Cass Review

Baroness Bottomley of Nettlestone Excerpts

Wednesday 17th April 2024 Lords Chamber

[Baroness Bottomley of Nettlestone (Con)]

My Lords, this is a deplorable situation. It is a formidably good report and I commend the Government on their firm action following its publication. I question why it took the NHS quite so long to stop the routine prescription of puberty blockers to children under 18—that seems rather slow off the mark.

However, I have a more important point. I fear that one of the great damages from all this is to one of our national and international centres of excellence. The Tavistock clinic has been in existence for over 100 years. It was started by Hugh Crichton-Miller for the treatment of soldiers with shellshock. It has been the home of John Bowlby, Lily Pincus and RD Laing. It has done incredibly important work in terms of mental distress, mental health and emotional well-being. It is a national and international centre of training, with about 2,000 students a year. If I may take up the Minister, for whom, as he knows, I have an inordinate regard, I think he said that the Tavistock clinic had closed. It has not closed; the gender reassignment clinic has closed for ever. I ask the Minister and everyone in this House to try to help reclaim the reputation and the respect that the Tavistock clinic rightly deserves.

[Lord Markham (Con)]

Yes, absolutely, and I thank my noble friend for correcting me and giving me the opportunity to correct that. Again being very honest, this shows that part of the challenge in setting up the new services is that this has become such a difficult, toxic space, and finding and recruiting staff who want to work in this area is a real challenge as well.

NHS GP Surgeries: Purchase by US Companies

Baroness Bottomley of Nettlestone Excerpts

Monday 5th June 2023 Lords Chamber

[Lord Markham (Con)]

I am not aware of any correlation between the type of ownership and the quality of the services from it. If there is one, then we can look at that, but we are focusing resources on the areas where they make most difference, and the focus is: what is the performance of that clinic? That is what we should all care about. How are the doctors there performing in terms of appointment times and everything else? I will not put a false target on who owns it and the structure of it, because that is not relevant. What is relevant is the quality.

[Baroness Bottomley of Nettlestone (Con)]

Is it not the case that the former chief executive of the NHS brought some extremely valuable experience back from America, from UnitedHealth? I remember long ago in the distant past, when the Labour Party was last in power, that Kaiser Permanente was constantly being consulted. Surely it is an arrogance to have a xenophobic approach to where we take advice and where we learn from other people’s experiences?

[Lord Markham (Con)]

I totally agree with my noble friend. I like to think that we will take advice from whoever is best placed to give it, whether they are public sector, private sector, UK or international.

Sodium Valproate

Baroness Bottomley of Nettlestone Excerpts

Monday 5th June 2023 Lords Chamber

[Lord Markham (Con)]

The noble Lord is absolutely correct. Everyone taking sodium valproate who is of childbearing age should be on a pregnancy prevention programme to make sure that those sorts of incidents do not happen. It is vital, when it is necessary for people to take it, that they really understand the risks and do everything to avoid pregnancy.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, mention has been made of the reduction in the prescription of sodium valproate but can my noble friend clarify that with a few more figures? In the report by my distinguished noble friend, which has done so much, mention was made of a redress scheme. In December the Select Committee tasked Dr Henrietta Hughes, the Patient Safety Commissioner, to bring forward proposals of what that might look like. Can he inform the House of progress there?

[Lord Markham (Con)]

I thank my noble friend. Yes, the number of cases of people of childbearing age—this is a key criterion—taking sodium valproate has reduced by 33% over the past five years. The number of pregnancies has reduced by 73% but clearly that is not zero so more work needs to be done. I was speaking to Minister Caulfield this morning about the Patient Safety Commissioner. We are expecting her report shortly and from there we hope and believe that there will be a lot more we can do on regulation.

