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Lord Hunt of Kings Heath: I fully understand the reasons why the noble Lord, Lord Laming, does not want the national care standards commission to regulate the private healthcare sector. But we are determined to strengthen the current regulatory arrangements for this sector, not least to ensure the quality of care for patients. We believe that the most effective ways of doing that are contained within the proposals in this Bill.

It is clear that we shall have further debate on this subject later tonight and indeed as the Bill progresses. But before responding directly to the noble Lord, I should set out the Government's general approach to the regulation of private and voluntary healthcare.

We believe that the starting point is that those who operate private hospitals should be accountable for all aspects of care undertaken in them--both the clinical and the non-clinical services. This includes the work of doctors to whom they grant admitting rights. It is not acceptable for hospital owners and managers to seek to wash their hands of their responsibilities on the grounds that patients contract separately with consultants for medical care.

We believe that there should be a strong regulatory regime for private healthcare. There is no doubt that one of the many weaknesses with the current regulatory regime is that 100 different health authorities are responsible for inspecting private hospitals. I believe that that has led to an inconsistent approach and that some health authorities have found it very difficult to regulate private hospitals appropriately.

We believe that establishing a single body, the national care standards commission, with responsibility for regulating private healthcare across the country, will ensure a consistent and clear approach to enforcing the standards that we set. The inspectors will be focused on the healthcare sector and will develop the expertise and skills necessary to ensure proper regulation of this sector.

I know that the noble Lord would like to have a separate body--or I suspect the noble Lord would like to have a separate body--regulating the independent healthcare sector. This would have been appropriate when the Government planned to have regional commissions for care standards, as there would not have been the same expertise at regional level nor the same need for regulating private healthcare in some areas as opposed to others. But as we have decided to have a national commission, that is no longer the case.

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Her Majesty's Government very much believe that having one body regulating all the areas encompassed in the Bill is the best way forward.

Having one body regulating healthcare alongside social care will mean that the commission will be able effectively to regulate facilities that provide both health and social care, using inspectors skilled in both areas. As well as ensuring inspectors will have the appropriate skill mix, it will also benefit providers, who will only have to be inspected by one body, compared with the current system under which they are inspected by both the health and local authority.

If we set up a separate regulator for private healthcare, there would be substantial difficulty for some providers being forced to cut in half the work they do across both health and social care. For example, mental health provision is often provided across the range of care needs. Our overall approach to breaking down barriers between health and social care is encouraging providers to develop innovative and flexible mixes of provision. This would be seriously undermined if we asked providers to register separately their different provision with two different national regulatory bodies.

I hope that I have convinced the noble Lord that although he does not necessarily agree with how we have dealt with the private healthcare sector, there is every reason to include the private healthcare sector within the provisions of this Bill and encompassed within the care standards commission. We shall be returning to this issue later in debate and specifically to the various aspects of private healthcare regulation. But I hope, having heard the arguments, that the noble Lord will now agree that the clause should stand part of the Bill.

Lord Laming: I regret to say that I am wholly unconvinced. I will say that again: I am wholly unconvinced by anything which the Minister has said. That is a first.

I find myself in a difficult position because I feel very strongly about Clause 2. As we go through the many amendments relating to Clause 2, I shall feel inclined to say: "Had you supported me in removing Clause 2, there would be no need to discuss this matter".

In the light of this discussion and what the Minister has said, and the fact that we will have opportunity to return to the matter, wise counsel suggests that I should withdraw my opposition to the Motion. But I must say that I do so with an extremely heavy heart.

Clause 2 agreed to.

Lord Burlison: My Lords, I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

Lord Burlison: My Lords, before we move to the Statement on influenza, I take this opportunity to remind the House that the Companion indicates that

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discussion on a Statement should be confined to brief comments and questions of clarification. Noble Lords who speak at length do so at the expense of other noble Lords.

Influenza

4.17 p.m.

