NHS: Liverpool Care Pathway

Baroness Browning Excerpts

Tuesday 15th January 2013 Lords Chamber

[Earl Howe]

Yes, my Lords. The LCP, if I may use the abbreviation, is internationally recognised good practice as a framework for managing care for people in their last few days or hours of life. It was created as a way of bringing hospice-style care into hospitals and helping staff who may not be palliative care specialists to provide appropriate care to allow people to die in comfort and with dignity. However, we have consistently made clear in guidance for implementation that the pathway cannot replace clinical judgment and it should not be treated as a simple tick-box exercise. I am afraid that, from the complaints that have been received, that sometimes appears to be what has happened.

[Baroness Browning]

My Lords, I, too, welcome the appointment of the noble Baroness, Lady Neuberger; I am sure that we all have confidence in her as chair of this review. Can my noble friend confirm that the terms of reference will specifically make sure that a direct comparison is made between what is appropriate in terms of the expertise and continuity to be found in the hospice movement and the rapid changes of staffing, including bank staff used in general wards of general hospitals?

[Earl Howe]

I am grateful to my noble friend for drawing attention to a very important point. It has always been emphasised in connection with the LCP that to ensure that it is used properly it is important that staff receive appropriate training and support, and that relevant education and training programmes are always in place. In view of the degree of staff turnover to which my noble friend refers, I am confident that the noble Baroness, Lady Neuberger, will have that fact in her sights.

Care Services: Winterbourne View

Baroness Browning Excerpts

Monday 10th December 2012 Lords Chamber

[Earl Howe]

My Lords, the noble Lord is not out of date, because this is a key issue and I am grateful to him for raising it. It is crucial that staff who work with people with challenging behaviour are properly trained in essential skills. Contracts with learning disability and autism hospitals should be dependent on assurances that staff are signed up to the proposed code of conduct that the Department of Health has commissioned from Skills for Health and Skills for Care and that there should be minimum induction and training standards for unregistered health and social care assistants. Those standards should be met. I would say that owners, boards of directors and senior managers of organisations that provide care must take responsibility for ensuring the quality and safety of their services. There are requirements set out in law in that regard, and they include safe recruitment practices, which necessarily involve selecting the people who are suitable for working with people with learning disabilities, autism and challenging behaviour, and appropriate training for staff on how to support people with challenging behaviour.

From April next year, Health Education England, which is the new, national, multi-disciplinary education and training body, will have a duty to ensure that we have an education and training system across the piece but including a system that can supply a skilled and high-quality workforce for this sector.

[Baroness Browning]

My Lords, my noble friend said that families’ concerns were ignored, but would he accept that there is huge push-back across all the public services involved with this group when anyone who is a family member of someone over the age of 18 tries to make representations on their behalf? I experienced that again personally, yet again, only this week. Paragraph 3.9 of the department’s response makes reference to:

“Where an individual lacks capacity and does not have a family to support them, the procedures of the Mental Capacity Act 2005 should be followed”.

I am appalled at the way in which the Mental Capacity Act, an excellent piece of legislation, is virtually ignored by many professionals who not only do not advise people of their rights under the Act but just ignore it. If ever a piece of legislation cried out for post-legislative scrutiny, it is this Act of Parliament. It is a strong, good piece of legislation but it needs to be enforced; we need more people to know about it and to use its powers to protect the vulnerable.

[Earl Howe]

My Lords, my noble friend is absolutely right. Over the coming months the Department of Health will be working with the Care Quality Commission to agree how to improve the understanding of the deprivation of liberty safeguards and to ensure compliance with them. We are very clear that this work is necessary to protect individuals and their human rights. We will report the results of that work by spring 2014. During 2014 the Department of Health will update the Mental Health Act code of practice, and this will also take account of findings from the review.

Autism

Baroness Browning Excerpts

Wednesday 5th December 2012 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Lord and I am quite sure that we in England can learn from what is going on in both Wales and Scotland in this area. However, we can take some encouragement from the National Audit Office memorandum earlier this year, which stated that considerable progress had been made in the two years since the strategy in England was published. Twenty-four of the 56 commitments had been implemented, and action was under way in response to the remainder.