Recovering Access to Primary Care

Baroness Bottomley of Nettlestone Excerpts

Tuesday 9th May 2023 Lords Chamber

[Baroness Bottomley of Nettlestone (Con)]

My Lords, I commend this plan most warmly. It has long been said that family doctors are the jewel in the NHS crown, but of course there has been a total transformation in the primary care team: it is not simply family doctors but a much more complex team, and the frustration so many of them feel is that they work to the minimum of their ability rather than the maximum. As I understand this, it will enable people to work to the maximum of their skills and use their training to extremely good effect.

The other great difficulty is that patients want to be treated like partners—they want information, they want contact—so opening up the opportunity to use pharmacies far more is going to be extraordinarily important. Will my noble friend say a little more about the contribution of the NHS app? Obviously, it will take time for people to be really comfortable with it, but it seems to me that this could be a transformational component in releasing family services and making them more available.

[Lord Markham (Con)]

I thank my noble friend for her comments and completely agree that this plan is all about making sure that we are using our most skilled practitioners in the most effective way. We want to make sure that those people who really need to see a doctor get to see one when they need to, but that patients in need of other treatments that can be delivered by a community pharmacist, a nurse or some other medic, such as a physio, are seen by the right people. Fundamental to the navigation of all that is the use of technology and the NHS app, as my noble friend mentioned.

What I see is the app really helping inform people—giving them their patient records so they can do their own research and understand and take ownership of their own health. We all know that, just as we have seen in the space of banking and other areas, giving people ownership, so they can take control of their health, is fundamental. Once they are armed with that information, they can be helped to navigate to the point of most use. That is where I see fundamental change: it is an area where we will see such change in the way we all address our NHS services and look after our own health. I truly believe that it will be one of the most fundamental changes we will ever see in this space.

Junior Doctors’ Strikes

Baroness Bottomley of Nettlestone Excerpts

Monday 17th April 2023 Lords Chamber

[Lord Markham (Con)]

I thank the noble Baroness. As I mentioned, we felt we had put a fair offer on the table—something that was recommended by the trade union leaders themselves. I think we need to see the overall verdict come out across the board on all this. I note that less than a third of the membership of the RCN actually turned it down in the end, so we have to see what the overall outcome is. There is an absolute commitment on our side to continue meeting constructively with the RCN and to use all means possible to get to a solution.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, those who have awarded degrees to doctors and heard them take the Hippocratic oath that they shall do no harm can scarcely be impressed by action being taken in which the public—patients—are suffering and in which enormous pressure is put on other colleagues in the health service. I, for one, think this is a very miserable occasion, and I hope to goodness that all those in the health service involved in action will think again.

I would like my noble friend to remind us about the importance of the pay review bodies, which were fought for long and hard. If we jeopardise or undermine them, that will be a long-term legacy that not only this Government but a Government of any other persuasion may pay the price for. Can he also say a little more about junior doctors and the steps being taken to increase their remuneration and deal with their working patterns?

All will agree that the health service today is extraordinarily complex. When I was Secretary of State, we spent 5% of GDP on health. That figure is now 12%, and there is not an infinite pit. I hope that reason will prevail.

[Lord Markham (Con)]

I thank my noble friend for her questions and the wise points borne out by her own experience. The impact this is having on patients is a regret to us all. On derogations, the history has been that the unions have sat down and made sure that life is protected. It is a regret that the BMA junior doctors have not done that in this instance, and that the RCN is saying right now that it is not considering derogations in its new strike. I hope that this position will change. I do not think anyone in this Chamber would want to see life threatened in this way. I know that we are doing everything we can on our end—as I say, offering more than devolved Governments—to solve this situation. I ask for good will on all sides so that we can protect patients first.

Ockenden Report

Baroness Bottomley of Nettlestone Excerpts

Wednesday 30th March 2022 Lords Chamber

[Baroness Bottomley of Nettlestone (Con)]

My Lords, this is a deeply shocking report, and I applaud the Minister for the way in which he has responded. Above all, I of course applaud Donna Ockenden for the formidable clarity of the way in which she has taken the evidence and, without emotion but with great empathy, set out the 84 recommendations and the 15 “Immediate and Essential Actions”. Of course, some of this is about resources, and the Minister has made some statements about this and the fact that, however much we have, we will always want more, but I welcome the resources invested in this.

