NHS: Cancer Treatments

Baroness Chisholm of Owlpen Excerpts

Thursday 25th January 2018 Lords Chamber

[Applause.]

[Baroness Chisholm of Owlpen (Con)]

My Lords, on a momentous day, I beg to move that we adjourn the House.

House adjourned at 6.12 pm.

NHS: Staff

Baroness Chisholm of Owlpen Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord Clark of Windermere (Lab)]

My Lords, I am looking forward to this debate. I think it will be an excellent debate, with a wide array of speakers representing a great deal of experience right across the health and care service.

We all know that the NHS is one of the living institutions of our country, loved, appreciated and needed by its people. In spite of the difficulties facing it, the service it provides is second to none as the British people seek medical attention and healthcare. Year after year, surveys show that it is regarded internationally as the most efficient organisation anywhere in delivering healthcare.

I shall be a little provocative in what I am saying at this moment. I know it causes some discomfort to some Members on the Benches opposite that a state institution employing 1.3 million people can compete successfully against private medicine. When I say that, I do not include the Minister because I know he is committed to the health service, but I believe there are people in the Conservative Party who find the NHS uncomfortable. It was interesting that the Secretary of State chanced his luck when he alleged recently that the NHS was actually invented by the Conservative Party—a case utterly rebutted by my noble friend Lord Pendry on 2 November in a letter to the Guardian, so I do not need to take that further.

I trust that when we on this side speak today, the Minister will understand the strength of opinion that the Government are slowly but surely allowing the NHS to deteriorate. Several years ago, when I began to question Health Ministers on the NHS, the situation was precarious. Now it is getting almost desperate. The bottom line is that the Government are not providing sufficient funds to meet the demands of an increasing and ageing—we must take those two facts together—population, and that no clever words can hide the fact that they are breaking their manifesto policy to increase spending on the NHS in real terms year on year. If you look at the anticipated spending, you can see that that will not be the case.

I mentioned 1.3 million employees. Those employees are proud to work not for the health service but in it. The service is at its most efficient only when it works as a team. Everyone is interdependent. I feel at times that the Government do not really appreciate that fact. If there is one thing lacking in our NHS, it is that it has no central workforce planning, and that is of real concern.

At the moment, almost all employees feel the same—demoralised and undervalued. They give their all, and more and more people are treated. But the staff feel that their treatment by the Government shows that they are not regarded highly enough. They feel that they are the individuals who suffer most from the Government’s now out-of-date austerity programme. Wherever we look—whether at consultants, doctors, nurses, midwives, healthcare assistants, physiotherapists, radiotherapists, GPs, clerical staff, porters, ambulance drivers, dentists or the scores of other occupations in the health service—it is the same story. The Minister must know this because I know he talks to staff. They feel demoralised and undervalued. Yet, these are the very people who keep our NHS going. It is because of them that patients still get a good service. However, it is slowly getting worse again. We are finding, in spite of the best efforts of staff that waiting lists are growing month by month. Increasingly, deadlines for cancer treatment are being broken. In spite of the Government’s bold declarations, the future for mental health services does not look as good as it should.

Following the Budget, I noticed that initially the press lauded the Chancellor for what he appeared to be giving the NHS. However, after examination of the small print, the general public, the press and those involved increasingly realise how short-changed they were by the Chancellor. They took on board Jeremy Corbyn’s comment that the money, was “well short” of what is needed. Sir Bruce Keogh tweeted that the Budget,

“plugs some, but def not all, of NHS funding gap … Worrying that longer waits seem likely/unavoidable”.

Sir Malcolm Grant, chair of NHS England, said that the money,

“will go some way towards filling the widely accepted funding gap … we can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available”.

NHS Providers stated that,

“tough choices will be needed and trade-offs will have to be made … It is difficult to see how the NHS can deliver everything in”,

the forthcoming year. I understand that just today the NHS England board is discussing what will happen—whether we will have rationing in health. This is against the background of the speech by Simon Stevens, chief executive of NHS England, who on 8 November said that an extra £4 billion was needed in 2018-19.

Yet only the Government seem to deny there is a problem. To pluck a number of key employees, we are short of 40,000 nurses. Recruitment from the European Union has all but dried up. Wages have been frozen at 1% since 2010, leading to a reduction in salary of 10.1% for nurses by this year. Unsurprisingly 70% of nurses reported feeling financially worse off, with 24% saying there were thinking of leaving their job because of money worries. The Government claim that there are 13,300 more nurses than in 2010 and 11,800 more doctors in hospitals. However, we have to question those figures. I do not dispute that they apply in hospitals but when looking at healthcare, we are talking not only about primary care in hospitals but aftercare—the care service. I have letters from care providers saying that they have had to close down some of their institutions because they simply cannot recruit nurses. There are insufficient nurses in this country.

