Menopause

Baroness Brinton Excerpts

Tuesday 18th October 2022 Lords Chamber

[Lord Markham (Con)]

I agree that we want to make sure that there is national access. I understand that, whereas we had 30% take-up as long ago as the 1990s, with the incorrect scare around some of the causes since then, that rate is only about 15% today. There is clearly a need to increase awareness and the ability for people to receive treatment.

I am aware of the issue around formularies; I have heard that they believe that it can be resolved. I will take it away and write to the noble Lord to make sure that it is properly dealt with.

[Baroness Brinton (LD)]

My Lords, in the initial Answer that he gave to the noble Baroness, Lady Thornton, the Minister said that access to support during the menopause is vital. Does he therefore agree that, for health and economic reasons, the menopause should be added to the quality and outcomes framework to encourage doctors to investigate and treat patients who present with symptoms associated with the menopause?

[Lord Markham (Con)]

Yes. The noble Baroness will be aware that only 55% of women showing symptoms felt able to talk to GPs about it and another 30% felt that there were delays in diagnosis. Clearly, more work needs to be done. I know that it is part of the core curriculum—that is not the proper phrasing; please excuse me. The whole point of appointing a women’s health ambassador is to make sure that every avenue and channel is used to maximise access, whether at the level of GPs or as part of the education or formularies.

Edenfield Centre: Treatment of Patients

Baroness Brinton Excerpts

Thursday 13th October 2022 Lords Chamber

[Lord Markham (Con)]

My Lords, I completely agree with the question in making sure that this does not happen or is not happening elsewhere. We have been in touch with the CQC, as one would expect, which has made significant changes to protect people in specialist services, people with learning difficulties and autistic people in mental health patient settings. These include making it mandatory for all staff to undertake specialist training before inspecting these settings and introducing a new single assessment framework, which would allow more frequent inspections of the worst-performing providers. The CQC is doing a number of things around that framework, including six key evidence categories, which set out the type of evidence that will be collected. These categories are: people’s experiences; feedback from staff and leaders; observation of care; feedback from partners; processes; and outcome of care. The new assessment means that more targeted time can be spent on site, taking longer to talk to people using services and making every minute count.

Those are some of the standing replies. On a personal level, there clearly need to be questions about how the CQC can go in on an ad hoc basis because, when an investigation or inspection has been announced, a place has an opportunity to put things right. One area of my interest—and I do not claim to be an expert on this—is how we can pick up those ad hoc cases quickly. Clearly, we should not be expecting people such as “Panorama” to be doing that; we want to pick those up ourselves.

[Baroness Brinton (LD)]

My Lords, despite the Minister just commenting on the way it is possible for some organisations to game-play inspections, it is noticeable that the CQC inspection of 2019, published in 2020, was “Good”, despite the finding that,

“In acute wards … records did not show that supervision of staff in the service was effective”,


which was a “breach of regulation”. This is really concerning.

Reform of the Mental Health Act is long overdue. It was created over 40 years ago, and many noble Lords have been fighting for that to happen. It was good to hear in the Queen’s Speech that there will be a draft mental health Bill, but there are real concerns that it is about to be shelved. My honourable friend Munira Wilson MP asked the Minister responding to this Urgent Question whether it was going to come forward. She did not get a straight answer. I ask the Minister whether Parliament, and this House in particular, will see the mental health Bill this Session.

[Lord Markham (Con)]

My Lords, like the noble Baroness, I am aware that the White Paper is in draft, but I have not seen its latest status. I know it will address some of the issues that we all agree are not to our satisfaction. At the moment, I can undertake only to understand the position of the White Paper and come back to her, if I may.

Skills for Care Report

Baroness Brinton Excerpts

Thursday 13th October 2022 Lords Chamber

[Lord Markham (Con)]

The noble Baroness is correct that a number of people are on zero-hours contracts. As I am sure she is aware, their employment is through a number of agencies and local authorities, but it is an issue in a number of places and goes to the wider conversation about how we make this sector an attractive place to work. Earlier, my colleague mentioned the Skills for Care working group, which found that a significant proportion of all employers—around 20%—have a turnover rate of only around 10% versus the 29% average. So, clearly there are areas where certain employers do a fantastic job of not only recruiting but retaining, and making the sector an attractive place to work. I believe that the whole emphasis of the conversation we are having now is exactly about how to make this sector an attractive place to work because, as we all know, it is a vital part of our care and health system.

[Baroness Brinton (LD)]

My Lords, the Minister referred to the £500 million investment in social care but this is only his fourth day in the job. Many people in your Lordships’ House know that that money is for winter pressures and was omitted from the budget for the NHS and social care at the beginning of the year. Without it, social care would be in even deeper trouble than it is now. The noble Baroness, Lady Chakrabarti, made an extremely important point about zero-hours contracts. The problem of staff working in domiciliary care is that there is not enough money even to allow them to be paid for travelling between clients. There is a real shortage of money. This is a group of dedicated workers who are being treated very badly. Will the Minister undertake to look at this particular problem?