[Baroness Browning]

My Lords, does my noble friend agree that if we are really going to achieve equality for the autistic community, we need to start looking now at the sort of services that they require when they become much older and frailer? It would be a tragedy if we improved services for children and adults but, when they become old and frail and are no longer able to maintain independent living, even with support, they are then segregated from the rest of society.

[Earl Howe]

My noble friend is right, which is why the existing statutory guidance extends not only to local authorities but to the NHS; it is unique in that regard. The strategy is about integrating care across the NHS, social care and all other local authority services, and its focus must be on putting people with autism at the centre of any plans to improve their own lives.

Care and Support

Baroness Browning Excerpts

Wednesday 11th July 2012 Lords Chamber

[Earl Howe]

First, I thank the noble Lord for all that he did as a member of the triumvirate of the Dilnot commission. There is no doubt that we owe him and his fellow commissioners an enormous debt. I am grateful to him for his kind remarks about this set of announcements. We propose to introduce deferred payment without the cap necessarily being in place. We believe that that can be done. I understand the direction from which the noble Lord comes, but a system that obliges local authorities to offer deferred payment where certain eligibility criteria—yet to be defined, admittedly—are met is deliverable in the absence of a cap. That is not to say that we do not wish to work hard to define what that cap should be.

On the noble Lord’s second question about the dead hand of the Treasury, I would not characterise my esteemed colleagues in that venerable department as dead hands. However, I acknowledge his central point about affordability. That is why we have felt it necessary to defer final decisions on how the funding of the Dilnot principles will be worked through until the next spending review. That inevitably means that my colleagues in the Treasury will have a direct interest in the result; it would be strange were it otherwise. Nevertheless, that does not preclude creative and constructive discussions between our two parties.

[Baroness Browning]

I welcome my noble friend’s Statement, but does he accept that there is still a significant challenge in providing appropriate packages of care, particularly for elderly people, on discharge from hospital following an emergency admission? This relates to the type of care required when there is a significant change in needs and people are unable to return to their home, or sometimes even to a residential home. There is a transition, but some of those people could make more progress in their recovery. I am thinking of stroke patients in particular. I hope the Minister will be able to reassure me that these changes will include looking again at this group.

[Earl Howe]

I agree with my noble friend. Only last week, I talked to people at the Norwich and Norfolk University Hospital who emphasised that very point. Very often, the absence of packages of care that are tailored to the needs of the individual results in delayed discharge from hospital and often a deterioration in the condition of the patient. That helps no one. There is therefore a burning need for commissioners, providers and those providing care in the community to work together to define appropriate packages. I fully agree with my noble friend that those who have had strokes are particularly in need of the kind of packages that can best assist them when they move back into their own homes. This is an area that is crying out for further work. We hope that it will flow from the creation of clinical commissioning groups and health and well-being boards at a local level.

Care Homes

Baroness Browning Excerpts

Wednesday 27th June 2012 Lords Chamber

[Earl Howe]

My Lords, my noble friend is right to call that matter into question. My department will be working with the NHS Commissioning Board Authority to agree by January next year how best to embed quality of health principles in the system using NHS contracting and guidance. Those principles will set out the expectations of service users in relation to their experience. We are taking a range of other action—the 14 national actions to which I referred in my initial Answer—which I would suggest my noble friend looks at. We are clear that there is a need not just for providers but for everybody in the system to focus on their responsibilities and to work together to drive up standards in the way that we all wish to see.

[Baroness Browning]

My Lords, given the number of years that have passed since we saw the Mencap report Death by Indifference, and the fact that these reports show an inadequate level of improvement, I find myself in the strange position of asking my noble friend if he would please reconsider a proper register, professionally supervised by those working in the care industry?

[Earl Howe]

My Lords, as my noble friend knows, we committed in the Health and Social Care Act to facilitate a voluntary register for care workers and health workers. We believe that the system should be tried before we think about any statutory regulation. However, I understand the urgency and strength of feeling around this issue and it is a matter that we will keep under regular review.