More important to me is the issue that the Minister touched on about multidisciplinary training. Midwifery has often been an area where there is almost tribal warfare between the midwives and the obstetricians and gynaecologists. Passing a patient on to a gynaecologist has almost been seen as an act of failure. Time and again, we see delays and this ludicrous target of a low caesarean rate. There has been a phenomenal fall in maternal and perinatal mortality over 100 years, but, at the same time, women now have babies when they are older, and babies are larger. There surely must be the interdisciplinary training that the Minister has referred to and that is so important—and the working group with the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.

Lastly, I come to this deplorable culture where doctors bury their mistakes. It has always been the case in the medical profession that there has been a reluctance to acknowledge failures and problems, saying, “There’s been a problem. Let’s put it aside. Don’t trouble the families with the truth; it’ll upset them more”. This culture of concealment is totally destructive. There are many other professions where mistakes and errors—goodness knows, much of this happens in the heat of the moment—are used as examples from which others can learn, not with a blame culture but with a culture of learning and progress.

I very much congratulate the Government on their approach. This has been a terrible example of groupthink and lack of action, and all of us must be vigilant over whatever institutions we are working with in whatever part of the health service.

[Lord Kamall (Con)]

I thank my noble friend for her points. I will take this opportunity to elaborate a bit on multidisciplinary training in the maternity workforce. Some £26.5 million of the £95 million invested in maternity services last year will allow training aimed at how multidisciplinary teams work together. There is a new core curriculum for professionals working in maternity and neonatal services—this is being developed by the maternity transformation programme, in partnership with professional organisations, clinicians and service users, to address variations in safety training and competence assurance across England. A single core curriculum will enable the workforce to bring a consistent set of updated safety skills and continue to learn. It is important that we have collaboration and close working relationships between midwives and obstetricians because that obviously benefits the mothers and babies within their collective care. The noble Baroness has already said that this has to be mother-centred and patient-centred.

I also thank my noble friend for highlighting the fact that the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists have been clear that the professions must work together collaboratively. We expect all maternity services to act on the recommendations.

We also have to make sure that staff feel able to and confident about speaking up, as my noble friend said. The Government have taken this issue seriously. In response to a recommendation from Sir Robert Francis’s Freedom to Speak Up review, we established the independent national guardian, to help drive positive cultural change across the NHS and, in addition, to provide support to a network of local freedom speak-up guardians. We will have to see how that works, what can be done better and how we can improve it. Putting in one measure will not solve all these problems. There is no silver bullet, but one of the reasons to put this in at local level is to see where it works and where it does not, and what we can learn from that.

Women’s Health Outcomes

Baroness Bottomley of Nettlestone Excerpts

Thursday 8th July 2021 Lords Chamber

[Baroness Bottomley of Nettlestone (Con) [V]]

My Lords, this is an important and timely debate and I give full congratulations to my noble friend Lady Jenkin on introducing it. I start by echoing the noble Baroness, Lady Walmsley, on the requirement for urgent action following my noble friend Lady Cumberlege’s report. It is harder being a Health Minister in the Lords because there are so many experts. I chose my noble friend Lady Cumberlege and we worked together harmoniously. It is time we had a patient safety commissioner. That is part of the recommendations, only one of which has been properly implemented. We need a register of doctors’ interests.

My real purpose in speaking is to relate my experience at the University of Hull. Only one in four medical deans is female. At Hull, Professor Una Macleod is a general practitioner who still works in east Hull. She shapes and fashions the medical school so that it is relevant to the disadvantaged and underprivileged. Many in the House will know that my first job was working for the noble Lord, Lord Field. He went to the University of Hull and, for 16 years, I have been proud to be its chancellor. It is trying to reach out to the disadvantaged and neglected, who I call the inarticulate needy, not the articulate greedy, to whom I was so used in my former constituency.

