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5 Mar 2009 : Column GC323
Grand Committee
Thursday 5 March 2009
Health Bill [HL]
Bill Information Page
Copy of Bill as debated
Today's Amendments
Explanatory Notes
Delegated Powers 3rd Report
Committee (4th Day)
2 pm
The Deputy Chairman of Committees (Lord Faulkner of Worcester): If there is a Division in the Chamber while we are sitting, the Committee will adjourn as soon as the Division Bells are rung and resume after 10 minutes.
71: Clause 12, page 9, line 30, at end insert—
“( ) The innovation prize shall not be paid for by monies deducted from existing research, training and education budgets.”
Baroness Tonge: Before I speak to the amendment, I would like to make a few general points and seek a bit of clarification on innovation prizes. Of course, everyone thinks that they are a good idea. They are one of those things that you could not possibly oppose, because we all want innovation in the health service. However, there is a slight worry among health professionals to ensure that the prizes cover everyone working in the health service, not just eminent consultants and leaders of clinical teams—that if it is to be an innovation prize, it should cover doctors, nurses, professions allied to medicine, managers and all other people working in the health service who want improvement in the way healthcare is delivered. There is also concern—I am certainly concerned—about what body will decide who gets innovation prizes, and who will decide on the composition of that body. It is important to make sure that there is a general membership that reflects the whole health service, not just the clinical side.
Having worked in the health service—not as a consultant—I worried about and saw the competition and machinations that went on about the old merit awards in the past, and saw how unfair they were seen to be. Everyone was glad to see the back of them and to see the clinical excellence awards put in their place. However, there is still a nasty taste in people’s mouths about those things, so we need to make very sure that innovation prizes are separate from clinical excellence awards and that the two do not cross over. I would be grateful if the Minister would elucidate that point for me.
It would be useful to know whether the prize will be a reward for work done, or an award in the form of a grant for a good idea that someone needs the money to implement.
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The subject of our amendment is that the money for innovation prizes must clearly not come out of existing research, training or education budgets.
The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): The amendment, jointly tabled by the noble Baronesses, Lady Barker and Lady Tonge, seeks to ensure that innovation prizes will not be funded from a topslice of existing research, training or educational budgets. The issue was raised by the noble Baroness, Lady Barker, at Second Reading. I am happy to reassure the noble Baronesses that funding for innovation prizes will be met from the overall resource envelope allocated to the Department of Health for the implementation of the commitments in the next-stage review, so it is new money as part of the next-stage review. As such, the funding available for innovation prizes—including that for administration—is all new money and will come on stream in 2010.
At Second Reading, the noble Lord, Lord Turnberg— he is not in his seat—pointed out an ambiguity in the Bill’s Explanatory Notes regarding the proportion of the budget given over to administration. I am pleased to have this opportunity to put the facts on the record. The Government intend to allocate a prize fund of £5 million per year for three years from 2010, totalling £15 million. There will also be an allocation of £1 million towards the administration, spread over the three-year period.
The noble Baroness, Lady Tonge, asked who the prize covers. It is open to everyone working in the health service and many honorary appointments—people working in the health service but not necessarily employed by it. We are aware of many people with university appointments who do full clinical work in the health service on honorary contracts.
It is expected that the expert panel will have 10 members, consisting of leading medical scientists, people in hospital management, economists and other academic representation. The panel will recruit dedicated selection committees for each prize to undertake the initial sift of entries and put the best candidates forward for that assessment. As I said on Second Reading, we are working closely with the Academy of Medical Sciences and other stakeholders at a national level in identifying the expertise required in setting up the panel as well as its sub-committees.
As I said on Second Reading, there are two types of prizes. The one in the Bill is the achievement prize, but there are also challenge prizes, which the law permits the Secretary of State to award in the form of a grant. The expert panel and the sub-committee will decide, for example, what the challenges should be in the future. We have heard numerous ideas, including how to tackle childhood obesity. The achievement prize pays towards an achievement already established or a scientific discovery that has had a huge impact on the NHS and patient care.
The prizes are very different. The distinction or merit awards are personal bonuses for a clear establishment of a scientific discovery that has had a major impact on healthcare. If you look at the history of the NHS over the past 60 years, as most of us remember during
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I believe that I have answered most of the issues raised. I hope that I have reassured the noble Baroness sufficiently for her to withdraw the amendment.