NHS: Liverpool Care Pathway

Baroness Browning Excerpts

Wednesday 20th June 2012 Lords Chamber

[Earl Howe]

Yes, my Lords. To ensure that it is used properly, the Liverpool care pathway emphasises the importance of staff receiving appropriate training and support in its use as well as accessing relevant end of life training and education programmes. A range of activity has been undertaken to support staff education and training and end of life care by the national end of life care programme and others. That includes the development of an extensive package of e-learning, which is free to access for health and social care staff.

[Baroness Browning]

Will my noble friend tell the House whether there is ongoing monitoring of patients who are sedated but not hydrated? Looking at people who are dying can take a long time. My noble friend mentioned a few hours or a few days. If you are not hydrated for days on end, inevitably death will come. What analysis is there?

[Earl Howe]

My Lords, one key feature of the Liverpool care pathway is regular monitoring of the patient—every four hours at a minimum, I believe. That regular monitoring process gives clinicians and nursing staff an opportunity to reassess the patient’s condition to see whether they are in fact responding to treatment, whether they require a different form of treatment or whether the treatment they are being given is unduly burdensome. That regular monitoring should, I think, take care of the point my noble friend raises.

Autism Act 2009

Baroness Browning Excerpts

Monday 26th March 2012 Grand Committee

Asked By

[Baroness Browning]

To ask Her Majesty’s Government what assessment they have made of the implementation of the Autism Act 2009 and associated autism strategy.

[Baroness Browning]

My Lords, I am very grateful to all noble Lords showing an interest in this debate this afternoon, and particularly to the Minister, who I know takes the Autism Act 2009 very seriously. I have brought it forward at this time because the Act needs to be kept under review. There are certain aspects that I want to air today particularly as far as the implementation of the strategy is concerned. I hope that the Minister will be able to take away some of the concerns that I have about it.

It is important to re-emphasise that this Act, introduced by my dear friend the right honourable Cheryl Gillan MP in another place, is the first, and I believe only, condition-specific legislation on our statute book. As a result, we have a particular regard for the reason why it came about. It was because, as a spectrum, autism is a complex condition, which has only begun to be understood in recent years, and because even those who present as more able on that spectrum can deteriorate in areas of mental health, particularly when they progress from childhood to adolescence and then on to adulthood, if they do not receive the appropriate packages of support, much of which will need to be lifelong for many, even the most able. It was for that reason that Parliament singled out the condition of autism in order to put this legislation on the statute book. The Department of Health has responsibility not just for implementing it but for overseeing it, so that this legislation carries out Parliament’s wishes in the responsibilities of the Secretary of State to,

“prepare and publish … a strategy for meeting the needs of adults in England with autistic spectrum conditions”,

and to issue guidance to local authorities and health bodies to secure the implementation of that strategy. There is also a duty on local authorities and health bodies to act under that statutory guidance.

I would like to begin by raising issues that are in the current strategy, on which I hope my noble friend will be able to answer my questions or, if not, to write to me afterwards. The first is to do with partnership boards. Page 29 of the guidance raises the matter of partnership boards, but in the guidance these are not to be required in every circumstance; there is simply a requirement for partnership boards to be there and to be a body where people with autism and their families could participate. It is not statutory that they should. Will partnership boards be monitored in terms of their being set up, and what is the Government’s position now on partnership boards including those with autism and their families? We know that this is one of those conditions where carers and those who can self-advocate in particular are in a key position to add to what is needed in their own services.

I would also like to raise with my noble friend the question of IQ, on which I have put down Written Questions. Page 15 of the guidance states:

“Assessment of eligibility for care services cannot be denied on the grounds of the person’s IQ”.

This is a very old problem which particularly affects those who present with Asperger’s or the more high-functioning Kanner’s autism. I apologise; I should have declared my interest as vice-president of the National Autistic Society. Having been in another place for 18 years, I have dealt with a lot of casework—not just my own but also that of other Members of Parliament. IQ has been the reason social services and other statutory bodies have denied people on the spectrum the right to an assessment and thus to appropriate services; I must tell my noble friend that I still receive casework of this nature today. The practice is clearly now illegal. In fact, I believe it was illegal under existing legislation affecting social services and their requirement to assess people. I ask my noble friend to take an interest in this, particularly for people who have previously been assessed but did not necessarily have IQs under 70 which would have determined them as learning disabled. It is still a problem in some areas. This legislation should have put a halt to that: my interpretation of the strategy is that it is quite clearly illegal.