It is no better for doctors. The BMA found a 13% decrease in applications to medical schools since 2013. Last year, there were 7,660 medical students beginning their course, compared with nearly 8,000 in 2010. GP numbers are falling. Almost one-third of GP partners are unable to fill vacancies. Only 13% of partners report that they do not need to fill vacancies, and figures show an actual decrease in the number of doctors working mainly as GPs. The result is that patients are having to wait longer and longer to get an appointment, increasing the demand on A&E departments in our hospitals, which are already under great stress. There needs to be some joined-up thinking.

Even if we go to the top of the tree and look at consultants, we find what I can only describe as a dire situation. The NHS has a shortage of consultants and would-be consultants. During the past year, 1,542 consultant posts were advertised, but only 853 certificates of completion of training issued. Not surprisingly, 45% of the advertised posts were left unfilled. There simply were not the qualified candidates. Ninety-five per cent of doctors in training report that poor morale is having a negative impact on patient safety in their hospital, with half reporting a serious or extremely serious impact.

I do not really need to continue. Perhaps I could sum up this point by citing the president of the Royal College of Physicians, Professor Jane Dacre, who neatly summed it up in her response to the Budget. She said that it,

“felt like we had been given short-term sticking plasters rather than the long-term sustainable plan our patients need”.

It is all very depressing. The Government take the view that it is really not their fault, but a lot of it is. I have to ask: why, when they came to office in 2010—with their coalition partners, but they were by far the leading partner—did they cut nurse training numbers by 22,000? It takes a long time to build up the shortfall that has been allowed. Why, at this critical moment when we do not know whether we have enough nurses or doctors—the Government say we have; I say we have not—why risk the numbers by abolishing the bursary scheme? It is a risk, and the Government know that there are fewer nurses going into training this year than in previous years. I do not have the precise figures but all the universities that I have contacted, with one exception, have found a considerable decrease. If there is no problem with nurses, why was it announced yesterday that we are to step up our recruitment of 5,500 more nurses from India?

I am being a bit critical of the Minister. I hope he will not take it personally but take this opportunity to write to me to correct the information. Last week, in a straightforward Question about agencies, I asked,

“what are the names and locations of the agencies registered to supply nurses to NHS trusts in England”?

It was a straightforward Question, but the Minister’s reply can be described only as gobbledegook. He said:

“Agency rules require that agencies are on NHS Improvement-approved frameworks and these frameworks monitor and approve agencies for supply to trusts. The approved framework operators are Crown Commercial Service, NHS Collaborative Procurement Partnership and HealthTrust Europe”—


I think HealthTrust Europe is an American company. The Answer continues:

“In addition to agencies on approved frameworks, trusts in exceptional patient safety situations can utilise the ‘break glass clause’ and work with an off-framework agency. Using an off-framework agency should be a culmination of a robust escalation process sanctioned by the trust board. Trust boards have primary responsibility for monitoring the local impact of the agency rules and ensuring patient safety”.


I spent a lot of time trying to understand it, and I have understood a bit of it. I have also found out—the latest figure I could get for any particular week—that there are 50,000 applications to use the “break glass clause”. Are those 50,000 nurses from agencies included in the Government’s figures?

[Baroness Chisholm of Owlpen (Con)]

My Lords, may I quickly say that there has been a mistake over the timing? If everybody speaks for 13 minutes, we will go two minutes over time. If possible, will your Lordships stick to 12 minutes? When the clock says 12 minutes, will noble Lords please sit down?

Brexit: Risks to NHS Sustainability

Baroness Chisholm of Owlpen Excerpts

Wednesday 12th July 2017 Lords Chamber

[Noble Lords]

Order.

[Baroness Chisholm of Owlpen (Con)]

My Lords, I am sorry, but this is a time-limited debate and that is not the way it works.

Alcohol Abuse

Baroness Chisholm of Owlpen Excerpts

Thursday 30th March 2017 Grand Committee

[Baroness Chisholm of Owlpen (Con)]

My Lords, this is an important debate, and I thank the noble Lord, Lord Brooke of Alverthorpe, for initiating it.