Lord Hunt of Kings Heath: My Lords, with the leave of the House, I shall repeat a Statement made by my right honourable friend the Secretary of State for Health in another place. The Statement is as follows:

    "With permission, I would like to make a Statement on the outbreak of influenza that is gripping the country and the impact it is having on NHS services.

    "As the House will be aware, the last few weeks have seen a particular strain of influenza--Sydney A--affecting thousands of people in all parts of the country. According to the Public Health Laboratory Service, which monitors the incidence of flu, it has been rising in all regions over recent weeks. The worst affected regions to date have been the north and central. Nationally in early December the numbers of people consulting their GP for the first time with flu-like symptoms stood at 40 per 100,000 population. Today I can tell the House that the latest provisional figure had more than quadrupled to 197 per 100,000.

    "The Chief Medical Officer, Professor Liam Donaldson, has advised that the official figures only reflect the people who have consulted their doctor and undoubtedly understate the true size of the outbreak. That is because heavy usage of the new service, NHS Direct, and the number of patients going to their pharmacist means many patients will not show up on the conventional GP-based tracking system.

    "The previous highest levels of influenza seen since monitoring began were in 1968-69 and 1989-90. The CMO believes that the present epidemic will not reach those levels, but he considers that there are people missing from official statistics because instead of consulting their GP they have used alternative routes of advice. That means that unless present levels of influenza activity peak soon we could be heading for the worst epidemic in the last decade. That certainly chimes with most people's experiences. There can hardly be a family in the land that has not been affected by the flu. Everybody knows somebody who has had it.

    "People also know that it is particularly severe in its effects. Professor Brian Duerdon, deputy director of the Public Health Laboratory Service, says that,


    'it is a more prolonged illness, at 10 to 12 days before people start to feel better rather than four or five'.

    "It is also having a particular impact on elderly people, some of whom have developed serious complications such as bronchitis and pneumonia. In addition to influenza, other viruses such as

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    respiratory syncytial virus (RSV) are contributing to acute respiratory illness. I am advised that RSV illness is at its peak at present.

    "Emergency admissions to hospital have risen as a result, with over 200,000 such admissions to hospitals in the past three weeks alone, an increase of almost 30 per cent over the past two months. The evidence that we are receiving from hospitals is that the patients who are being admitted are more ill than normal and are staying longer than normal.

    "This serious flu outbreak has placed additional strain on local health services in many parts of the country. In the last three weeks the number of people attending accident and emergency departments in hospitals has risen to over 600,000. There have been a quarter of a million calls to ambulance services--up almost one-third on last year--and a similar number of calls to NHS Direct over the last three weeks, many of them flu related. According to Professor Mike Pringle, chairman of the Royal College of GPs, over the millennium GP co-operatives had 50 per cent more calls than last year, mainly due to the flu.

    "These figures demonstrate very clearly that the flu outbreak has put very real pressure on NHS services. There is no doubt about that. Equally the evidence suggests that the NHS is dealing with these pressures. All acute hospitals across the country have remained open throughout the winter period. Of course both GP surgeries and hospitals are very busy.

    "The highest priority is being given to patients who are most seriously ill. As is usual and as had been planned, most hospitals have been undertaking little routine elective surgery over the last few weeks in order to be able to concentrate their efforts on emergency cases. The number of emergency admissions remained unusually high last week because of the flu outbreak and many hospitals which had planned to start surgery today have decided to delay until the immediate emergency pressures subside. Hospital managers and clinicians will make judgments about how best to balance their workload in light of local experience over the next few weeks. This approach represents a sensible deployment of NHS staff and resources. It is allowing the health service to cope with the surge in emergency demand that the flu outbreak has brought.

    "Thanks to the staff who are running critical care services, they too are coping with the demands being placed on them, despite the fact that intensive care is under very real pressure. About half of the patients being admitted to intensive care have flu or flu-like illnesses resulting in pneumonia or, less commonly, septicaemia leading to multiple organ failure.

    "This year the Government have provided a record number of intensive care and high dependency beds. We have worked very closely with the Intensive Care Society to plan critical care facilities in hospitals.