I also raise with my noble friend the matter of diagnostic leads in NHS bodies, featured in the guidance. Page 15 states that there will be a clear pathway to diagnosis in every area by 2013. Page 16 goes on to say that:

“Each area should put in place a clear pathway for diagnosis of autism, from initial referral through to assessment of needs”.

Page 15 also states that,

“the end goal is that all NHS practitioners will be able to identify potential signs of autism, so they can refer for clinical diagnosis if necessary”.

I know that we are waiting for NICE guidelines to be published on this. I do not know whether the Minister can give us some indication of the timeline as far as the NICE guidelines are concerned. However, in view of the omission in the guidance of foundation trusts and the implication of the Health and Social Care Bill regarding the bodies which will replace PCTs, I wonder whether my noble friend could tell me how the requirements of the autism strategy are going to be met. Are we in danger—and I hope I am wrong in my interpretation of this—of having postcode lotteries in terms of the requirement of the strategy? For changes in health service organisation, those requirements under pages 15 and 16 may well not be achieved as far as the health bodies are concerned. How are these diagnostic leads and their work to be benchmarked? In other words, how are we to assess how capable they are of doing that work? How are we to assess the geographic spread, bearing in mind that there are many cases of autism among adults that are quite complex?

I am not saying that it is easy to diagnose. Diagnostics across the autistic spectrum, including for children, require people with experience of working regularly with those people. However, by the time people enter adulthood—and sometimes people present quite late in life—there can be really complex needs. A mental health condition commonly overlies an autism diagnosis. I point out to my noble friend for the record—I know that he will know this—that autism is not of itself a mental health condition. However, we know—this applies as much to the more able end of the spectrum as to those with more complex Kanner’s autism—that many learning to get by in life as adults often present very strange behavioural patterns. These are not necessarily psychotic but all too often people who are inexperienced in diagnosing find it difficult to disaggregate rather strange autistic behaviour—I choose my words carefully—from what might sometimes be misinterpreted as a psychotic basis of need following a clinical psychiatric diagnosis. Sometimes, of course, both conditions apply and sometimes it gets more complicated than that. What I am really saying to my noble friend is that I am concerned about these diagnostic pathways, who will be doing them, how we will benchmark their qualifications and the quality of the pathways, and how they will be provided given that foundation trusts are not listed in the strategy and that changes are to be made to the structure of the health service through the Health and Social Care Bill.

The other matter I want to raise concerns the professional training of local authority staff. The end goal is to have staff with clear expertise in autism within each area. I am very nervous of tick boxes. I do not want to see a situation where people who have been on training courses tick boxes but we are unable to define what expertise they have or their interface with the autistic community. Therefore, I hope that my noble friend will find a way of evaluating this training to ensure that it is not just a tick-box exercise.

I am looking at the Whip, as I am sure that she will call me to order fairly soon. However, I want to raise a final matter.

I asked my noble friend Lord Freud whether his department had conducted consultation on the Autism Act before introducing the Welfare Reform Act. The Autism Act is a unique piece of legislation. The Department of Health should check whether new legislation that is brought forward by other government departments affects the provisions of the Autism Act. I am concerned about changes being introduced in housing legislation that affect the under-35s and how the strategy for moving towards independent living will work. I do not know whether my noble friend can tell me what discussions his department has had with the DWP but I am seriously concerned that judicial review will be instigated following what I regard as severe defects in other legislation that clearly has not taken the Autism Act into account. I hope that, as the Minister in charge, my noble friend will make it his responsibility to ensure that this does not happen on an ongoing basis.

Health: Stroke Care

Baroness Browning Excerpts

Monday 30th January 2012 Lords Chamber

[Baroness Browning]

My Lords, I, too, welcome the opportunity that the noble Baroness, Lady Wheeler, has given us to discuss this subject. I was a member of the Public Accounts Committee in 2006 when we received the National Audit office report, and again in 2010 when we reviewed the progress of that report. It is concerning to think that some of the concerns of the Public Accounts Committee in 2010 were picked up in the CQC report. I will pick up on one or two of them.