I applaud much of the research, often by nurses and the professor of nursing, because nurses listen and are where the patients are. We have talked about underrepresentation in surveys, and Professor Lesley Smith has done some magnificent work on why younger women in lower socioeconomic groups are less likely to take part in population surveys. She has fashioned a tool to reach out to underprivileged, disadvantaged, less-connected and younger women so that we can understand what they need and want.

Dr Roger Sturmey talks of one in four women suffering from a miscarriage, but of only 2% of research going into miscarriage. A nursing professor of perinatal mental health said that women’s health outcomes and that of their babies are not good enough. He has designed a new measure, a revised birth satisfaction scale.

Over the years, there has been a dramatic improvement in women’s health. When William Wilberforce lived in Hull, women lived to 44. Now, the overall life expectancy is 82.7 years for women and 78.7 years for men but, as noble Lords have said, this conceals areas of neglect and suffering. It is not the extra years only, but the quality of them. I believe that, by looking more deeply and working with professions other than the traditional medical professions and by focusing our research, we can do more to meet the unmet need that so many in this House are so knowledgeable about and have contributed so strongly on.

NHS: Staff Pay

Baroness Bottomley of Nettlestone Excerpts

Wednesday 21st March 2018 Lords Chamber

[Lord O’Shaughnessy]

I thank the noble Lord for giving me the opportunity to provide that confirmation. In the 2017 Autumn Budget we set aside in the reserves £800 million a year, which will fund the first year of the Agenda for Change pay deal, and obviously if the members of the NHS trade unions accept the agreement, that funding will be released. The Chancellor will also provide the additional funding required to fulfil his commitment through the 2018 Autumn Budget and make available £4.2 billion over three years to fund the deal. I hope that gives the clarity the noble Lord and others seek.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, the Government have every reason to be proud of providing for this very substantial pay increase. However, can my noble friend remind NHS staff that, as would be the case for any other staff, with increased pay has to come change? There are no groups of employees in any enterprise anywhere who do not have to change, restructure or change the skill mix. Appraisal and training mean doing more and achieving greater productivity. We have a heroic mission to provide care free at the point of delivery to all. This can be achieved only with a much more positive attitude towards changing the skill mix, team working, and through the many other ways of delivering cost-effective care.

[Lord O’Shaughnessy]

My noble friend is right and she speaks from great experience. I emphasise that, as the Secretary of State has said, this is a something for something deal which will deliver greater productivity in return for higher pay. That absolutely has to be the right way of doing this. I also point out that there will be an explicit focus on improving the health and well-being of NHS staff, so that they are not only happier and more likely to stay in post, but more productive as well.

Health: HIV

Baroness Bottomley of Nettlestone Excerpts

Monday 5th September 2016 Lords Chamber

[Baroness Bottomley of Nettlestone (Con)]

My Lords, warmest congratulations are due to my noble friend Lord Black of Brentwood on securing this important and particularly timely debate. The arrival and availability of PrEP, the benefit that it can provide, is something that I hope we all support and strongly urge. Even timelier, as my noble friend pointed out, is the arrival of the first male Lord Speaker. I appreciate that we have had the most distinguished female Lord Speakers, but perhaps it is now time for a male Lord Speaker. We welcome him most warmly to the Woolsack. As my noble friend said, the noble Lord, of all people, deserves enormous credit for his pioneering and courageous campaign, “Don’t die of Ignorance”, the shocking, bold, unstoppable campaign of 1987.

My noble friend mentioned the noble Lord, Lord Fowler, but I want to mention one other person, the then Chief Medical Officer, an eminent physician and epidemiologist, Sir Donald Acheson. Uncompromising, he on the whole thought that Ministers had to be tolerated. As long as he got his way, which he was determined to do, he was happy and easy to work with, and he worked with great principle and distinction. When he first became CMO in 1983, fewer than 30 AIDS cases had been seen. By 1985, two years later, 121 people had died and 10,000 were thought to have the condition. That was the most phenomenal situation: the greatest new public health threat of the 20th century.