[Lord Markham (Con)]

Any industry with the sort of turnover rate that was mentioned earlier demonstrates that there is a need to look further into it, so I absolutely accept the premise of the question and, as I mentioned before, the importance of this area. As I have said before, this is also about looking at areas of best practice because we can always look to spend more money but we know that there are limitations on the public purse. I would not be doing my job if I did not try to see where we can learn from good employers, employ those practices and see whether we can spread them wider so that everyone has the same level.

The other point that I made previously was about opening this up. We know that our healthcare system is founded on good workers from all around the world. They can be a bedrock. I am delighted that we are looking into that area now. We are starting to see good numbers of people coming in from abroad. It is an excellent level of entry into our country. There are a number of things we can do to improve the situation but I completely agree with the noble Baroness on the importance of tackling it.

Pharmaceutical Research and Development Spending

Baroness Brinton Excerpts

Thursday 13th October 2022 Grand Committee

[Baroness Brinton (LD)]

My Lords, I too congratulate the noble Lord, Lord Hunt, on securing this debate and thank the noble Baroness, Lady Wheeler, for stepping in at such short notice and giving us such a comprehensive introduction. I also thank the ABPI, Roche, STOPAIDS, dementia awareness and the Lords Library for their very helpful briefing.

Four decades ago, I was a manager at Newmarket Venture Capital in the City. We funded the first wave of spinning out monoclonal antibodies. I remember one of the senior managers involved with it saying, “This will transform pharmaceutical treatments over the next few years”. She was right. A hundred years ago, my great-grandmother, who also had rheumatoid arthritis, had been told there was no treatment other than gold injections. She was in a wheelchair and unable to use her hands because they were so badly deformed.

Twenty years ago, I started on disease-modifying drugs and these days, along with many other people with my condition, I use a JAK inhibitor, which is a tablet that I take once in the morning and once at night. I used to have to spend a whole day in hospital having my infusion of a monoclonal antibody. We need to recognise the enormous advance in pharmaceutical work that has transformed the work of the NHS. It has reduced the number of beds needed and addressed a large number of other issues. But only one in 10,000 compounds and only 7.9% of medicines that get to clinical development actually make it to approval. It takes around eight to 12 years from initial discovery to launch, although I really hope that we have learned some lessons from the Covid pandemic and are able to start speeding things up somewhat.

Between 2015 and 2019, 43% of NICE recommendations were optimised for access to new medicines. This meant that they were recommended for a smaller patient population than the medicine had originally been approved for by either the European Medicines Agency or the MHRA. Of those optimised recommendations, around two-thirds recommended treatment in less than half the approved population. So, from a patient perspective, in the UK, a large number of patients are not getting access to the treatments that have been approved. The uptake of new medicines is a major concern. For more than 75 medicines recommended by NICE and launched between 2013 and 2019, the per capita utilisation in the first three years was around 64%, which was around the average in 15 comparator countries.

I want to focus on advanced therapy medicine products, the use of data and the voluntary pricing system, also known as VPAS. Advanced therapy medicine products are new, revolutionary medicines based on genes, tissues or cells and have the potential to save, lengthen and improve patients’ lives by treating the root cause of diseases. But they present challenges to health systems because they are so different from traditional medicines. Because they are used as a one-time-only treatment, they have a very high up-front cost, particularly if it takes 10 to 12 years to develop them and possibly up to £1 billion in research costs.

Currently, only a very small number of ATMP treatments are on the market and the NHS is managing to provide access despite these challenges. But, looking at monoclonal antibodies and the way that they are used now, it is likely that ATMPs will become the go-to drug for the future. Unfortunately, already we are behind other countries such as France, which is taking a very forward-facing example. France introduced a measure in its 2023 social security financing bill to allow innovative payment models to be used for ATMPs to share the risk between the manufacturer and the healthcare system.

We must not forget the transformative use of global pharma R&D, especially that which has been developed in the UK, in the spend on the wider world. It is one of the big lessons that we learned from the Covid pandemic. Oxford’s early R&D for the vaccine platform became the AstraZeneca vaccine, but unfortunately those technologies were unobtainable and inaccessible to most of the globe. Many noble Lords present spoke about that in your Lordships’ House during the Covid pandemic. We must make sure that that does not happen again, so I ask the Minister, what lessons have been learned from developing these drugs and how can we share that technology, probably through TRIPS waivers and other systems. in the future?

On data, during the passage of the Health and Care Bill, many Members across the House discussed the use of patient data and the safety net that we needed, but there is absolutely no doubt that the NHS has unique potential, given its large and diverse patient pool, to be one of the most effective engines for research. The Data Saves Lives strategy, announced earlier this year, is a good vehicle to overcome these barriers, and it was very much welcomed by the pharma sector. In implementing the strategy, I hope that the Government and the NHS will work to ensure that the national trusted research environment is fit for purpose, and has the necessary functionality to enable safe, high-quality research and the use of advanced analytical tools to derive insights. I am particularly concerned about this after the patient data—the care.data—and the GP data débâcles of this year and five years ago. It is really important that patients’ data can be protected.