Baroness Tonge: I thank the Minister very much for that reply and apologise if he had to repeat some of the things he said at Second Reading. He must know that this sort of thing can cause a lot of feeling and debate among people who work in the health service and it is terribly important to get it clearly stated as many times as possible. In view of his response, I beg leave to withdraw the amendment.
Debate on whether Clause 12 should stand part of the Bill.
Earl Howe: I should like to spend a few minutes looking at Clause 12 in the round and, more especially, its policy rationale. Let me say immediately to the Minister that I have no difficulty accepting the argument made in the impact assessment that the NHS currently lacks an enterprise and innovation culture and that something needs to be done about that. The impact assessment advances a number of possible reasons for that situation: for example, a risk-averse mentality running through the NHS; short-termism in the way that priorities are set; a lack of the necessary leadership to support innovation; and little in the way of reward for either the innovator or the body for which he or she works.
It is thought that a series of innovation prizes may make all the difference in turning that situation around. Once people know that there is a pot of money on offer, so the thinking goes, and once there is visible evidence that innovation is regarded as being important to the NHS, people will get excited and innovative thinking will be stimulated. The idea, as we have heard, is for an expert panel to devise specific health challenges for which the prizes will be awarded and to recommend the winners to Ministers. We are led to understand that at the moment there is a legal bar to a prize scheme of that kind, which is that, although the Secretary of State has the power to award money prospectively, as with a research project, he may not do so retrospectively for work that has already been done.
I would very much welcome a more detailed explanation of that point. The impact assessment states that the Secretary of State's existing powers enable him to award grants “to backfill costs” in a research project. I am not sure what the difference is legally between backfilling costs and awarding a retrospective prize, but there clearly must be one. We are also told that it is intended to launch the first tranche of prizes during 2009,
If a prize competition for innovation can be launched in the absence of the clause being enacted, the natural question that arises is what practical difference the clause will make to a scheme of that kind. Why, precisely, is it needed?
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I have a difficulty with the general principle of public money being used to reward people retrospectively for having done something. My difficulty is the impossibility of demonstrating value for money. It is bound to be a completely hit and miss affair. You cannot know in advance of awarding the money what you are going to get for it. I know that that sounds like rather a purist view, but it is why, up to now, Treasury rules have prevented such a thing happening. In this case, at the point where the terms of the competition are set, there can be no way of knowing how many will enter or whether any of those who enter will be able to deliver innovation to a value at least equal to the value of the prize. If they do, that will be fortuitous.
We must remind ourselves that we are dealing with public money. It is not the same thing as a private individual using his personal money, which he would be entitled to splash around as liberally as he wants, regardless of whether he gets value for it.
My other doubt is whether the existence of a prize will of itself incentivise people in the health service sufficiently to imbed a culture of enterprise and innovation. I am not sure how many prizes there will be; that is to say, whether the money will be spread across several winners, in which case the amounts involved may be quite small, or whether there will be one or two bonanza wins. In either case, the degree for incentivisation of large numbers of NHS staff to launch themselves into innovation mode does not seem that great. The impact assessment talks about the prestige and kudos attached to winning and the attraction of associated publicity. I have no doubt that the Alan Johnson prize for innovation will indeed bring with it a lot of prestige and kudos, but will it imbed a culture of innovation? To my mind, much more is needed to do that than simply an annual prize.
To be fair, I acknowledge that Ministers themselves have made that point and mention is made in the impact assessment of the regional innovation funds held by strategic health authorities, and the setting up of NHS Evidence. We need to register that there still does not appear to be an agreed Memorandum of Understanding in place for the health innovation challenge fund—the Minister may correct me on that—let alone any money distributed. Equally, one has to wonder about the Health Innovation Council, whose creation was announced in October 2007. According to the DoH website, the council has met only twice and the last time was in April 2008. Personally, I still feel that the introduction of quality accounts is an opportunity to start creating the necessary culture in a way that would reach all levels of the health service very rapidly.