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    "Patients who need acute and critical care are being looked after. There has been an increase of 100 critical care beds this year and, with exceptional demand, staff and facilities are being used flexibly to ensure patients receive the care they need. Staff are doing an excellent job in difficult circumstances. The number of beds available fluctuates by the hour, but I can tell the House that as of mid-morning today there were 22 beds available. Local surges in demand, particularly as the flu moves around the country, will however continue to place particular pressures on critical care facilities. Where appropriate, local NHS hospitals have made arrangements with local independent hospitals for critical care.

    "Where transfers between intensive care units are required as a matter of last resort, the chief executives of NHS trusts have been asked to ensure that the arrangements run smoothly and that clinical staff are given as mush support as possible.

    "So the influenza outbreak has put particular pressure on the NHS. But the NHS is coping. As the chairman of the BMA, Dr Ian Bogle, said earlier today,


    'all parts of the NHS have been put under pressure but doctors and nurses are coping well from GP services to intensive care. The incidence of new cases of flu is uneven but wherever it is occurring it is a particularly nasty strain. Thanks to the high level of planning across the country we are coping'.

    "Of course the NHS is under severe pressure. Winter is always the busiest time of year for the NHS. This winter the NHS and social services have also had to deal with the special pressures brought by the extended millennium period. That is why planning for this winter began earlier than ever before. Local winter planning groups were established in April 1999 in every part of England to co-ordinate the planning and provision of health and social services over the winter and millennium period. Each group includes health authorities, social services, NHS trusts, primary care groups, out-of-hours and deputising services, NHS Direct, police and fire services, CHCs and other local authority departments and the voluntary and private sector.

    "Each local group submitted its plans for dealing with winter pressures by the end of September 1999. These were followed by visits from health and social care professionals from the Department of Health's Millennium Executive Team to ensure the robustness of the plans. We have extended the capacity of local health services to deal with winter pressures. Extra beds have been opened, and over the millennium period, for example, there were 45 per cent more ambulance staff on duty than the year before.

    "Winter planning has also included a major public information campaign. The aim of the campaign has been to encourage the public to use the most appropriate service for their needs--whether that be the local pharmacy and NHS Direct or indeed self-care as a complement to GP or

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    hospital services. The campaign was backed by the BMA, the RCN and the Patients Association among others. All of the evidence we have received to date suggests that the public have responded positively to this campaign by recognising that health services should be used responsibly and appropriately.

    "The campaign was also supported by a large increase in flu vaccinations made available to the public through family doctors. Flu vaccine can never eradicate flu but it can help to provide further protection for vulnerable groups. This winter 8.6 million doses of influenza vaccine were made available: a million up on last year. We do not as yet have uptake levels for flu vaccine this year but we will be reviewing them when they do become available. I have asked the Chief Medical Officer to look at ways to enhance uptake in future years. Increased use of computerised call-up systems is one possibility.

    "Over the last few weeks the NHS has risen to the challenges it has faced. That is not to say that services are not stretched. They are. We owe an enormous debt of gratitude to the staff of the NHS for making sure that services have been there for people when they need them. I hope that the House will want to join with me in thanking them for their efforts over Christmas, the millennium and now into the new year. The staff of the health service have done a quite magnificent job and I know the whole country is grateful to them. They are up against a very serious flu outbreak but I have every confidence that they will go on delivering care for patients where and when they need it".

My Lords, that concludes the Statement.

4.28 p.m.

Earl Howe: My Lords, from these Benches, I thank the Minister for repeating the Statement. At the outset, I pay tribute to the nurses, doctors and other healthcare professionals throughout the country who are devoting their efforts so assiduously to the care of patients with influenza. It is a period of great pressure in many hospitals and at times like these we are glad to rely on the skill and conscientiousness of NHS staff.