Briefly, on VPAS, the Voluntary Scheme for Branded Medicines Pricing and Access between the UK Government and the pharmaceutical industry has historically been very useful, but Roche says that fluctuations of spend are now causing a rapid increase in VPAS payment rates, undermining the industry’s ability to sustain and invest in the UK. There has been a 10% jump from 5% to 15% over the last year and, worryingly, there is a projection that this may increase to over 30% next year. The worry is that this will impact the whole of the sector. Can the Minister say whether the Government are discussing VPAS with the extended life sciences sector?

NHS: Winter Challenges

Baroness Brinton Excerpts

Monday 10th October 2022 Lords Chamber

[Lord Markham (Con)]

We are facing unprecedented challenges, as the noble Lord states. We also have unprecedented investment, a plan for patients which is focused on the key elements that will make a difference—ambulances, the backlog, care, and doctors and dentists—and a group of Ministers who are focused on making a difference where it really counts. We have record investment, and a record number of doctors, nurses and people ready to face those challenges.

[Baroness Brinton (LD)]

My Lords, the plan for patients refers to the expansion of virtual wards in hospitals this winter. My local hospital, Watford General, pioneered this in 2020, but it put considerable pressure on GPs, community nurses and social care. Will there be extra funding for those areas that have virtual hospitals this winter to make that work?

[Lord Markham (Con)]

I had the pleasure of visiting Watford General just a week ago, and I saw the virtual wards first hand, so I agree on the excellence we saw there. To give the House a sense of that, the wards have reduced 90-day readmission rates from around 45% to 7%. When I talk about performance improvements, those are precisely the sorts of areas in which I wish to see investment made, so that we can roll that out across the NHS. It is in those areas that we can make a real difference.

Health and Social Care Update

Baroness Brinton Excerpts

Monday 10th October 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, it may have been some weeks since this Statement was made in the other place, but its subject matter is as relevant today as it was when it first saw the light of day. The big questions remain: among them, where are the costings and how will it be funded?

The NHS is facing the worst crisis it has ever seen, with patients waiting longer than ever in A&E, stroke and heart attack victims waiting an hour for an ambulance and some 378,000 patients waiting more than a year for an operation. Those figures date back to the summer—before we even get to the winter and the challenges winter always brings.

At the time of the Statement, the NHS Confederation’s verdict was that

“these measures will not come close to ensuring patients who need to be seen can be within the timescales set out … they will have minimal impact on fixing the current problems that general practice is facing over the winter”.

But has not the situation got even worse since this Statement was first heard? The scale of the challenge faced by our health and social care services, the people who work in them and the public who rely on them has worsened as the state of the economy worsens. The country is now experiencing spiralling inflation which far exceeds the assumptions on which budgets were set, while those who work in the health and care services are struggling with the cost of living. What will be the response to this? How and where will the so-called efficiency savings demanded by the Treasury be found?

What we do know is that the impact will not be equal. As the right reverend Prelate the Bishop of London addressed at the weekend, it has been reported that the Government’s long-promised White Paper on health disparities has been dropped. Can the Minister confirm this? If that is not the case, can he advise on when can we expect this crucial plan to narrow the widening inequalities in health outcomes between the poorest and the wealthiest, between white and black, Asian and minority-ethnic people and between those in the north and south?

The Statement says that patients will be able to get a GP appointment within two weeks, but let us remind ourselves that, prior to 2010, the guarantee of an appointment was within two days, not merely an expectation of two weeks. Can the Minister provide more detail as to how the two-week expectation will be met? I ask this in the context of the record numbers of GPs indicating that they will be retiring or leaving the profession, where burnout and low morale are at an all-time high. How will the numbers stack up when 4,700 GPs have been cut over the past decade, and the long-promised 6,000 GPs are not on course to be delivered? With 330 practices having closed in just the last three years, where will these appointments take place? Are there plans to open new practices?

The gaping hole at the heart of the Statement is, as we know, the lack of a workforce strategy. In the ABCD plan presented by the Health Secretary, the only reference is under D, which refers to doctors and dentists. They are important—there is no doubt about that—but what about the nurses, paramedics, technicians, care workers, cleaners and caterers? Without a plan to tackle the whole staffing crisis, there is not a plan for the NHS.

What are the Government going to do about the staff shortages of 132,000 in the NHS today? This cannot be overlooked. Earlier today, the Minister told your Lordships’ House that there were 200,000 more staff in the NHS than 12 years ago. Perhaps he could elaborate further. Are these full-time equivalents? Where are they and what roles do they perform? Crucially, does the Minister accept that there still needs to be a fully costed plan to deliver the workforce that we so desperately need?

The Statement refers to some £500 million to speed up delayed discharges. Can the Minister help with some more detail on this? Is it a new investment or a re-announcement? How will it be funded? It is indeed right to say that if patients cannot get out through the back door of the hospital because care is not there in the community, we get more patients at the front door and more ambulances queuing at the front. That is exactly the situation we see today. The crucial point is that unless the Government act on care workers’ pay and conditions, employers will not be able to recruit and retain the staff they need. What is the plan to address this?

