Face-to-Face Medical Appointments
Baroness Browning Excerpts(5 years, 6 months ago)
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Lord Bethell (Con)
The noble Lord makes an incredibly interesting parallel with Iceland. It is not one that I knew, but I will take care to look into it, because it is instructive and informative. He is right to say that Covid has demonstrated the power of telemedicine, and we are keen to learn that lesson. We do not want the elastic band of old practice to snap back to where it was before. To reflect the words of a noble Lord who spoke previously, there will be occasions when tele- medicine is right. The key is getting the blend correct and ensuring that the right format is used in the right circumstances.
Baroness Browning (Con) [V]
I quite accept that there is a role for telemedicine, but an accurate diagnosis in cases of serious disease and illness is dependent not just on the questions that the doctor asks and the observations he makes but on the ability of the patient to give accurate information. I will give the example from my family in the past few months of antibiotics prescribed for a “lung infection” that was actually a fatal pulmonary embolism. Getting that mix right is not easy; there are very many shades of grey.
Lord Bethell (Con)
My noble friend makes a very good point. Diagnosis is phenomenally difficult and, quite often, patients who present with seemingly one condition have something altogether different. It may be that a face-to-face appointment will be the moment when that difference is spotted and caught. She is entirely right to say that we cannot omit that format for the right circumstances, but a great many patients see their GPs very regularly. Their journeys may be onerous, uncomfortable and stressful, and telemedicine might offer them an alternative opportunity. There are others for whom speed is of the essence, and having telemedicine, particularly when it is supported by apps that provide essential information about their condition, can be an important and urgent alternative.
Hospitals and Nursing Homes: Do Not Resuscitate Notices
Baroness Browning Excerpts(5 years, 8 months ago)
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Baroness Browning
To ask Her Majesty’s Government what assessment they have made of the use of Do Not Resuscitate notices in hospitals and nursing homes since March.
Baroness Browning (Con) [V]
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer to my interests in the register.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)
My Lords, the department is very clear that the blanket use of DNACPR and DNR is unacceptable. An agreement to a DNACPR is an individual decision and should involve the person concerned or, where the person lacks capacity, their family, carer, guardian or any other legally recognised advocate. I can inform the House that the Minister for Patient Safety and Mental Health will be writing to the Care Quality Commission requesting that it investigates and reports on DNACPR issues.
Baroness Browning (Con) [V]
I am grateful to my noble friend and am aware of the letters written in respect of people with learning disabilities and autism during the first phase of the Covid-19 outbreak. However, with the second wave looking as though it is on its way, my noble friend will be aware that there is still concern from charities such as Mencap and the National Autistic Society, not least because of the attitude in some areas that people who have social care support needs are rather lesser human beings than the rest of us. How will the Care Quality Commission carry out this assessment as the second wave increases?
Lord Bethell (Con)
My Lords, it is completely unacceptable for any group of people to have blanket DNACPR provisions apply to them. The adult social care winter plan published on 18 September reiterates that and makes the position crystal clear. The General Medical Council is providing additional support and guidance to clinicians on how to meet the needs of patients and relatives, and the Resuscitation Council UK is creating a large amount of resources to provide training. The CQC is monitoring the situation extremely carefully.
Covid-19: NHS Long-term Plan
Baroness Browning Excerpts(5 years, 8 months ago)
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Lord Bethell (Con)
My Lords, the right reverend Prelate is right; health inequalities are a massive priority for the Government. Covid has demonstrated how health inequalities play out when an epidemic such as this one hits the country. That is why we put education and levelling-up on health generally as major government priorities, why we are investing in 50,000 new nurses and 40 new hospitals, and why health remains a number one priority for this Government.
Baroness Browning (Con) [V]
My Lords, my noble friend will be aware that the long-term plan has set an ambitious target for 2028 of 75% of cancers being diagnosed at stages 1 and 2. Does he agree that this must involve GPs, and that GPs having face-to-face consultations with patients is the only way that this target will be achieved?
Lord Bethell (Con)
We are enormously proud of the commitment to early intervention on cancer. This is the absolute core of our life science priorities. It is envisaged that we will have a revolution in the diagnostic capabilities of the NHS in order to hit these targets and, where necessary, face-to-face GP appointments will be made available. However, I am not sure that every single appointment needs to be face to face. One of the learnings of more than half of the 100 million consultations that took place between March and June was that telephone and video appointments can be extremely productive.