Following that was a model of the way in which a Government can decide that they are going on a war footing against a new condition. There was not only the great public health education campaign in the health service. In the voluntary sector, my noble friend paid tribute to the Terrence Higgins Trust and the National AIDS Trust, but there was also London Lighthouse, Mildmay and Landmark. It was extraordinary how the voluntary sector mobilised, rather in the way that all the children’s charities mobilised at the end of the 19th century, holding the Government to account in every area, even in the Diplomatic Service.

I took over at the Department of Health, only being half the man of the Lord Speaker, because he manfully was able to handle both the enormous Department of Health and the then Department of Social Security, now the Department for Work and Pensions. No mere mortal Secretary of State has been able to handle those two enormous responsibilities since then, but he did so with great distinction, so perhaps he will be the man to handle our colleagues’ business here. At the time, there was a real problem internationally because in many African countries, acknowledging the development of HIV and AIDS was thought to be a threat to the tourism industry. I remember going to the World AIDS Conference in Paris in 1990, when the British ambassador to France was proud in his red ribbon, which I think his mother would have been amazed to see him wear. There was a campaign to try to persuade the Russians to accept that HIV/AIDS was a serious problem in Russia. All of us in our different times have had different campaigns to handle this real threat to the human race which so extraordinarily, through the work of our scientists and the pharmaceutical industry, has become a manageable chronic condition, if only it can be identified, diagnosed and treated.

I confess to a tension I held in my term of office, because there was resistance to testing when there was no available cure or treatment. I found it very difficult because, without going into too much detail, any women in the House who have had a baby will know that you are tested for all sorts of different things without any counselling or consent; that is what we are told we have to do. Nevertheless, at the time it was felt that people should not be forced to have assessment or treatment, even if they were going into hospital for a major operation, without counselling.

I tracked down where the source of all that lay and then declared war in the most joyful way on the insurance industry. The ABI used to weight people on their insurance if they had had an HIV test. It did not matter whether the test was negative—the fact that they had been tested meant that they were high risk and therefore should pay the penalty on their insurance premium. Prince Harry would then have been a wonderful example which one could have used. I fear that I was just rather aggressive, insistent and disagreeable, but I am delighted to say that since 1994, ABI policies have been absolutely clear that a negative test is not a barrier to obtaining insurance. All the way through, we see stigma, resistance and obstacles. Together we can unite and work to overcome these many barriers and improve diagnosis and treatment.

There is no doubt that that early campaign was a model which many of us felt proud of internationally. My noble friend has pointed out that we now have more to learn from other parts of the world which are developing their services and approach faster than us, but it remains the case that, as a percentage of the population, France, Spain and Italy each have twice as many people living with HIV as we do in the UK. As my noble friend said, HIV has been responsible for the deaths of over 35 million people worldwide, including 1.1 million in 2015 alone. There is still a long way to go. The WHO reported in 2015 that there were approximately 26.7 million people living with HIV worldwide. In South Africa, Zimbabwe and Uganda, 19%, 14.9% and 7.1% respectively of the adult population is living with HIV. In the UK, it is 0.3% and in the US 0.6%, but any percentage, any number, is something we cannot tolerate without greater effort.

The UN sustainable development goals, established in 2015 to end poverty and fight inequality and injustice, include the commitment to end the epidemic of AIDS by 2030. UNAIDS has set interim targets for 2020 which have been agreed by political declaration by UN members, including the UK. This goes back to the part we can play internationally as well as nationally. Noble Lords may feel that the international is not part of the debate today, but in this extraordinarily permeable world, with mass migration, there is no such thing as looking at the situation in the UK without having regard to the international situation, such is the movement of people. Whatever the outcome of Brexit may be, I doubt we will bring an end to the mass migration of populations.