Finally, can the Minister reassure the House and patients across the country that the response to the crisis in the NHS will not be to lower standards for patients but to raise performance instead? I am sorry to say that this Statement misses the target. I hope the Minister will reflect on the points that I have raised, and other noble Lords will undoubtedly raise, and take the opportunity to use his new and important position to make proper change and improvement.

[Baroness Brinton (LD)]

My Lords, I echo the comments of the noble Baroness, Lady Merron, about the nature of the plan. It is full of warm words and aspiration, light on detail, especially on funding, and seems to disregard the reality on the ground at the moment. I also echo her concern about the rumours of the White Paper on inequalities being shelved. That is really important. Many of us spent a lot of time in your Lordships’ House during Covid hearing about the problems of people with Covid, particularly those from ethnic minorities and deprived backgrounds. There is a lot of data to say that those people have really struggled.

The workforce plan is something else that from these Benches we asked for consistently long before work started on the Health and Care Act, but absolutely consistently since then. Turning to the plan itself, on ambulances, the announcement in July was welcome but three months on—and this was an emergency announcement—it feels as if nothing has changed. The number of delayed discharges remains stubbornly high, and we know that there is a new wave of Covid rising: the ZOE study figures today suggest around 230,000 new daily cases and 2.2 million active cases. That is going to continue to rise: all the medical experts in this area say we are now definitely at the beginning of this wave.

B stands for backlogs, and I am afraid that that is not really improving either. Although it is good to see that the two-year waiting list is reducing, the under-two year list continues to grow: 6.8 million at the end of last month. The plan talks about patients being redirected from hospitals, but our primary care system—GPs, community nurses, physios, speech and language therapists in the community, and especially social care—is already at breaking point. It is good to be offering Covid boosters, but why are under-12s excluded unless they are immunocompromised? Children at schools without proper ventilation were drivers of the last two waves of Covid, and it just seems ridiculous that they have not been included, because that would be an easy win.

In my question earlier today, I asked the Minister about care and particularly about virtual hospitals. It is good that the plan is picking up on some excellence in the NHS, and I am very proud of my local hospital for doing it, but the Minister did not actually answer my question, which was: given that this work of virtual hospitals creates more work for GPs, community nurses, physiotherapists in the community that in the past would have been done in hospitals, will there be extra resources for primary care? Without it, primary care is already at breaking point; they cannot just magic extra time and energy to do it.

The section about GPs is admirable in spirit, but doctors have repeatedly said that their main problem is a lack of doctors. We also know from the BMA survey back in the spring that GPs’ workload has increased by 30% on clinical administration alone. It is not Covid; it is mainly to do with digitisation and complex systems. It is all very well talking about getting administrators in to do it, but these are administrative tasks that doctors have to do themselves. Unfortunately, it is causing a problem, and I do not see any solution in the plan.

Whenever Ministers talk about doctors, they talk about the highest number ever—indeed, the Minister did so earlier—but there are two problems with that. There are more patients than ever, and that is never reflected in any comments by Ministers. Government funding for doctor training has not been sustained. This year, far too many—hundreds, just under 1,000—newly qualified doctors, fresh out of university, could not get training places because there was no funding for hospitals to be able to do it. The exodus of NHS staff was reported in the Times just last Saturday. The net change is not positive now; it is negative.

On dentists, it is very good news about the simplification of government rules regarding overseas dentists qualifying to work, and we look forward to seeing the regulation shortly, but the main problem is the drastic need to overhaul the government contract. While the Statement says first steps are being taken, I ask the Minister when the major work funding for it will be concluded. Will he also tell your Lordships’ House what provision there will be for the 3 million people who are either immunosuppressed or immunocompromised—for example, because of blood cancer or because of strong medication which has to suppress their immune systems? The government advice on the web page still says that people in this group should not mix with people who are not fully vaccinated or may possibly be brewing Covid, but a year ago all support to this group was ended. Along with other people in this group, because I am one of them, I am about to have my sixth Covid jab, but I have no idea how long I am going to be protected for—that is why I wear a mask a lot of the time in the Chamber. Half a million of the most severely immunocompromised people cannot make any antibodies in response to the vaccine. They were promised antiviral medication or Evusheld. Five million doses of antivirals were ordered, but only 50,000 were handed out, and the Government have just refused to allow Evusheld to be used. What will the Minister do to ensure that this group of people will be protected?

Finally, the Health Service Journal has said that two out of three integrated care systems have fallen off track on their financial plans because of the impact of inflation, Covid cases not being funded this financial year and higher spending on agency staff. This plan will not work if the new integrated care systems cannot work. It is vital that the Minister tells us what plans there are to make sure that ICSs will be supported properly.