We in the Public Accounts Committee said:

“The Department lacks evidence about what types of post-hospital support and long-term care are most effective for stroke patients and does not have a clear plan as to how such care should be funded”.

I hope that my noble friend this evening will be able to assure us that that has been taken on board, particularly in the light of the changes to the health service. Also, despite 11 per cent of stroke patients being newly admitted to care or residential homes after their stroke, there is little understanding of what services stroke patients need in these settings. As a former constituency MP, I know not only that stroke is life-changing but how much more so it is when somebody one day has a stroke at home and never goes back to that home, instead going into nursing or residential care. I hope that that group of people will not be forgotten and that my noble friend will address them as well.

There is also the question of the joint care plan, which is picked up in the CQC report, and particularly, as part of that care plan, the need for regular reviews. I think the point was very well made about this two-year cut-off point. In fact, the CQC report shows that those plans which incorporate the structure of six-week reviews and six-monthly reviews are not only ongoing but that the best quality care is usually delivered as well. Yet we see that only two-thirds of people had six-weekly reviews, 44 per cent had six-monthly reviews and only one in 10 information packs given to patients on discharge mentioned the reviews at all.

At the UK stroke forum in December last year, the Secretary of State for Health announced that work will begin this year on the development of an outcomes strategy for cardiovascular disease. Will the outcomes strategy for cardiovascular disease replace or complement existing national strategies, such as the stroke strategy? How will it focus on the areas most in need of improvement, such as longer term care and support for stroke survivors? I hope that when he replies my noble friend will also be able to tell us what progress has been made on the development of the outcomes strategy for cardiovascular disease.

Nursing

Baroness Browning Excerpts

Thursday 1st December 2011 Lords Chamber

[Baroness Browning]

My Lords, it is a great pleasure to follow the noble Lord, Lord Hunt of Kings Heath, with whom I have debated many issues in this Chamber.

I agreed with every single word that he said in this debate. I stand in awe of what he has done in his trust. He recounted the list of things that had been implemented, not all of which seemed to need an awful lot of money, although I understand what he said about education and training. You wonder why such practice cannot be rolled out around the country and why exemplars cannot be picked up rather than having trusts that try to reinvent the wheel, struggle or in some cases attract rather adverse headlines, as we have seen in recent years.

I had the great privilege to serve as a Member of Parliament for 18 years in another place. During that time I had the pleasure of working with and for nurses and midwives in my constituency, many of whom came to see me to discuss the problems that they encountered in their work. Sometimes they came individually and sometimes collectively. I pay tribute to the work that the profession does. There are people out there who go that extra mile. As patients or relatives of patients, we should all be extremely grateful to them for that. I know that I am.

However, as has been mentioned by other speakers, healthcare, which includes the nursing profession, has been the subject of some very worrying and adverse headlines, not just in recent weeks but for a long time. Some eight years ago in a debate in another place I raised concerns about nutrition and fluid intakes based on my personal experience of having an elderly relative in a hospital. It seems to me that these things have gone on for a very long time. Mencap still has concerns in this regard. Three years ago it published a report, Death by Indifference, which discussed people with learning disabilities who had died on hospital wards not through disease but through neglect. That is an indictment of us as politicians and of our nation. Members of the nursing profession and others involved in healthcare must feel that very keenly when they see and read about what is happening.

As I listened to the noble Lord, Lord Hunt of Kings Heath, I wondered how hard it would be to make best practice universal if there was a political will and a professional will in all parts of healthcare to look at what works and to implement best practice. I realise that budgets come into these things and that there are always differing opinions on how to do things. However, we are starting to see some common themes coming through, not least in the report Front Line Care, which the noble Baroness discussed. There is a common theme in this report. There is great confusion in the healthcare system, particularly in hospitals, and we as patients are also confused. It is quite possible to go into a general hospital ward and come away still not really knowing who was in charge. It is the uniforms, it is the way people conduct themselves. It is not that people are not doing their job, but you cannot always say who is in charge.

