Health and Social Care Bill

My Lords, we come to another group of amendments that relate to the Commissioning Board. These are three separate amendments but they are grouped together because they all relate to the functioning of the board. The first, Amendment 50A, aims to embed quality and good practice in services while eliminating unacceptable variations in standards of specialist services by ensuring that the NHS Commissioning Board conducts its functions in accordance with NICE guidance. Unfortunately, we know that NICE guidance is not being observed as widely as one would hope. The amendment has been particularly strongly supported by the Neurological Alliance and a lot of other groups representing patients with less common conditions, which feel that their services are not necessarily as good as they should be. I shall give some examples from neurology. If epilepsy is suspected, the NICE guidance currently says that these patients should be assessed by a specialist, but 49 per cent of acute trusts have none. The guidance says that they should be seen urgently within two weeks but 90 per cent of patients are not seen within that timeframe. It says that they should have access to an epilepsy nurse but 60 per cent of acute trusts do not have one. With regard to multiple sclerosis, a relatively common condition across the country, 56 per cent of the 89 MS centres are multidisciplinary; the remainder are not. One-third of Parkinson's patients are waiting longer for diagnosis than the NICE guidance suggests that they should. Unfortunately, some pathfinder commissioning groups have vocalised that they do not see a need for specialist services and indeed that they are not following NICE guidance. That is why the amendment is worded as it is, with the phrase, "““in relation to specialised services””." It may seem as if that is superfluous to the wording already in the Bill, but I have worded it in that way to bring a focus on to specialised services. NICE is an independent way of establishing the evidence for best practice, and its appraisals are widely recognised around the world as being of a high standard and setting high standards. It also provides a basis on which services can be accredited. There are clinical guidelines and services can be audited so that they can be assessed on the standard that they are providing. That allows quality outcomes and patient outcomes to be measured. Amendment 63A relates to commissioning for conditions that are less common. This amendment in particular has very wide support. Quite apart from neurological disease, there are patients with haematological diseases such as sickle cell or haemophilia, conditions that are affecting children and young people into early adulthood. These patients need to be able to access services rapidly, wherever they are living. These services become part of the general haematological services available where they are, but they have to be provided to a high standard. In the past we had a tragedy with patients with haemophilia, and we see the problem of patients with sickle cell who are not appropriately treated and as a result have much more damage than they might otherwise have. There is also a risk of the inappropriate prescription of analgesics at the wrong time and at the wrong dose, which can result in long-term dependency without establishing good pain control, whereas during the acute crisis patients have terrible pain and need adequate treatment. Sadly, some of these young people have been labelled as being addicted because the severity of their pain has not been recognised. Other areas that such commissioning needs to focus on include trauma centres and severe burn units and conditions such as immunodeficiency, where again there is a critical mass for the service to be provided. Some services have improved enormously, as has happened particularly in London, but the NHS Atlas of Variation shows a 25-fold variation in anti-dementia drug prescribing across England. I give that as an example of the wide variation in care provided. Many years ago my tutor and mentor Julian Tudor Hart described in a paper for the Lancet the perverse relationship between the need for healthcare and its actual utilisation. The principle behind Amendment 63A is to try to make sure that we do not inadvertently leave the inverse care law being perpetuated once this Bill is enacted. Amendment 64ZA is the last amendment in this group. This relates specifically to emergency services and unscheduled care. This amendment has three parts which I would like to explain briefly. First, the amendment seeks to ensure that emergency health services are adequate for the population served. Until recently, emergency departments have tended to be placed in a rather ad hoc way, but work done in London, which has designated emergency services and major trauma centres, has been shown to improve clinical outcomes for patients. These have been calculated on a population needs basis. The second part of the amendment recognises the importance of integration between emergency care and specialised networks and associated specialties. This is particularly important because the emergency department sits on a spectrum of provision. Patients may be seen in primary care and may be sent in to the emergency department either in or out of hours, but there is good work to show that it is only 10 to 30 per cent of cases that could be classified as ones that could have been dealt with in