The plan for patients has many warm words for delivery. I know this is something the Minister cares greatly for, and we will support him, but the words on their own will not do it. Our NHS and care sector are on their knees already. The Nuffield Trust report says that data shows that even without the pandemic, the backlog would have been well over 5 million. It says the NHS was already stretched. I look forward to hearing the Minister explain how the NHS and care sector will be able to deliver on this plan in their current state.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

I thank noble Lords again for the warm welcome they have all given me today. I feel like an old hand already—I wish. Before I begin, I draw attention to my declaration of interests in the register as a new boy here, so to speak.

I am grateful to noble Lords for the interest they have shown in our plan for patients and will try to address the questions raised. As my right honourable friend the Secretary of State said in the other place, these measures across a number of important areas are the start, not the end, of our ambitions for health and care. They will help us to manage the pressures that health and care will face this winter and next, and they will improve these vital services for the long term.

First, I want to set down that there is record investment going into this area. In fact, we are spending about 12% of our GDP, which is the highest level ever. To answer the noble Baroness’s question directly, the 200,000 figure I gave was for FTEs since 2010. That means 200,000 more full-time equivalent employees in the health services than in 2010, so the investment is there, and we have a plan, set out in the plan for patients, to increase supply by 30% in terms of electives. I have seen some excellent examples of that already in Chase Farm Hospital, one of the new hospitals.

As I think I mentioned earlier, the new hospital build programme is one of the areas for which I am responsible; a £10 billion investment per year will go into capital programmes such as this and other initiatives. It is all about increasing supply by 30%, because we will be able to get on top of these issues only if we increase supply.

At the same time, as has been drawn out, I appreciate that we face an unprecedented challenge in the levels of Covid we are seeing and in flu respiratory issues; we have had less warning about that than ever before, because normally we can see what happens in Australia and use that as a warning. I am aware that we are likely to face more challenges there than ever. At the same time, we are putting forward the beginnings of a long-term plan to tackle this. I will talk about that and, I hope, answer the questions raised—my own ABCD, if I may.

I will start with care, because not only is it important in its own right to make sure that people are cared for in the correct place—it is much better and more cost effective for people to be in a care home than in a hospital—but freeing that up will free up the whole system. We all know the problem is often that A&E is full because it cannot put patients into hospital beds and therefore the ambulances cannot release their patients into A&E, backing up all the way through the system. That is why one of my priorities is the care side.

I will need to get back to the noble Baroness, Lady Brinton, on virtual wards in terms of support for GPs. I have seen the excellence at first hand, and the incredible reduction in figures that it can make, so to my mind we should focus on that and make sure that GPs and their surgeries have the right focus and support to help them. I will follow up with the noble Baroness with more detail on that, if I may.

I see this as key to care and the £500 million spend—again, I will give the noble Baroness, Lady Merron, details of how that is being used, because we want to make sure that we work with the integrated care boards, as she said, to ensure that it works to best effect. With that, I think we will start to see improvements come in for A&E and ambulances. As I mentioned before, we have seen a 10% increase in staff there versus 2019-20; that is what the 7,000 new beds are all about.

However, in terms of performance, we have seen great disparities. I am sure noble Lords have heard before the statistic that 15 of the hospital trusts account for 45% of all waits. I want to understand why that is. It is fair enough to trot out that statistic—I expect noble Lords to challenge me in a couple of months’ time to ask what was happening in those 15 trusts and what I have done to put it right and make sure they are performing well. My task is very much to put them under the spotlight and try to understand how we can perform much better in some areas and take those learnings to help them in others. I am under no illusions that it is tough out there. My wife is a dentist, so I have some knowledge of this; also, my mother was a practice nurse, so I understand how important and tough the role is.

Working through the backlogs and getting on top of the waiting lists will be key. There is an £8 billion programme, as we are all aware, to increase supply by 30%. I have seen fantastic examples at Chase Farm, as I have mentioned, and Watford of robotic surgery—I had the pleasure of playing with it myself, though not on a real patient—that I am sure will be revolutionary and transformative. It is about doctors, dentists and all care workers—all of them. As I say, I have a particular interest in the nursing profession.

It is all about releasing the 50 million more appointments, which I am glad to say we are making progress on. A lot of that is about making sure that you see the person best suited to meet your needs. We must make sure that we use GPs where they will best meet those needs. They are our most skilled specialist resource, so I want to make sure that they are focused on the cases that are best for them. As I say, I have experience through my mother’s role as a practice nurse of how much she could do and how much we can use them to meet a lot of the appointments targets—and make it a better job for them, because they have the skills and can be very valuable. The same is true of community pharmacies. Funnily enough, I worked at one in my first job—many years ago—so I have a little experience of that. It is all about trying to expand capacity.

I apologise, I cannot answer the noble Baroness, Lady Brinton, right now on the 3 million immunosuppressed so I will need to get back to her on that.

As the noble Baroness, Lady Merron, said, it is about trying to raise performance across all areas. The brilliant thing is that we have seen very good areas—I am sure we have all seen them when we visit hospitals—which have excellent performance, but my feeling, coming in as a bit of an outsider from business, is that it is patchy. There is an opportunity to spread that performance, really understand what good looks like and do more work to make sure that it is spread across the system. Part of my remit will very much be the performance agenda and working with the NHS executive team to make sure we see those improvements across the board.