As my noble friend has pointed out, we are not doing well enough because we are still finding that one in 6 of those 100,000 people living with HIV in the UK now is unaware of it. Only 82% of those with HIV know that they have the condition. If a person is diagnosed a long time after they have been infected with HIV, it is more likely that the virus will already have seriously damaged their immune system. Late diagnosis is a huge contributing factor to illness and death for people with HIV and, if an individual is unaware of the situation, to further transmission. In 2014 it was estimated that 40% of the adults in the UK—

[Baroness Mobarik (Con)]

My Lords, I apologise for interrupting the noble Baroness, but she will be aware that this is a time-limited debate. The guide time has been increased to eight minutes but I hope she will be seeking to conclude quite quickly.

[Baroness Bottomley of Nettlestone]

I apologise to the House; such is my enthusiasm to support my noble friend in his excellent work. I had another 40 minutes of speech here, but I will now bring it to an end and simply commend my noble friend and our most distinguished Lord Speaker. I hope to support them in every way that I can.

Southern Health NHS Foundation Trust

Baroness Bottomley of Nettlestone Excerpts

Tuesday 3rd May 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, a number of serious questions have been asked. I shall make a personal observation. This trust is the result of the merger of three trusts: a mental health care trust, a community trust and a learning disabilities trust, three very complex businesses being brought together as one. They have 250 separate locations with over 1 million patient contacts every year. The risk inherent in that kind of business at this time is huge. In putting in a governance structure, we have to be very careful that we do not just draw up such structures in a boardroom or come up with strategies that cannot be implemented.

In the report, I was very struck by the fact that now there is almost a tick-box approach to the duty of candour; you tick the box to say that you have done it. Culture is usually important in this. What is the culture in the trust? That is one of the big issues that the CQC report is trying to get at. In response to the question of whether we can give guarantees about patient safety: this is inherently a very risky activity. Putting in strong governance structures is very important, but much will depend on the culture within the trust.

I turn to some of the particular points. I, too, was struck by the fact that there were still problems with ligature points in some of the facilities, as had been pointed out by the CQC some time ago. I was struck by the fact that the epilepsy protocol for those being bathed or showered had not yet been approved two and half years after Connor Sparrowhawk’s death. Clearly, there were very significant problems at the trust. On the question of where accountability and responsibility lie, the chairman has resigned. The principal job over the next three or so months will be assessing the capability of the executive management. That seems the right way to approach this.

It is always tempting to call for a public inquiry; I understand that temptation. We have an independent regulator, the CQC. The inspection team was led by mental health professionals and is fully transparent. We now have to give the trust the chance to respond to the CQC’s report and watch for serious improvements.

The noble Baroness asks if there have been any improvements. There are some illustrations and examples in the CQC report of where there have been some improvements, but putting in a new governance structure, changing the whole culture about raising concerns about those kinds of issues, will not happen overnight. Of course, I appreciate that for Connor Sparrowhawk’s family this happened two and a half years ago, and one must never lose sight of that.

A question was asked about NHS Improvement. It put in an improvement director. These people do not grow on trees. If we are honest about the NHS, we are very short of highly qualified and highly skilled senior management, and it sometimes takes time to find the right people.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, the history of people with learning disabilities and mental health problems and the institutions in which they live goes back a long way. Many appalling situations have taken place, and I do not want to belittle this deplorable situation. However, did the report also identify areas of very good-quality care and professional standards? The danger is that vilifying an institution—and even going on to a public inquiry, which prolongs the agony even further—does not give it the opportunity to build on its strengths and provide the quality of care that the hundreds of people working there wish to provide and wish to be proud of doing.

[Lord Prior of Brampton]

I am grateful to my noble friend for those comments. There are many examples in the CQC report of good care. In one of the domains that the CQC inspects, which is caring, it is clear that the vast majority of people who work for Southern Health are deeply caring, committed people. We have to be careful. I am afraid it is a question of the curate’s egg; the report is good in parts. I go back to what I said originally: an organisation this big is incredibly difficult to manage. That is one of the learnings that we need to take from this. The temptation to merge organisations to get centralised cost reduction, or whatever, is very tempting but leads to serious issues around governance.