The next sentiment which springs to mind is less happy. It is that we have been here before. What are the data which have led the Chief Medical Officer to classify the current outbreak of influenza, as I believe he has done today, as an epidemic? Is that assessment the result of a collation of recent hospital statistics, together with an extrapolation of reported cases of flu patients who have either visited their pharmacists or are recovering at home having been treated by their GPS? Will the Minister tell the House what is the official definition of an "epidemic"? The figure in the Statement falls quite a long way short of the figure which I thought defined an epidemic; namely, 400 reported cases in every 100,000. I am unclear whether the definition can rest on an extrapolation as opposed to definite reported cases.

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I turn to the matter of intensive care beds. Can the Minister tell the House how many IC beds there are in the country? He said that there had been an increase of 100 critical care beds, which of course is welcome, but how many of the total number of beds are available and staffed for use as opposed to being available theoretically? How many IT beds are currently unoccupied in London where pressures are particularly severe?

I have read a report that stated that last Thursday all 275 intensive care beds in London were full. There appears to be a mismatch between beds that are nominally available and those that are actually available for use. Last week it was reported that only six out of the 10 intensive care beds at St Thomas's Hospital were available for use.

What is the Government's policy towards using the private sector? I believe that in London there are 30 empty IT beds available in private hospitals and yet flu patients are being transferred out of London--sometimes over long distances--to other hard-pressed NHS hospitals. That is a minor scandal which will not appear to be so minor if the patient being transferred happens to be you or a member of your family.

On vaccinations, can the Minister say what percentage of the elderly population has received a vaccination this winter? Can he expand on what the Statement said regarding a call-up process to vaccinate elderly people against influenza next winter? How far have those plans progressed? Does he recognise the contribution that the vaccination of hospital staff can make to reducing morbidity and mortality? Is he aware of a study in the Lancet which showed that vaccination of hospital staff could save many thousands of lives? Last year, in hospitals where half the staff were vaccinated the overall patient death rates fell to 13.6 per cent compared with 22.4 per cent in hospitals where staff had not been inoculated. How many hospitals offered their staff inoculation this winter?

I am left a little bemused by the Statement and why it has been made. Is the Statement related to the Government's pledge to reduce waiting lists? As the Statement said, elective surgery has been cut back severely. That may be a sensible response to the flu outbreak, but what penalties will be imposed on NHS trusts that do not meet the targets set by the Government? The Minister knows my views on the Government's waiting list pledge. I believe that the targets are gravely misguided. Can he undertake that such hospitals will not be penalised for failing to contribute to the Government's waiting list targets?

4.32 p.m.

Lord Clement-Jones: My Lords, like the noble Earl, Lord Howe, I too thank the Minister for repeating the Statement. I also have a feeling of deja vu. On 11th January last year, the noble Baroness, Lady Hayman, made a Statement of similar length. However, I believe that this year the politics in relation to the practical medical aspects are to the fore. It seems strange that, although there is a rising

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incidence--rather than an epidemic--the Government have announced that an epidemic is in train. I understand that "epidemic status" means 400 cases in every 100,000 people. Can the Minister explain whether or not we have reached that point or is the Chief Medical Officer simply saying that, although it is not yet an epidemic, if the incidence graph continues to rise at the current rate, we shall reach that situation?

Before asking the Minister a number of questions, I have to declare an interest. I am one of those winter pressures myself as I saw my GP over the winter Recess. I can testify to the length of the virus as in my case it lasted for four weeks and a day. I congratulate the NHS staff who have been involved, many of whom had to cancel holidays in order to assist with the enormous pressures.

Every winter it seems that the staff are asked to cope with such pressures and that we have a winter Statement. It appears that it is a tradition, rather like the 12 days of Christmas, that every winter the Government are obliged to make a Statement in a pear tree! Do the Government treat this situation as inevitable, rather like swallows in summer and the wind and rain in winter, or are they actively coping with the matter? On these Benches we cannot help but feel that declaring an epidemic status now is a way of disguising the fact that the Government are not injecting adequate resources into the NHS at the moment. There is no doubt that a full debate on the resources needed by the NHS is required.

