have asked for further detail on the Government’s plans, such as whom direct payments may apply to, how they will be implemented, the safeguards that are envisaged and the support that will be given. The noble Baronesses, Lady Howarth and Lady Young, raised the issue of advocacy. We would expect the PCTs to work with local authorities and third sector organisations to provide guidance and support to people being offered personal health budgets. Independent or peer advocates may also have a role in supporting people through the process. Some of the evidence from other healthcare systems suggests that peer, or expert, patient involvement as advocates may be very effective. The noble Baroness, Lady Thomas, spoke from the breadth of her experience, particularly on muscular dystrophy. Several noble Lords raised the issue of other complex cases. I would like to reassure the noble Baroness, Lady Pitkeathley, that we hope to present as seamless a service as possible with those receiving social care and personal healthcare budgets. These budgets should be pooled as far as possible, as far as is practical and as far as is legal. That may require careful auditing and we will look into it further. It is one area that we need to explore as we consult on the type of pilot. Several noble Lords, including the noble Baroness, Lady Barker, spoke about intended safeguards for direct payments. We intend that, before a healthcare direct payment is issued, all parties must agree the underlying principles as well as the clear objectives of the care plan. The care plan needs to be signed off by the patient and their care plan manager. Once the direct payment is running, it should be regularly monitored to ensure that the appropriate and agreed services are being used. It would also be appropriate to monitor budgets more frequently, probably in the early weeks and months of patients receiving direct payments and less often once the user becomes an established user of health budgets. If a patient is no longer able to manage direct payments, then this should be withdrawn by the PCT and services should be delivered directly. Several noble Lords considered the Government’s plan to use quality accounts. I firmly believe that that has the potential to embed a completely new culture in the NHS. That is what I referred to as a transformational change. It excites me because it is the language that the 1.3 million people who work in the NHS identify with and own up to because it reflects the quality of care that they provide to their patients. I thank my noble friend Lady Wall for her encouragement regarding quality accounts. I reassure her that we plan to develop our approach through a close working relationship with stakeholders to ensure that our plans are pragmatic. The noble Baronesses, Lady Murphy and Lady Young, both raised points about the role of foundation trusts, their governance and the independent regulator. The Bill is designed to accommodate the inclusive design process currently under way; that includes other factors that are not in the Bill, such as the national quality board, in which we can align the system out there when it comes to having quality as the organising principle within the NHS. I very much hope that, as was pointed out, the purpose of quality accounts is not purely for regulation. I have had many discussions with the noble Baroness, Lady Young, about the role of the regulator. The regulator has an exclusive right in ensuring that core standards in the NHS are met. The potential in the quality accounts is much higher than that. The Care Quality Commission and other regulators will have an inclusive role with all other stakeholders, including professional bodies and people in the NHS, in driving forward this innovation in improving the standards of care and aspiring to excellence so that we can compete nationally, as well as internationally with many of our European counterparts. On accountability, I strongly believe that the quality accounts will hold healthcare providers accountable to the users of those services. The noble Earl, Lord Howe, discussed whether this would create a further burden in the NHS. The noble Baroness, Lady Barker, referred to the wealth of information and data that the NHS captures. I could not agree more, but there is not ownership of it by the individuals providing that healthcare. Through the quality accounts, we are trying to reignite that interest in taking ownership of the information gathered, with a very clear framework of safety and effectiveness but also patient experience. As the noble Lord, Lord Walton, said earlier, the best clinical teams who work in the NHS constantly measure what they do because that is the only way you can improve services. There is nothing novel about it and we have the opportunity now that we have made investments in the NHS to move on and focus on what we provide. On the auditing of quality accounts, a number of individuals and bodies will have an interest in the provider’s quality account and are likely to scrutinise it more thoroughly. We therefore do not believe it is necessary to require providers to have their quality accounts independently audited in order to obtain an assurance that the account is trustworthy and reliable. However, as I said earlier, providers