Covid-19
Baroness Browning Excerpts(5 years, 9 months ago)
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Lord Bethell (Con)
The right reverend Prelate is entirely right to raise this point; it is emerging as a massive concern. The idea that Covid will somehow pass through Britain and leave people untouched, a bit like simple winter flu, is beginning to prove worryingly untrue. Her anecdote from Bristol is completely consistent with what we are seeing across the piece. In particular, those who have had acute infection but also, I fear, some who have had relatively asymptomatic or low-symptom Covid have found in later weeks and months symptoms of fatigue, arrythmia, renal impact, scarring on the lungs and memory loss. These are extremely worrying symptoms. Sir Patrick Vallance, the Government Chief Scientific Adviser, is running an operation to understand what the right reverend Prelate rightly calls long Covid; we are using big data to analyse the scans we have collected from acute patients and to understand the impact of asymptomatic infection. This is an extremely worrying manifestation of Covid, one that we are acutely aware of, and we are investigating very urgently.
Baroness Browning (Con) [V]
My noble friend will be only too aware of the consequences of non-Covid patients’ reluctance to present themselves at hospitals and even to GPs for treatment and support. With the winter months approaching, what can he do to make sure that, at a local level, in advance of people having symptoms, they are reassured that they will be safe to approach the NHS? The idea that “it will be all right on the night” and just requires encouragement has clearly not been enough in the past and, I fear, will not be enough in the coming months.
Lord Bethell (Con)
My Lords, my noble friend is entirely right that confidence in attending NHS venues is hard hit by Covid. One of the inspiring and interesting things that has happened has been the switch to using telemedicine—video and telephone calls—for referrals. This has been particularly and interestingly used in mental health, where attendance at clinics is something that many patients would wisely seek to avoid, but in fact the delivery of mental health therapy through telemedicine and calls has proved to be incredibly effective and has worked very well. We are working hard, through the NHS, to try to de-weight attendance at venues, particularly big central hospitals, and move much more towards attendance in the community, or through technology, in order to give patients a choice and to increase our engagement at a time when people are fearful of going back to their GP surgeries.
Covid-19: Personal Protective Equipment
Baroness Browning Excerpts(5 years, 10 months ago)
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Lord Bethell [V]
My Lords, I completely share the concerns of the noble Baroness, Lady Andrews, about a second peak and we are working to prepare for that. I respect the views of the PAC and emphasise that our approach to PPE is incredibly serious. A huge amount of work has gone into it and a huge amount of progress has been made.
Baroness Browning (Con) [V]
Can my noble friend identify what lessons have been learnt so far from both the quantity and quality of the PPE that has been used in homes and hospitals? What action will be taken to minimise cross-infection for those who have to go into people’s domestic homes and who often work in more than one location?
Lord Bethell [V]
My Lords, the big lesson from Covid is that the quantity of PPE needed for a disease like this is massively more that could ever have been expected, particularly compared with our past experience. It has hit every country in the world and has hit the global supply chains incredibly hard. A benign lesson is that British manufacturers are capable of stepping up the challenge, and I salute their work. Contamination from itinerant workers was always one of the greatest challenges of the care sector, and we have put in a huge amount of work and financial resources to avoid the need for workers who move from home to home.
Hospitals: Patient Safety
Baroness Browning Excerpts(6 years ago)
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Baroness Browning
To ask Her Majesty’s Government what steps they are taking to update the guidance given to hospitals about ensuring the safety of patients who do not have Covid-19 who require life-saving emergency treatment.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)
My Lords, despite Covid-19, the day-to-day health of the nation remains the business of the NHS. That is why the NHS has issued a new operating framework to help hospitals to continue providing essential and emergency care for patients who do not have Covid-19. This guidance is being kept under review. I have placed a copy of the framework in the Library.
Baroness Browning (Con)
Emergency admissions, of which we have seen many, though perhaps not enough, have resulted in people being very afraid of going into hospital, because there has been a lack of information for the general public. For example, what happens at the triage stage, what sort of PPE will people be wearing and how will they be protected? What can the Minister do to reassure the public that they will be safe and, on top of their emergency, will have the absolute minimum chance of getting Covid-19?