The Government cannot simply apologise when the newspapers have filled their pages with horror stories of people having to travel hundreds of miles for intensive care beds. In some cases, people have died. It is no good the Government apologising to the House and telling us how good a planning process there has been when, in fact, the outcome of that process has been so bad. Can the Government assure us that they will review the way in which those plans were carried out? The Minister has described them, but clearly they have not been effective. There may not have been adequate resources. The scale of the epidemic may not have been contemplated.

The Minister quoted the president of the BMA. However, I can quote back to him the BMA's GP leader, John Chisholm, who said:


    "The Government is to a certain extent using this as an excuse. Underneath it there is an endemic problem, with the lack of beds and lack of staff to meet the needs of the population".

Stephen Thornton, the chief executive of the NHS Confederation, which represents hospital trusts, said:


    "It all adds up to the inevitability of a January crisis. Occupancy rates are so high, that when hospitals do get a burst of activity they can't cope. The Government is doing nothing to prevent it happening next year".

Stephen Thornton is a moderate person. He does not launch into great verbiage. He succeeded the Minister in the role of chief executive. As the Minister knows, in such a position one does not launch into tirades against the Government unless one feels extremely strongly because one depends on a good relationship with the Government.

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What happened to the beds review? I have asked the Minister that question both orally and in written form. The beds review was designed to see how many beds and, in particular, how many intensive care beds we would need in future. That has long been promised but we have not yet seen it.

When will the Government end the crude efficiency targets? The NHS Confederation has asked for that in a press release, which says:


    "NHS management is calling for an end to the crude efficiency saving targets that have been imposed on the service by successive governments--starting this year.


    Stephen Thornton ... said: 'The NHS is running too fast and hot. NHS hospitals have been encouraged by successive Governments to become more and more 'efficient'. This means that average bed occupancy has gone up from 70 per cent or so in the 1970s to over 90 per cent today'".

What chance do hospital trusts have of coping with that sort of situation? What does the Minister have to say on bed occupancy?

Can the Minister discuss also the issue of anti-flu drugs such as Relenza? We know that the Government took a firm stance on the subject. Will they reconsider the matter? It appears that such new drugs will have considerable effect at least on alleviating some of the symptoms and will certainly help to get people back to work. When considering the type of flu that the Minister mentioned in the Statement, where periods of incapacity are much longer than they have traditionally been for other strains of flu, it seems sensible to consider expenditure on those types of anti-flu drugs.

4.40 p.m.

Lord Hunt of Kings Heath: My Lords, first, I thank both the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, for their tribute to the staff of the National Health Service. The contribution of doctors, nurses, ambulance crew, managers and indeed all staff of the NHS over the past few weeks has been tremendous. I am therefore happy to endorse those tributes.

Both the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, said that we have been here before. It is certainly true that at this time of the year the NHS is particularly prone to such things as flu epidemics and this year there has been the added pressure of the millennium period. However, the Department of Health in conjunction with NHS trusts throughout the country put an enormous amount of effort into preparations to handle the potential problems that might arise this winter. Those preparations have already contributed greatly to enabling the NHS to meet the problems that have already arisen. The noble Lord, Lord Clement-Jones, referred to my previous career in the health service. I can say that in the 25 years in which I worked in the NHS I have never seen it as well prepared as it has been this winter.

The question arose as to the definition of "epidemic". As the noble Lord, Lord Clement-Jones, said, the formal definition is 400 patients per 100,000

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of population consulting their GP in one week. Last week we recorded 144 patients per 100,000 of population, but the levels are still rising. The final peak of activity is likely to reach the 200 to 400 range and it is fair to say that that range can be termed a moderate epidemic.