A recent study in the south-west showed that one in three adults exceeds the permitted government guidelines and that 83% of at-risk drinkers see themselves as moderate or light drinkers, whereas 69% are not concerned about how much they drink. There appears to be a common assumption that the benchmark for too much alcohol is when control is lost on the occasional bender, reliance on alcohol is required to get through the day or a bad hangover is experienced. Few understand the risk to their health, their family or the wider community. High blood pressure, mental health, accidental injury, violence and liver disease are just a few health issues directly linked to alcohol. As the noble Lord, Lord Brooke, mentioned, liver disease is arguably one of the biggest health issues facing the NHS along with deep-seated serious health problems, and the harm is being done to a large extent in the privacy of people’s homes.

Alcohol admissions and related injuries put A&E departments under huge pressure. Estimates have suggested that three in every 10 patients attending A&E are there because of alcohol. People are calling ambulances like cabs to ferry them to hospital when they become incapacitated. Those who are not injured often just need to sleep it off in a place of safety, but they arrive in A&E by ambulance or cab or are taken there by friends. Those who have sustained injuries can be aggressive towards staff, leading to staff being vulnerable and of course adding to the difficulty of treating the injury.

Alcohol harm knows no boundaries. Its tentacles can affect anyone in a community—rich, poor, young, old, the well-educated and those who are not. What can be done? There is no easy solution. Perhaps the following could help towards people being more responsible about their drinking as well as cutting the cost to the NHS. A combination of price control and taxation would successfully target those who drink more of the cheapest and strongest alcohol products.

A comprehensive cultural change is required to educate young people towards activities that do not revolve around drinking. Is an advertising campaign the way forward to educate parents and families about the dangers? Parents play the biggest role in educating their children about the dangers of alcohol abuse. Parents should know who their children are hanging around with and make an effort to get to know the parents of their children’s friends. When parents are involved, they are more likely to be able to pick up the signs of any problems. Of course, that is the perfect scenario and, as we know, many children come from homes where good parenting is not the norm, so educators have a role to play.

Effective approaches include teaching students how to resist peer influences and improve life skills, involve families and provide students with the opportunities to get involved with positive experiences. There is no point in just lecturing on the dangers. That tends to cause most teenagers just to switch off. What programmes are available in schools? Is health and well-being part of the curriculum, particularly in primary schools where recent reports suggest that one child per week is being excluded for heavy drinking. Perhaps the alcohol industry should be asked to contribute towards the cost of these classes. What training are GPs and psychiatrists being given to recognise the signs of alcohol misuse?

The Nelson Trust, a drug and alcohol treatment centre in Gloucestershire, is talking with the local CCG to consider placing workers in A&E to target frequent visitors whose admissions are alcohol related. A senior nurse told the charity that local hospitals are doing 30 in-patient detoxes a month on individuals who have come into hospitals because of a fall or a gastro problem, for example, and who are found to be alcohol dependent. They require a 10-day in-patient stay only to go out and repeat the process. We are fortunate in this country to have experienced, successful charities involved in addiction. Let us have a joined-up approach and use their expertise in medical settings and educational facilities.

We all have a responsibility to ensure that alcohol is drunk in a responsible way. As an A&E consultant pointed out, it appears that people do not make plans at the end of an evening to get home safely or look after their friends. A whole department can be disrupted from just one drunk patient. The Government’s role is to address the problems caused by alcohol and to support people to stay healthy without unfairly affecting responsible drinkers and businesses.

Mental Health: Young People

Baroness Chisholm of Owlpen Excerpts

Thursday 9th February 2017 Grand Committee

[Baroness Chisholm of Owlpen (Con)]

My Lords, I thank the noble Baroness, Lady Massey, for initiating this debate. Mental health is coming out of the shadows and into the light. This generation will benefit from the greater awareness that their parents and grandparents were denied. It is a largely taboo subject for older generations, and because of this, physical health is talked about far more openly than mental health—for instance, we talk about children’s allergies but not their self-harming.

Conversations about mental health issues should be about hope and support, not shame and confusion. As parents, we recognise when a child is physically unwell, but mental health is far more complicated. Differentiating between normal problems experienced by children and the kind of behaviour that could be the first signs of a mental disorder is difficult, yet we know that early intervention is the first step towards effective treatment. As the noble Baroness, Lady Massey, said, half of all lifetime cases of mental illness begin by the age of 14. Parents have a vital role in contributing to support and solutions for successful outcomes. Those who develop good communication skills are more likely to pick up problems.