The heading on page 60 of the report says, “The Proliferation of Roles and Titles”, and I would add uniforms to that. At one time I thought I understood all the uniforms on a ward, but I have to say that I do not now. Having been in hospital this year, all I can say is that the lady in the pale blue uniform did a jolly good job for me, but I still do not know what her job title was. The report says:

“especially doctors … were often unclear about what skills and competencies they could expect from individual nurses and support workers, exacerbated by the plethora of job titles and role descriptions”.

It is bad enough that I as a patient was confused, but the fact that doctors are also confused tells us that something needs to be sorted out, and urgently.

Much more seriously, if doctors do not know what they can expect from these different job titles and uniforms, and if the nurses themselves have to delegate—I will come on to delegation in a moment—it is no wonder that there are problems and that some of them become systemic. I say to my noble friend, for whom I have great respect for the work he does on the Front Bench, that these problems are now systemic and need to be treated as a matter of urgency.

Frankly, we do not need another five years of reports and anecdotal evidence. It seems pretty obvious that some people are now overcoming these problems—the noble Lord, Lord Hunt, explained what happens in his trust—and this could now be rolled out. While I understand the need for localism and local decision-making, the Government have to take some leadership in making sure that this is rolled out and that they act as the catalyst to ensure we do not have the same debate in five years’ time.

I return to the subject of nurses and the nursing profession. I agree with noble Lords who have said that it does not necessarily follow that because someone has a degree in nursing, they lack compassion. That is a rather terrible thing to say. However, there is a question about the structure of nursing, which yet again is picked up very well in the report on page 87, under the part entitled “The Way Forward”. The report says:

“There was much comment on the style of leadership needed for the future. ‘It’s to do with whether we’re transactional (you will do this, that or the other—talking down to staff)”—

the Hattie Jacques scenario, I suspect, although a lot of people would quite like to see a few more Hattie Jacques on the ward—

“or transformational leaders (embracing staff and recognizing skills and contributions)’”.

The report goes on to talk about mutual respect, not working in silos, and working as a team. Anyone who has worked in any large structure, whether in healthcare or elsewhere, will recognise those two different styles of management, although I have to say that it does not have to be one or the other. Leadership is about taking difficult decisions and about looking holistically across the whole. I quite agree with colleagues who have said today that those in charge of a ward should also have the authority to deal with nutrition and cleaning. I remember a debate in a German hospital, where the wards were absolutely spotless, about whether cleaning services should be contracted out. The question was asked, “How do you make sure that these wards are so absolutely spotless?”. The reply was that the cleaning was contracted out but that the person in charge of the ward was able to stop the payment of the contract if they were unhappy with the results. That is the sort of authority and leadership that is needed on a ward, and it should be placed with an individual. This is not rocket science. If we had the collective will to implement that, it could be done tomorrow.

Nurses also have to delegate. I was very interested to hear Tony Hazell giving evidence on Tuesday to the Health Committee, which is holding an inquiry into education, training, and workforce planning. He said that there will be more training, both for nurses and for healthcare workers to whom nurses delegate. From this report, it is clearly rather important that everyone in the structure knows and understands their role, and that people are prepared to delegate so that they are not working in silos. In-service training is also important for nurses working in hospitals, out in the community and elsewhere, as well as for those who are not nurses but who work in a supportive role. If such ongoing training were in place, we would not get the horrendous stories, which I have personally experienced on more than one occasion and with more than one person, of food being left at the end of the bed for someone who cannot access it. In-service training and education throughout is important, and it will also help nurses.

Finally, it is important that where there are serious problems, nurses should be able to report colleagues in a structured way. It is called whistleblowing—a horrible term—but in my experience, where really good nurses experience this and hit the buffers in trying to report problems, too many of them leave the service. They find it just too difficult and too unpleasant. We have to build that into the structure when we come to reform these services.

Herbal Medicines

Baroness Browning Excerpts

Thursday 13th January 2011 Lords Chamber

[Baroness Browning]

Is my noble friend aware that it is common practice in many GP practices to make recommendations for alternative medicines, such as tea tree oil for ingrowing toenails and arnica cream for bruises? In my former constituency, one GP practice actually grew its own herbs in the garden.

[Earl Howe]

My Lords, it is a long-standing practice and tradition in this country that medical professionals should be able to take it upon themselves to prescribe freely, as they see fit, in the interests of the particular patient in front of them.