Throughout this period our advice to people with flu has been that it is better to stay at home and only to call the doctor if it is really necessary. Those figures are an indication of what is happening and do not aim to catch all cases. The signs are that over the holiday period--this is reinforced by messages we received from the National Health Service--fewer people may have consulted their GP. We have clearly had the added advantage of NHS Direct which, in those areas where it is fully operating, provided an effective alternative to visiting the GP. Also, our campaign, Choose the Right Remedy, encourages patients with symptoms to seek advice from their community pharmacist as an alternative to going to the GP. Therefore if we accept the likely under-reporting of flu-like symptoms because of the effectiveness of NHS Direct and the campaign to encourage people to visit their community pharmacist, there is no doubt that the health service has been under considerable pressure.

The noble Earl, Lord Howe, asked about the flu vaccine. The vaccine is offered to people of all ages with certain underlying medical conditions such as chronic heart or chest disease; to all people in long-stay residential accommodation; and to all those aged 75 years or over. Those groups are more prone to severe or complicated illness should they contract influenza. This year, exceptionally, the flu vaccine was also offered to NHS staff in order to minimise staff sickness over what we knew would be a pressurised winter period. The noble Earl asked also about the uptake of the vaccine. We will not know exactly who received the flu vaccine until later in the year, but over 8 million doses were made available by manufacturers.

The noble Lord, Lord Clement-Jones, asked whether Relenza would have helped. Our advice from the National Institute of Clinical Excellence is that Relenza's benefit is limited to merely reducing the average length of illness from six to five days. There is no evidence so far that it provides any specific benefit to older people and those who are most vulnerable to the serious effects of flu.

The noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, asked about the impact on waiting list targets and on the ability of the NHS to withstand the kind of pressures arising at the moment. The Government do not apologise for establishing waiting list targets. It must be a priority of the health service to reduce the number of people on waiting lists. We have done that successfully and will carry on doing so, but not at the expense of providing urgent emergency treatment when that is required.

The noble Earl, Lord Howe, asked how many ITU beds were available to the health service. He will know that we added an additional 100 this winter, taking the total up to 1,570. In relation to the use of private sector facilities where appropriate, many local arrangements

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are in place to use the private sector. There has never been any prohibition on NHS use of appropriate private sector facilities. Our understanding is that NHS trusts are in discussions with local private sector operators. We have no objection to that; indeed, we encourage it. In many cases, of course, the NHS is taking back from the private sector intensive care cases which may need the greater expertise and facilities the NHS has to offer.

The noble Lord, Lord Clement-Jones, quoted my distinguished successor as chief executive of the NHS Confederation in relation to finance. In fact, when the Comprehensive Spending Review was announced, he said it was beyond his wildest dreams. The three-year period of the review brought a considerable amount of extra resources to the health service. That indicates how important we feel the NHS is. It enabled us to expand services and facilities. I am confident that we will continue to see that kind of investment producing further improvement in services. It indicates the importance that the Government place on the National Health Service.

The noble Lord, Lord Clement-Jones, raised the issue of efficiency targets. Given the size of the NHS budgets, we can never be complacent in ensuring that we spend our resources wisely. It is extremely important that mechanisms are in place to ensure that the service is as efficient as possible.

4.49 p.m.

Lord Laming: My Lords, I thank the Minister for repeating the Statement. It may be because I am an innocent, but I was a little surprised that an epidemic only became an epidemic over the weekend.

However, I add my congratulations to the Government on the way in which they set about planning for the winter. Although the Minister concluded his Statement by rightly expressing gratitude to the staff of the NHS, will he also add congratulations to the staff of the social service departments, in particular the domiciliary care services? They went out of their way and are still doing so to attend to people who are not only house-bound but bed-bound. They are making extra visits and caring for people who often live alone.

The Minister said that the advice was for people to stay at home and indoors. That seems to be right, but many people who are at home and indoors need extra help, often of a personal nature. In this country we are fortunate to have home carers who go well beyond the call of duty in caring for people who are extremely dependent, particularly at this time.

Will the Minister acknowledge that local authorities have opened up respite care beds? They have also gone to great trouble to keep services going, even when key staff have fallen victim to the flu themselves. I hope that the Minister will acknowledge the contributions from social care.


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