I hope that gives noble Lords a flavour of how I hope to address what we see as our plan for patients. It is our commitment to what our patients can expect. I hope we can see that it is proactive, not prescriptive; ambitious but also achievable. We hope that, by empowering patients, they can start to challenge and drive performance as part of that, as a first step. Through that, we will be able to help, as part of the long-term plan, both the NHS and health and social care deliver for them. As such, I commend this Statement to your Lordships’ House.

Primary and Community Care: Improving Patient Outcomes

Baroness Brinton Excerpts

Thursday 8th September 2022 Lords Chamber

[Baroness Brinton (LD)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Watkins, and to hear the voice of the nurse talking about their important role within primary and community care. I also congratulate the noble Lord, Lord Patel, on securing this vital debate: I cannot think of a better champion to talk about reform of medical services—I will not use the word “NHS” because I think “medical services” is what we are discussing here today. I thank all the organisations that have sent us briefings.

Like the noble Baroness, Lady McIntosh, I want to go back to 1947-48. My husband’s grandfather was a general surgeon at Huddersfield Royal Infirmary, as well as being a GP and a qualified pharmacist. He had to make the choice in 1948 and he chose the hospital. It was right for him. An amusing side note is that after his death, when we were clearing his house, his entire pharmacy was in the attic, in those glorious 19th century-type glass bottles. He took his joint role very seriously. One thing that has happened to general practice over the last 10 to 15 years has been the beginning of general practice specialisation, which is almost inevitable because of the specialisations of hospital doctors as well. I think that, although I have not heard much discussion of it, we should focus on that as well.

Primary care is the bedrock the NHS but, Cinderella-like, is often out of the limelight while providing that first point of essential contact for a patient, be it with their GP, the practice nurse or the healthcare assistant. But what is primary care? Always, the public will tell you that it is the GP, but we have heard in this debate today that it is so much more. It is community nurses; it is physiotherapists; it is occupational therapists; dentists; end-of-life care practitioners; health visitors; school nurses; and those who provide support to people with long-term conditions. And, of course, it is the invisible support staff who back them all up.

But primary care is broken and too many of those working in it are at breaking point too. The noble Baroness, Lady Finlay, helpfully laid out the real problems in her contribution. The noble Baroness, Lady Hodgson referred to some research. Unfortunately, research by GP Online, published in January this year, showed that GPs were completing 46 patient contacts a day, and the corresponding admin work that goes with it, which is 84% more than the 25 daily contacts recommended as a safe limit. Ministers have complained frequently, including during the recent leadership campaign, about too many part-time GPs, but that research also showed that, because of the 30% increase in paperwork over the last five years, most GPs are working 12 to 14 hours a day: that is one to three hours extra at the end of the day on admin alone, as routine, as well as being on call. One GP, responding to a publication of this survey, said, “It’s awful, it’s unbearable, there is too much to do to get it all done safely and if you try to be efficient, patients complain. I’m shattered and there is just no stopping the demand.” The noble Baroness, Lady Meacher, spoke movingly about the increasing number of GPs leaving. This is why.

I come back to the more general strategic issue, outlined so well by the noble Lord, Lord Kakkar, who gave us an overview of the crisis facing us. The service has changed; the funding has changed. Twenty years ago, when Governments of all colours started to reduce the number of hospital beds on the grounds that people did not need to stay so long in hospital, which is absolutely right—although demography needs to be taken into account, and they have gone beyond that point—what failed to happen was an understanding that recovery time and support is needed in the community, and there was no corresponding increase in support, finance and reframing of primary care services. That is one reason we have the problem that we do.

The noble Baroness, Lady Masham, raised the issue of sick notes, and perhaps reforms are needed there. I make the point that that is one of those admin jobs that has increased and grown. It may be that we have to review how sick notes are dealt with.

The noble Viscount, Lord Eccles, talked about his experience of community care and said he was given no explanation of why it happened. I have to say, from a recent discussion with a person awaiting an assessment of care adaptations that would be needed to their home as their long-term condition was worsening, that no explanation was given other than that they would have this appointment. That individual was terrified that their house was going to be changed out of all recognition for things they did not want to happen. When they actually had the assessment, their life was transformed, but the difficulty was that for the three weeks between being told that someone was going to come and make changes to their home to the point at which that happened, the communication was not good enough. But I suspect that that is because the pressure on the service as a whole means that in a five-minute appointment, you cannot explain.

The noble Baroness, Lady Pitkeathley, was absolutely right to focus on carers, whether paid or familial. Yet again, communication to patients is vital. I agree too that social care is not fixed: it may be that the money coming in is now being paid from a different source, but where is it going to go? How are we going to improve the workforce in social care and the support? Familial carers are currently having to pick up extra burdens, such as the increase in virtual wards at home that we were discussing in an Oral Question just a day or two ago. In all the discussions, there has been no mention either of the extra support for familial carers of virtual wards or of primary care support, which must inevitably grow. So I ask the Minister: will there be support for primary care with the increase in virtual wards?