Lord Bethell
My Lords, I acknowledge that people’s concerns have led to a decline in attendance at A&E. That is why the NHS is running an “Open for business” media campaign, encouraging all patients in need of urgent or emergency medical care to seek appropriate treatment, including, where appropriate, attendance at A&E.
Mental Disorder: Autism and Learning Disabilities
Baroness Browning Excerpts(6 years, 7 months ago)
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Baroness Blackwood of North Oxford
I thank the noble Baroness for taking on the chairing of the independent panel. I cannot think of anybody better placed to do so. When it comes to her question about the detention of an individual to improve their behaviour, again, I do not think that anybody in this place or elsewhere could disagree with her. On changing the Mental Health Act, we commissioned the independent review led by Sir Simon Wessely, who is also a leader in the field. He reported in December. In its findings, the review made it clear that we need to modernise the Mental Health Act, ensure that views are respected and ensure that patients are not detained for any longer than is absolutely necessary. Sir Simon stated that there is “no clear consensus” on removing autism from the Act, and that,
“we have heard also about the many negative consequences that could arise from being outside this framework … this should be kept under review”.
Obviously, we will not respond to that immediately. There will be a White Paper by the end of the year. We will consider this carefully and we recognise the strength of feeling on this matter.
Baroness Browning (Con)
In support of what the noble Lord, Lord Touhig, and the noble Baroness said—we greatly welcome her chairmanship of the review—there is a very good reason for removing autism as a mental disorder: it is not a mental disorder. It is as simple as that, although it is true that people with autism, including children, will have comorbidities and will develop a mental health condition on top of their autism. I do not know whether the Minister understands my frustration, but I have been raising this issue in Parliament for nearly 28 years. The real problem is that we do not have sufficient psychiatrists who understand and can differentiate between autistic behaviour and what they believe to be psychotic behaviour. Once patients start the spiral of medication for psychosis, the autism disappears and the person disappears altogether.
Baroness Blackwood of North Oxford
My noble friend puts this very clearly. The Government accept completely that autism and learning disability are not mental disorders. The question is whether being excluded from the legislation would cause challenges or difficulties for those who may have autism and mental disorders. We will have to consider that carefully as we go into the process of considering a review of the Mental Health Act. As my noble friend just said, we recognise that we will have to go through a careful process. We also recognise the strong feelings—and the correct view—that autism and learning disability are not mental disorders. There is no disagreement on that point.
Health and Social Care: Malnutrition
Baroness Browning Excerpts(6 years, 7 months ago)
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Baroness Blackwood of North Oxford
The noble Lord is quite right that this is about leadership not only at board level but from the very top. It has been instructive that not only the Secretary of State but the chief executive of NHS England, Simon Stevens, have made it one of their priorities to ensure that the quality of food and food safety standards throughout the hospital and care systems should be improved. This is one of the key ways that we will drive out malnutrition from our health and care sector.
Baroness Browning (Con)
Could my noble friend please take a look at the frail elderly living alone at home who are not necessarily regularly seen by doctors because they do not present with symptoms? Very often, the older people get the more difficult it is, as the body starts to age, for them to absorb nutrients, even when they are eating a mixed diet. Could she take a look at that particular group, in the way that we look at people who have regular check-ups with a GP for heart problems and diabetes, to ensure that they are not just deteriorating? It is not until they deteriorate to the point where they become ill and symptomatic that people start to notice that there is a problem.
Baroness Blackwood of North Oxford
My noble friend is absolutely right. Evidence is on the rise that malnutrition is worse among older age groups and is both a cause and consequence of ill health. We must make sure that we are identifying and intervening as early as possible to make sure we are not leading to some of the challenges raised by the noble Baroness. That is why the malnutrition universal screening tool has been developed by the Malnutrition Advisory Group to assist those in nursing and in general practice to intervene as early as possible to prevent some of the challenges that she has identified.
Carers: Support
Baroness Browning Excerpts(6 years, 11 months ago)
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Baroness Blackwood of North Oxford
The noble Baroness has raised an important point, which is that we need to provide carers with the support they need, because they do an amazing job. Unpaid care is a vital part of a sustainable health and social care system. This is why the long-term plan has put in place an ambition to ensure that we provide sustainable support across the public health system, and will ensure that we have a quality mark for primary care to highlight best practice. I am very sorry to hear about the experience of the carer in the case that the noble Baroness highlighted and would be pleased to follow this up with her directly, after today’s Question Time.