primary care. However, primary care is increasingly taking a gatekeeper role. With a shortage of beds and a decrease in resources, there is also a rationing role in the other parts of secondary care. The third part of the amendment relates to emergency departments. The one place that remains with its doors constantly open with no gatekeeper role and with open access is the emergency department. Patients increasingly turn up in the emergency department with acute conditions that need management and treating. These conditions are completely undifferentiated, unscheduled and range from the most severely life-threatening to others which certainly need to be treated fast. These can be less immediately serious, although if they are left inadequately treated they can become life-threatening in a remarkably short time. The nature of unscheduled care means that these patients have to be planned for in consideration for the way that primary care is working, in and out of hours. Where out of hours is inadequate more and more people will go to the emergency department or may indeed be advised to by telephone triage services, but they may be inappropriately advised. This accounts for the range of 10 to 30 per cent of those who could have been treated in primary care. I understand that the Commissioning Board is developing a clinical outcomes framework. That should make a link between the national framework for the Commissioning Board and the clinical commissioning groups, with consultation on NICE indicators, some of which have already been developed for primary care. This clinical outcomes framework should also provide guidance for clinical commissioning groups on how to commission emergency care locally. I hope that the Minister will be able to assure me that this guidance will continue so that work with the colleges, particularly the College of Emergency Medicine, will contribute to the whole commissioning framework. Emergency medicine is different from other parts of the service because competition is not appropriate and choice, as we talk about it in other parts of the Bill, does not apply. People who need emergency treatment need to be taken to an emergency department that can deliver a service to meet their clinical needs. These patients may be unconscious; they certainly cannot choose where they will go. They also need to be assured that every emergency department to which they are taken will meet a standard that will provide them with the care that they need. Competition has also been shown to be inappropriate. Breaking the Mould without Breaking the System, a document that was published last year by the Primary Care Foundation and the NHS Alliance, pointed out that tendering in emergency medicine results in a decrease in the quality of services because it is expensive, costing around £100,000 for the commissioner and each provider involved. The document also pointed out that the quality of care is driven up by working with providers to look for incremental improvements, rather than by going out for a competitive tendering process. This document is very helpful to commissioners because it also points out how triage is less safe than rapid see-and-treat processes and is used to compensate for delays caused by poor capacity planning. When accident and emergency departments are overwhelmed the admission rate goes up, but a well functioning department will be able to decrease the number of admissions. The number of patients retained overnight needs to be looked at in relation to the severity of their conditions and not as an absolute number. Without good services for the frail elderly and without somewhere else for patients to go to be observed, they need to be admitted into observation wards overnight because they often deteriorate rapidly, particularly those whose symptoms and history suggest that they are on the cusp between potentially improving and potentially deteriorating. If they are sent home, they may be at great risk. There is a need for collaboration from primary care right through to secondary care. The problem is that without incentives for primary care to improve home-care services for the frail elderly and out-of-hours services, an increasing number of these patients will end up at the doors of the emergency departments, as happens at the moment. With the decrease in the number of beds, it becomes increasingly difficult for them to be placed anywhere, yet they are often too frail to be sent home at midnight or in the early hours of the morning and need to be kept in overnight. Emergency medicine acts as a portal. The vulnerable come in with their life stories. There is no pressure group to argue for patients who access emergency medicine because they are a completely heterogeneous group. Disease groups, such as those for neurological diseases, cancer, diabetes and so on, can argue for their patients but emergency medicine covers just about everybody. It has been estimated that, on average, a member of the population accesses an emergency department once every three years, compared to once every six years for out-of-hours primary care services. Therefore, I hope that the Minister will be able to reassure me that emergency medicine will be looked at in its totality and across the spectrum from primary to secondary care; and that commissioning will take into account that it is in a different position, with its constantly open access portal, from the other services in the NHS. I beg to move.