The noble Lord, Lord Farmer, spoke of family hubs and the inverse care law: I think that was very powerful. I hope—as the noble Baroness, Lady Pitkeathley, said—the “not invented here” syndrome and not learning from excellent practice elsewhere will change within the NHS.

The problems in dentistry absolutely speak to the issues that GPs are beginning to face. Net government spend on dentistry in England was cut by over a quarter between 2010 and 2020. Over 40 million NHS dental appointments have been lost since the start of the pandemic, and 91% of NHS dental practices were not able to accept new adult patients, mainly because of the problems with the contract. That is a real issue because—as with primary care, particularly rural primary care—when there are inequalities, it is much harder to access those services.

The noble Baroness, Lady Hodgson, spoke of the effective triage systems that are needed, and also how it can happen very poorly. She spoke powerfully about the need for patients to know their GPs. I absolutely agree with that, which is why I am concerned. The noble Lord, Lord Bethell, said it: we do not need a certain number of GPs; what we need if we are reframing services is the right number of GPs to be able to support the population. It is all about the needs of patients and what we are expecting GPs to do, while accepting that technology is going to play a part and that support staff and other healthcare professionals will have an increasing role. If we start the discussion about reforms by saying we can manage with fewer GPs, we are deluding ourselves.

I do not think I have heard anyone mention the role of expert patients. I am lucky to be such an expert patient. I have a long-term condition; I have done the course—tick. I have to say that that has transformed my relationship with my GP and other staff. Hospitals often do not understand it: I was told once by a consultant when I had a temperature and had gone in that I knew too much about my disease. My specialist soon put him right, I have to say. But my GP surgery completely understood.

So we do need reform. We need to start afresh. Let us accept new technology and other roles, but the key issue must be that primary care remains free at the point of access, available as needed, with signposting and education for the public. The post-pandemic period is a good time for this, because the public have accepted changes. But we must have real investment in doctor training, campaigns to encourage GPs to come forward and, above all, we must get to grips with the current crisis so that we do not lose more of our really valuable primary care staff.

NHS: End-of-life Care

Baroness Brinton Excerpts

Thursday 8th September 2022 Lords Chamber

[Lord Kamall (Con)]

The noble and learned Baroness makes an incredibly important point about getting this right and getting the right balance. We know how difficult and sensitive these cases are when they have come to court. One issue that has been discussed by a number of parties is mediation: can we avoid it going to court in the first place, but also at what stage should mediation take place? It should not just be offered right at the end when everything has ended. We must make sure we really hear the voices of professionals as well as those affected, and families, to get the right balance. So far, we have relied heavily on the courts for some of these cases, sadly, but we just want to make sure we get this right.

[Baroness Brinton (LD)]

My Lords, over the last six years, the provision of palliative care for children and young people has become very patchy. CCGs across England have been closing down palliative care for children. Are the Government taking action to hold integrated care boards to account publicly on implementing their duty to commission palliative care for children and young people?

[Lord Kamall (Con)]

The noble Baroness will be aware that earlier in the week, when we had the debate on integrated care boards and their responsibilities, we added—thanks to the work, once again, of the noble Baroness, Lady Finlay—palliative care services to the list of services that integrated care boards must commission. Integrated care boards will be accountable to NHS England, but also the CQC will be doing a lot of evaluation and they will be measured against the list of services that they have to commission. Clearly, there will have to be accountability on palliative care services.

NHS: Access to Treatments

Baroness Brinton Excerpts

Wednesday 7th September 2022 Lords Chamber

[Lord Kamall (Con)]

The noble Lord raised a number of different points, which I will try to respond to. One issue is that, although we are recruiting more doctors, at the same time clearly there are doctors who are looking to leave. There is a demographic of people reaching a certain age, and one of the issues is pensions and whether they hit the limit. Those discussions are going on. There are also lots of discussions going on about how we can improve retention of those staff who feel overworked and have had enough.

In addition, at certain levels, for example primary care, it does not always have to be a doctor that the patient sees. It could be a practice nurse or a physiotherapist. There is also more emphasis on the Pharmacy First programme, whereby people can get advice from pharmacies, unless they actually need to see a doctor.

[Baroness Brinton (LD)]

My Lords, for elective surgery, it does need to be a doctor that the patient sees. On Monday, a patient waiting for a long-delayed hip operation was told by his doctor about the delay. He thought he heard “18 months’ delay”: the doctor corrected him. It is 80 months’ delay in that particular area. This is the workforce problem that other Peers have already raised. What are the Government going to do? Setting up emergency elective places does not solve the problem when there are not enough doctors to go around at the moment.

[Lord Kamall (Con)]

If we look at elective care, we have seen a record number of referrals. We are also seeing more people receiving treatment. Of those on the waiting list, 16% are waiting for in-patient surgery. A lot of those on the waiting list are waiting for diagnostics. We have the surgical hubs and community diagnostic centres. On top of that, the two-year waiting list has been virtually eliminated, except difficult cases and those who need complex treatment. The next target is to eliminate the 18-month waiting list by 2023. It is a concerted effort right across the system, looking at a number of innovative solutions.