Baroness Browning (Con)
After decades of being a carer myself, I can say to my noble friend that it would help carers enormously for there to be an integrated approach to the carer and the person they are caring for. I cannot remember how many times I filled in a form asking what my needs are, and wrote across it, in large letters, “If the needs of the person I care for were met, my needs as a carer would be greatly reduced”. Until there is that joined-up approach in practice, carers will continue to suffer.
Baroness Blackwood of North Oxford
As so often, my noble friend speaks with common sense and insight. This is something that our carers innovation fund is supposed to root out, with its creative and innovative ways to drive reform and improvement through the system. That is why we brought it in, but it is also a commitment of the long-term plan. Best-practice quality marks in primary care are supposed to drive better identification and support of carers in the system. We will ensure that we see that.
Mental Capacity (Amendment) Bill [HL]
Baroness Browning Excerpts(7 years, 3 months ago)
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Baroness Browning (Con)
My Lords, I will be brief. I too had concerns about this definition when the original legislation went through pre-legislative scrutiny—it seems an eternity ago now. It does not seem to be any easier for my noble friend to put this in the Bill. But there are some concerns. I declare my interests as a vice-president of the National Autistic Society, which has written to me, along with other similar charities, to say that it has concerns, not so much on the substance but on the clarity.
As my noble friend has just pointed out, there are two areas here. One is the clarity of the legal definition which lawyers will need, and that is important. But also, as the noble Baroness, Lady Tyler, has said—I assume this will be in the guidance and consultations that my noble friend is now undertaking—it needs to be in clear English for practitioners, relatives and people deprived of their liberty. If anybody asks in the future what Parliament’s intention was at the time—a question which I understand is sometimes asked in courts of law and to which we perhaps pay scant attention when we are legislating—I hope that on both counts, in terms of the legal definition and the guidance for others who are not lawyers, my noble friend will make sure in those documents that Parliament’s intention in defining deprivation of liberty is clear.
Lord Mackay of Clashfern (Con)
My Lords, this area of the definition of liberty is, and always has been, extremely difficult. The Strasbourg court has wrestled with it. It is absolutely vital from the legal point of view—I understand the distinction that has been made and I will mention that again—that this definition should be in accord with the convention; otherwise, we will have trouble maintaining this in the face of challenge. It is difficult to say that the Government’s definition is not in accordance with the convention. It seems clear that it is so. Therefore, all the decisions taken here and in Strasbourg in respect of it are available to help in the formulation of guidance.
If a different definition is taken which does not expressly subscribe to the convention, there is certainly room to try to squash definitions or applications which are in line with this definition as amended by the noble Baroness. It is perfectly open to use the legal definition in the main, in accordance with the convention, and then to help people as best we can to understand what it is all about by giving guidance, which is not authoritative in the same way as judicial decisions. There is quite a lot of scope for trying to do that with guidance which will be in accordance with what the practitioners have asked for. I should say that I am an honorary vice-president of the Carers Trust, but that does not affect what I have to say about it. I can see the need to help people in the actual work they have to do; this is a legal definition, and not all legal definitions are absolutely self-apparent to people who are not lawyers. But the guidance provided for can help in that respect, and there is a serious risk that, if we do not do something of that kind, the result will be litigation which could affect the viability of this clause in the future.
Baroness Blackwood of North Oxford
My Lords, It is vital that those who are deprived of their liberty are provided with the information necessary for them to be able to exercise their rights. Although there is a duty to provide information in Article 5 of the European Convention on Human Rights, noble Lords have rightly flagged that the Bill should be explicit about this duty, and amended the Bill to this effect.
The Government listened to noble Lords and agreed that the Bill should be explicit on this matter. However, the amendment tabled in this place was not clear about when information should be provided; we felt that this drafting could cause some confusion for practitioners, so we tabled alternative amendments. Amendment 24 clarifies that, as soon as practicable after arrangements are proposed, the responsible body must take such steps as are practicable to ensure that the person understands the key steps and safeguards in the authorisation process. This is particularly important to ensure that people are aware of their options to challenge the authorisation. Importantly, there is also a duty to provide the same information to any appropriate person who is providing representation and support to the person. This is important in ensuring that family members and those close to the person are also provided with the necessary information to enable them to effectively provide representation and support to the person.