2.15 pm
I have expressed my fears about demonstrating value for money and the risk of disappointing levels of incentivisation arising from the new innovation prize, but let us set aside those fears for a minute. The bottom-line question we need to ask the Minister is this: if the evidence is correct and compelling that innovators need to be celebrated and recognised for their achievements, and that by this means management and staff need to understand that innovation in the NHS really matters, why do we need public money to
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- “may far exceed the cash value of the prize itself ... competitors (in other sectors) have been collectively willing to spend up to 10-16 times the cash value of a prize ... to meet the objectives”.
“This may be due to optimism bias; but it may also speak to the value of kudos in stimulating and rewarding effort”.
Is not that the central point? Are not the recognition and kudos what people really value, and is it not that which prompts them to invest what some would see as irrational amounts of time and effort in a project relative to the financial reward on offer? It is the contest itself that fires people up. If it were possible to create a national award whereby a number of award winners were celebrated and feted for their achievements, would the existence of a pot of money make the crucial difference to the uptake? I shall be very interested to hear the Minister’s comments.
Baroness Murphy: I add my note of scepticism to the notion of innovation prizes. I particularly want to ask the Minister about the timeframe. Major health innovations are often developed over many years. As regards the award of the Nobel Prize for chemistry, physics and medicine, over 10 or 15 years an innovation becomes gradually understood as constituting a fundamental change. An obvious example of that was the award of the Nobel Prize to Peter Mansfield for his MRI innovation, which has transformed the whole of imaging over the past 20 years. However, during the 20 years before he made the discovery for which he got the prize, he slogged away in a laboratory in Nottingham with nobody taking much notice of him at all. Is Peter Mansfield eligible for one of these innovation prizes? I hope so.
Many innovations in medicine have been actively opposed by colleagues in the NHS; for example, in my own field, the newer anti-psychotic medications have made a fantastic difference to a certain group of seriously ill psychotic people who were resistant to the old drugs. However, because they were so much more expensive, for many years there was massive resistance in mental health services to their being prescribed.
Are people going to apply for these prizes? I am trying to imagine myself as a consultant and my team applying for one. How much would the prize money be? Would it be enough to help us develop the service? Alternatively, would the prize be for me or one of my staff as an individual or for the whole team? I do not really understand how it is to work. However, I am interested in the timeframe. Like the noble Earl, Lord Howe, I have great difficulty in conceiving how the money attached to these prizes would be an advantage over the kudos that you are likely to experience within your peer group—your professional colleagues—as some years down the line your innovation gains recognition as a major contribution. The timeframe
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Baroness Tonge: I think that both noble Lords who have spoken are being a bit curmudgeonly about this. Prizes are much sought after, and it is a matter for debate whether for the kudos or the money. However, I do not think that anyone in the health service who wins such a prize would put the money into an offshore bank account or book a holiday to go around the world. They would plough it back into their research into what they want to do.
I have to have a little go at the noble Earl, Lord Howe, because for years the Conservative Party railed against ideas such as that children should be equal, that nothing should be competitive, that everyone must be given the same level of recognition and that it is bad to be a loser or a winner. Come on, here we are saying to people working in the health service, “Be a winner. Do something great. Think of something different”—if they have the time, that is. What I have not mentioned is that we need to have a bit of slack in the health service so that people have enough time to think of new ways of doing things. Let us be a bit more visionary about it.
Earl Howe: The noble Baroness will not hear me speak one word against the idea of a contest and having winners. My question revolved around the use of public money.
Lord Darzi of Denham: I am grateful for the contributions made by noble Lords. Let me start by reminding the Committee of our debate at Second Reading, when I clearly said that the next-stage review, High Quality Care for All, made a significant commitment to changing the culture of the NHS by stating that quality will be its organising principle. We should also recognise that quality is a moving target, and the reason it is constantly moving is because of the innovations made by both those who work in the health service and those outside who translate such innovations into patient benefits. This policy is one of many set out in High Quality Care for All through which we are trying to address the challenges referred to by the noble Earl when it comes to the culture of the uptake of innovation in the health service. I believe that it is one of the most important enablers in the effort to ensure that quality remains in a state of constant improvement. Indeed, perhaps I may share an example over the past eight years where innovation has had a huge impact: the area of cardiovascular disease.