Urgent and Emergency Care

Baroness Brinton Excerpts

Tuesday 6th September 2022 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I echo the comments of the noble Baroness, Lady Merron, that it is good to see the Minister in his place, although I notice that since he came into the Chamber his Secretary of State has changed. I wish the new Secretary of State well in her new role.

After many of the angry words over the past few weeks between the contenders to become the leader of the Conservative Party and the next Prime Minister, it is important to say that the crisis we face is not caused by the NHS and its staff, or the same in social care. Ambulance response times are still appalling, so much so that I have a friend who was once again advised by their GP this week to bypass the ambulance system to get their husband direct to hospital. Despite the numbers talked about in the Statement, the situation does not appear to be easing at all in the country.

It was encouraging to read at the beginning of the Statement that resources will be boosted on the front line, but from examining these figures it is quite difficult to follow the real increases on the front line and when they will happen. Some £150 million extra for trusts to deal with ambulance pressures is welcome, and I echo the thanks and congratulations to St John Ambulance; it is good that the Government have finally put on a formal footing the work it has been doing behind the scenes. But the number of extra 999 call handlers to be appointed between June this year and this Christmas is another 150, which, split between the 11 ambulance trusts, is not that many extra call handlers. Of course, they are taking not just health 999 calls.

Similarly, I cannot get to the bottom of the increase in call handlers to 4,800 or find out the previous figure. Call handlers on 111 refer callers mainly to primary care; 64% was the last data I saw. The issue is that there is no mention anywhere in this Statement of the pressure on primary care—whether that is GPs, community nurses or physiotherapists. There is absolutely zero mention, which means that the extra 111 call handlers will essentially be pushing patients into the void that primary care currently faces, given the pressure that GPs in particular are facing.

I echo the points about the training of more paramedic graduates, but it is outrageous that young people who have just qualified as doctors at university this year have been unable to find jobs because the money has not been found in the NHS for their training places.

It is important to note that the discharge frontrunners “testing radical solutions” will be testing on people in live situations to work out what happens.

On these Benches we welcome the international recruitment task force and particularly the code of practice, which the Government published just over a year ago and have updated in the last few weeks. The code of practice is vital for making sure that this recruitment happens ethically and that staff who come from abroad are supported. It sets out the fair framework for payments that they might have to pay back. But this is still fixing our problem by taking people from other countries. I note that this list includes red countries, which the Minister has referred to in the past, including Pakistan, Bangladesh and some countries in Africa. The rules must be followed very carefully, because those countries desperately need their own staff. While we need to be very grateful to all of them for coming to help us at this time, this is not a long-term solution. I hope the Minister can talk about what that longer-term solution might be.

The Statement makes reference to the better care fund. I am bemused that the better care fund is being used

“to pool budgets, to reduce delayed discharge.”

That is one of the things it was created for at the tail end of the coalition, and it has indeed been the focus of it.

My big worry about this Statement is that ICBs, which we have spent a lot of time discussing in your Lordships’ House over the last few months, are now trying to implement a new system for shared care and shared costings. This Statement says the entire focus will be on delayed discharges, so what extra resources will be available for ICBs?

The Statement also talks about the need for additional beds. It is good that the Government are at last recognising this; 7,000 additional beds is a start, but how many of those 7,000 are real beds and how many are beds in virtual wards—that is, people at home being observed by telemetry? What extra support is going into primary care to support the nurses and doctors who will also be fulfilling some of that? The Statement is completely silent on that.

The end of the Statement talks about Covid and the new vaccine, which is very good news, but why has Covid testing for staff in hospitals been stopped in the last couple of weeks? Too many patients are still catching Covid in hospital. A friend’s mother in her 90s had been tested on arrival in A&E and was then admitted. Three weeks later, when she was about to be discharged for a care home, the hospital refused to test her. Eventually it was pressed to do so. She had Covid, but it did not test anyone else on her ward. She died of pneumonia, and the death certificate said the reason for the pneumonia was Covid.

Another friend died last week, aged 51. She was on the shielding list and had had all her vaccinations, but had a stroke. She caught Covid in hospital and died. She would have been eligible for Evusheld, so it is very disappointing to hear that the Government still will not approve this drug for the 500,000 who are clinically extremely vulnerable.

Finally, the booster campaign is great, but why have the Government decided to stop giving boosters to under-12s who either are immunocompromised or have family who are immunocompromised? We know that schools where air circulation is still poor are an absolute vector. All the experts are warning us that there is likely to be another wave of Covid, and schools without ventilation will be a real problem. If the Minister cannot answer that question today, perhaps he can write to me.

This Statement admits that our NHS and social care sector are still under the most phenomenal pressure. It is the first time I have heard Ministers talk about the system being “at winter state”. When and how on earth will we cope with the winter months when they arrive?

[Lord Colgrain (Con)]

My Lords—