However, for parents to be able to give the support required, they in turn must be listened to and supported. Parents can feel sidelined. Building resilience in the family brings a better chance of helping a young person in the long term. Making parents part of the solution can help reduce the need for crisis intervention. They have a critical role to play in joint decision-making. It can be devastating and bewildering to realise that something is seriously wrong, and that can be after parents have been struggling for months. Their first port of call is usually the GP. Here they should find heightened awareness, information, advice and options available so that the right decisions can be made about supportive treatment, yet most GPs have very little mental health training. Is this going to change?

Schools have a vital role. Teachers are a large part of a young person’s life. Some 65% of primary school children were in contact with NHS mental services for the year ending June 2016. We must focus on prevention, and parents and schools are central to that. Studies have shown that school-based counselling services have a positive impact on learning. Will the Minister confirm that funding for this counselling will continue?

Oliver Goldsmith Primary School in Peckham is delivering a new programme, funded by the South London and Maudsley NHS Foundation Trust, called CUES-Ed. The programme teaches children to recognise the signs when things are not right, and behavioural techniques to help them to manage their mood. However, this is rare. What training are teachers getting in dealing with mental health problems among schoolchildren? The time has come for joined-up decision-making and care between healthcare professionals, parents and teachers. We must ensure that there is access to effective treatment, that services are tailored and responsive to their communities, that children get the help they need and that parents are included so they are part of the solution. Our children have the right to timely treatment, just as they would get with a physical health problem.

Nursing and Midwifery: Student Applications

Baroness Chisholm of Owlpen Excerpts

Tuesday 7th February 2017 Lords Chamber

[Lord O'Shaughnessy]

I am grateful to the noble and learned Baroness for bringing up that issue. I have not seen the report, but I shall certainly look at it. It is true that, across the public sector, there is an issue with an ageing workforce. To some extent, that will be addressed by the fact that we will all be working until we are older. The Government will also be introducing increases to the number of training places, which was a critical reason for moving from a bursary to a fee-based system. The bursary system involved a cap; we are now able to release that cap and bring more numbers through in the training.

[Baroness Chisholm of Owlpen (Con)]

My Lords, as a very old retired nurse, can I ask my noble friend what the Government are doing to encourage an alternative route into nursing like the back to nursing course, which I took when my children were old enough to allow me to go back to work?

[Lord O'Shaughnessy]

I thank my noble friend for that question. There are a couple of new opportunities: one is nursing associates and the other, in common with changes across the public sector, is that there are up to 1,000 new nursing degree apprenticeships providing alternative routes into nursing for those who do not want to go down the university route.

Mental Health: Children’s Services

Baroness Chisholm of Owlpen Excerpts

Thursday 19th January 2017 Lords Chamber

[Lord O’Shaughnessy]

I could not agree more with the noble Lord. It is significant that the Prime Minister made the announcement on mental health and committed herself to a big improvement in both the amount of funding and the services offered. Part of that is making sure that schools and health work together, with every secondary school in the country being offered mental health and first-aid training, but clearly there is much more to do.

[Baroness Chisholm of Owlpen (Con)]

My Lords, clearly prevention is better than cure. What is being done by the Department for Education and the Department of Health to work together to educate teachers—in fact all those who come into contact with people in our schools and universities—to notice when a young person might be having a mental health episode?

[Lord O’Shaughnessy]

The sad fact is that the prevalence of mental illness among young people, whether it is self-harm or eating disorders, is growing and there is a real problem. Schools have to play a central role along with health services in addressing it. One of the Prime Minister’s announcements was a major thematic review of children and adolescent mental health services, which is being carried out by both the Care Quality Commission and Ofsted, so that is an important point about joint working. Indeed, the Green Paper that we are committed to producing will be put together by both the Department of Health and the Department for Education. That is a very important statement of intent. Clearly there is a lot of work to do to fill it with good content that will make a difference, but there is absolute determination from the PM downwards to make that happen.

Atrial Fibrillation

Baroness Chisholm of Owlpen Excerpts

Wednesday 4th November 2015 Lords Chamber

[Lord Rea (Lab)]

My Lords, I congratulate the noble Lord, Lord Black: he has done us all a service by bringing atrial fibrillation before us. It is not the first time it has been debated in the House, but it is very relevant. Like him, I suffer from the condition of paroxysmal atrial fibrillation. What he and many other people have said more or less follows what I have prepared; I agree with nearly everything that has been said so far. Atrial fibrillation is on the increase and is a really serious problem, in that it can cause a stroke.

It is also relevant that I am a former GP who has treated a number of people with atrial fibrillation, but that was some years ago and we did not have the tools and medications—the drugs—that we have now. Some of my information, therefore, has been gained through reading rather than practice.