Post the NHS Plan and during the passage of the Health and Social Care Bill in 2003, many of our debates concerned the long waiting lists for patients requiring coronary artery bypass graft procedures. I see that the noble Lord, Lord Crisp, is here; at the time, we were trying to ensure that we increased the workforce, or at least the number of surgeons who were able to perform coronary artery bypass grafts, because we had an 18-month waiting list and many patients were dying while on the list.
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It is fascinating to see what happened in the following five years. I shall go through them one by one. First, the major innovation, which was taken up in the NHS fairly quickly, was the concept of angioplasty and stents. A number of drug-eluting stents came in, and that is a fantastic example of innovation. Secondly, at the same time the statin trials were published. I am delighted to say that the bulk of those trials were carried out in this country on NHS patients, and they showed the benefits of statins. Thirdly, and I am sure there will be another debate on this, there was the ban on smoking in public places, which I am sure we will see the fruits of when it comes to cardiovascular disease. I have given the Committee three areas of innovation in five years that have reduced the overall mortality rates of cardiovascular disease in this country by 46 per cent to 47 per cent. That is why I talk about a moving target; innovation comes in, and the NHS needs to be ready for it.
I shall describe the package in High Quality Care for All. Innovation prizes are only a small part of our enablers in the system—the nudgers—to transform that culture. One of them, which the noble Earl referred to, is the innovation fund that we are about to launch through the strategic health authorities, which is, if I am correct, up to £200 million.
At the same time we are introducing a number of innovation vehicles into the health service with the creation of the academic health science centres. The Committee may be aware that this week a number of organisations have come to be interviewed by an international committee that is assessing their applications to become such centres, which are a vehicle by which universities and NHS providers can be brought together into a different type of governance structure, ultimately driving innovation in the health service. In addition, I have made reference to the health innovation and education clusters that we will be launching in due course.
I hope I have given a flavour of what innovation will be all about in the NHS in the next decade. I shall move on to Clause 12 and describe some of the specifics of the prize, how we see it being administered and some examples of the NHS’s contribution historically to innovation. Under existing legislation, the NHS Act 2006, my right honourable friend the Secretary of State for Health can currently award grants for future research purposes. That is clear. In terms of awarding prizes, the power is limited and does not extend to awarding money retrospectively to recognise and reward work that has already been completed.
I am grateful to the noble Baroness, Lady Murphy, who raised the issue of Peter Mansfield. I know something about this subject because imaging is an area of research that I have an interest in. She could not have picked a better example. It was 1967 in Nottingham when Peter Mansfield built the first MRI device. I think the point being made was that he was recognised as a Nobel laureate, but he was not recognised until 2005 for that achievement, and even then not in this country. The noble Baroness has made the case for such a prize being given to people who have made huge scientific contributions in this country. I am sad to say also that the fruit of Mansfield’s discovery did not happen in
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2.30 pm
I could make many other references. We have had a tradition of medical innovators. I shall mention three people who have had a huge impact on the surgery as we know it today. They include Florence Nightingale and Alexander Fleming. Penicillin was discovered accidentally, I know; the individual happened to work in my organisation, went on holiday and when he came back he saw the fungus. That had a huge impact. Again, that individual was not recognised in this country. Joseph Lister introduced asepsis into surgical techniques. The NHS has a proud history of innovation and innovators. We are trying to encourage that and acknowledge these achievements.
Baroness Tonge: I thank the Minister for giving way, because I cannot resist intervening. While we are on the subject of innovation prizes, perhaps we could give a prize to every person working in the health service. The book Notes on Nursing, by Florence Nightingale, would help them tremendously in their fight against cross-infection.
Lord Darzi of Denham: I am grateful for that suggestion and I would be more than happy to look into it. I could not agree more that we should look at anything that will recognise the big contributions made by many people in this country in relation to clinical care—for example, nursing, midwifery and so on. I could go on and share with the Committee the innovations that have happened over the past 60 years.
To address some of the issues raised by the noble Earl, Lord Howe, in relation to private sponsorship, I cannot see any reason why, by establishing these prizes, we will not just work in partnerships in future but even attract funding. The distinction of these awards could be so great that people in the private sector and other sponsorships may wish to work with us. Many competitors in other sectors have previously been collectively willing to spend 10 to 16 times the cash value of a prize on relevant research to meet the objectives. The best example would be the X PRIZE Foundation in 2007.
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