The duty on the responsible body is to take steps as soon as practicable to provide the person with the information. This means that this should be done as soon as possible after the responsible body is aware that arrangements are proposed. The responsible body will need to identify an appropriate person or appoint an IMCA at the earliest possible stage to provide support and representation for the person; the same principle applies for the duty to provide information. Information should be provided in the early stages of the process so that the person can make an informed decision regarding the support they receive through the process, and is able to exercise their rights. The code will provide details about how this will work in practice. We have already established a working group on the code of practice, which includes stakeholders from across the sector, ensuring that information is provided at the earliest possible point to form a part of these discussions.
Amendment 24 also introduces a general duty to publish information about the authorisation, including: the process; the circumstances in which an IMCA should be appointed; the role of the appropriate person; and the right to challenge an authorisation in court. This ensures that anyone who has an interest in the welfare of the person is subject to liberty protection safeguards authorisation, has access to the important information about a person’s rights, and is able to raise objections on behalf of the person.
Amendment 25 requires that the responsible body remind the cared-for person and any appropriate person of this information after the authorisation is granted. The information that needs to be provided to the person, and to any appropriate persons, includes details of the authorisation process, access to representation and support from an appropriate person or an IMCA, the right to request a review, and circumstances in which an AMCP will consider a case, which includes objections and the right to challenge authorisations in court.
On the matter of challenging authorisations in court, the responsible body under Article 5 of the European Convention on Human Rights has a duty to ensure that relevant cases are referred to the Court of Protection. I know that there has been a particular concern about ensuring that in very rare cases where it is not in the person’s best interests to receive support and representation, those people are enabled to challenge in the Court of Protection if they want to. In these cases, the responsible body will need to ensure that the cases are referred to the court. If it fails in this duty, it can be challenged in court.
I understand that Amendment 25A, tabled by the noble Baroness, Lady Watkins, seeks to require responsible bodies to keep a record of the decision and justification for not immediately giving a copy of the authorisation record, and if an authorisation record is not given within 72 hours, there must be a review into whether the lack of information is appropriate. I understand her desire to ensure that information about an authorisation record is provided promptly. However, we think that the drafting of the amendment would cause some issues; for example, it is not clear who is responsible for the duty to record or carry out a review. I am certainly willing to reflect on how best we can ensure that information is shared promptly, but I hope that I can reassure the noble Baroness that we will generally expect the information to be provided earlier than this, and we will set out reasonable timescales for the responsible body in the statutory code of practice. I hope that, with this reassurance, she will decide not to press her amendment.
The House has made clear its view that the Bill should be explicit about the duty to provide information. The Government have listened: these amendments outline clearly the duty to provide information at the earliest possible stage; to require, as far as possible, that the person understands the information they are being given; and to take action on it if necessary. I hope that noble Lords will accept these changes made by the House of Commons, and on that basis, I beg to move.
Baroness Browning
Is my noble friend able to define what the Government describe as “as soon as practicable”, which she said was going into the code of practice? Linked to that, how will it be defined for those people who will need the support of speech and language therapists, of an approved mental capacity professional or of an IMCA? It seems that we will need information to be provided at a very early stage, so that it can be considered and then decided whether there is a need for additional support. Can she give us some indication of how she is going to deal with that in the code of practice?
Baroness Watkins of Tavistock (CB)
My Lords, I welcome the Minister to her new role, and look forward very much to working with her. I also acknowledge that the Government have gone a very long way in responding to previous amendments in the name of Lady Hollis and myself with regard to the supply of information to the cared-for person and other relevant bodies.
I turn briefly to my Amendment 25A. While I fully appreciate that it is not always practicable for the responsible body to ensure that a copy of the authorisation record is given to the cared-for person and other bodies immediately after authorisation, as outlined, Commons Amendment 25 is not at all specific about the time limits. I believe this means that busy clinical staff may not always feel it necessary to chase up this issue and make time swiftly to explain issues to the cared-for person or the appropriate person. This needs to be done quickly enough in terms of ongoing deprivation of liberty safeguard orders for appeals or challenges to the authorisation to be made, if individuals so require.