will have to change their quality account if an error is brought to their attention, either by the CQC, the local strategic health authority or Monitor. We will also encourage providers to seek external validation, perhaps through their local PCT, their local involvement in relation to the LINks, or even the local authority to ensure that the views of key local bodies are reflected. This in turn will enhance the credibility to the user of the service. The noble Baroness, Lady Tonge, and my noble friend Lord Turnberg raised the issue of innovation prizes. Although the final decision to award a prize will be made by Ministers, it is important to remind ourselves what we are trying to achieve. We are trying to put the right incentives in the system, to encourage the NHS to come up with breakthrough discoveries. We have seen many, many discoveries in the past 60 years of the NHS. We wish to recognise these achievements or at least to put forward prizes for addressing some of the major challenges facing our healthcare system over the next decade or two. We are working with expert groups, and I am delighted to tell my noble friend that we are also working with the Academy of Medical Sciences, an organisation of which he was once the president. In response to the noble Earl, Lord Howe, although it is not in the Bill, there are many innovation policies in the White Paper published in July, ranging from innovation funds—new funding, not from our R&D budget—holding strategic health authorities legally accountable to innovation and identifying innovation metrics that we can introduce into the system, no different from the business industry and done very successfully. On the provision of trust special administrators and the points raised by the noble Baroness, Lady Young, before the Secretary of State or Monitor decides that a trust or a foundation trust will enter the regime, they will have to consult the trust, the strategic health authorities and the relevant commissioners. It is expected that any quality issue relevant to that decision will be raised through these routes. The noble Lord, Lord Walton, also raised the issue of who would take the role of a trust special administrator. It will need to be someone with the right skills and knowledge to work collaboratively with staff, patients and local and national bodies to develop a solution that will meet the needs of the local population and the wider health system. They will also need to have significant expertise in the NHS and to understand the particular challenges facing the provider organisation in question. We have had a passionate and informed debate on the important tobacco proposals in the Bill. They will form one part of a new comprehensive national tobacco strategy, which will be published later this year. I emphasise that smoking remains a serious public health challenge, a major cause of health inequalities. The Government believe they have a particularly important responsibility to empower and enable children and young people to make informed healthy choices, a right that is undermined by the marketing—that is the point I wish to make a reference to—of tobacco. The Government have carefully reviewed the evidence base, which I am sure we will discuss further in Committee. Further information will be available in the impact assessment. We consider a prohibition on tobacco display and age restriction on use of vending machines to be effective and proportionate measures in preventing premature death and illnesses caused by smoking. The noble Earls, Lord Liverpool and Lord Howe, and my noble friend Lady Golding mentioned the impact of the measures on small businesses. I reassure them that we will work with trade bodies and provide all the support needed in the ample lead-in time for compliance to minimise any burden on businesses. The noble Lord, Lord Naseby, raised comparisons between the NHS in 1997 and the NHS in 2008. I suggest that he reads in Hansard the contribution of my noble friend Lord Tomlinson. I am delighted to say that I have a copy of the missing letter sent to the noble Lord’s offices in December. I shall hand it to him. I also acknowledge the confidence of the noble Lord, Lord Selsdon, about the potential contribution of the NHS to the economy of this country. A business which has 1.3 million talented staff, spending £110 billion, has the potential to make a tremendous contribution to our economy. I acknowledge also the contribution of the noble Lord, Lord Tugendhat, in relation to the potential of academic health science centres, where we see the integration of university and the NHS. The sum is greater than the parts, and I wish the noble Lord the best in leading the new organisation. The noble Baroness, Lady Finlay, raised transplantation, which I have no doubt we will have plenty of time to debate in Committee. I look forward to seeing the relevant amendment before I address the issue that she raised. I thank all noble Lords for their contributions at Second Reading, which has provided an important opportunity to consider the main themes and issues in the Bill. The Health Bill contains a number of important measures, and I very much look forward to working with your Lordships in Committee. Bill read a second time and committed to a Grand Committee.