Atrial fibrillation increases with age, so it is not surprising that a number of your Lordships suffer from it. Some of us may not even be aware of it, as has been said, since it gives rise to quite mild symptoms and sometimes none. Sometimes it is continuous, but sometimes it is episodic or paroxysmal. Treatment consists of measures to detect and, as far as possible, correct any conditions that might underlie the atrial fibrillation—and there are quite a few—and then to restore normal rhythm, if possible, with drugs, electrical cardioversion, or surgical ablation, as has been mentioned. Most important is the prescription of suitable anticoagulants to minimise the formation in the left atrium of clots, which can be carried around the body, block an artery and deprive an area of the brain of its blood supply, leading to an ischaemic stroke. A stroke caused by atrial fibrillation is often more serious than one from other causes, so it is particularly important to detect it as soon as possible and start treatment with effective anticoagulation. Until recently, this was not emphasised adequately by clinicians and the standard drug used was inadequate—low-dose aspirin.

Trials have shown that more powerful anticoagulants have a measurably better effect than aspirin in reducing embolic stroke. The first of these, as has been said, is Warfarin—rat poison—which inhibits vitamin k action, an essential part of the clotting process. It is remarkably cheap, and its cost is amply repaid by the savings incurred by the National Health Service that it gives rise to through stopping atrial fibrillation-related stroke. I take warfarin, like the noble Baroness, Lady Gardner. My condition is under control, but having to be tested from time to time is a nuisance. I thoroughly agree with the suggestion that self-monitoring should be made available. The instruments cost about £200.

The main trouble with warfarin is that it takes some time for its effects to cease, and it can cause internal bleeding. If such bleeding occurs and cannot be brought down quickly, that is a worry. Despite what the noble Baroness, Lady Masham, said, NOACs allow the clotting time to increase quite rapidly after stopping taking them, so they are safer than warfarin.

On detection, it is very important, as has been said, to find the cases that do not have much in the way of symptoms. I will say a few words on that. Sadly, detection has been woefully inadequate up to now. That may be simply because the doctor or nurse has failed to take the patient’s pulse.

[Baroness Chisholm of Owlpen (Con)]

Order.

[Lord Rea]

Yes, I understand. I back the suggestion from the noble Baroness, Lady Murphy, that people should always learn how to take their own pulse.

The other thing that I wanted to ask the noble Lord quickly—

[Baroness Chisholm of Owlpen]

I am sorry, but time is up.

[Lord Rea]

May I ask him afterwards?

[Baroness Chisholm of Owlpen]

Yes.

NHS: Medical Staff

Baroness Chisholm of Owlpen Excerpts

Monday 15th December 2014 Lords Chamber

[Earl Howe]

I agree with the noble Baroness. It is important to underline that the medical training initiative, which is the means by which we can present an offer to foreign doctors—that is, postgraduate medical specialists—to come to train here, is a fixed-term arrangement for up to two years. It seeks to promote circular migration so that participants in a scheme can return to their home country and apply the skills and knowledge developed during their time in the UK. That is very valuable for those individuals and those countries.

[Baroness Chisholm of Owlpen (Con)]

My Lords, during my career as a nurse, I had the privilege of working with nurses from all over the world, including the African continent. They showed enormous compassion and dedication to their work. Does my noble friend feel that it is important that, when these nurses come to England, they are given all the support and training possible so that they reach the high standards that our nurses reach in their training here?

[Earl Howe]

My Lords, I do. My noble friend will be aware that the Nursing and Midwifery Council has established standards which ensure that the quality of the nurses whom we get from overseas is absolutely up to that of home-trained nurses. Support for those nurses while they are in this country is of course an essential ingredient if we are to keep them here for a reasonable length of time.

Care Sector

Baroness Chisholm of Owlpen Excerpts

Tuesday 25th November 2014 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, I thank the noble Baroness, Lady Kingsmill, for initiating this debate and the noble Baroness, Lady Howells of St Davids, for the thought-provoking words we have just heard. This is such an important issue. Our ageing population is growing, which is going to lead to an increase in demand for residential and home care, day centres and meals—but care workers look after people of all ages.

As a former nurse, I know only too well the invaluable service that care workers perform in our communities throughout the country. They carry out some of the most important work in society, caring for those who are elderly, frail, disabled both mentally and physically, and in some cases suffering from addiction problems. Their work is physically and emotionally demanding, often undertaken in unsocial hours. As a nurse, I know that looking after someone can be and is a rewarding experience, but it can also be a deeply emotional, draining and lonely one.

I would like to turn briefly to those carers who perform this vital role unpaid, and how important paid care workers are to this group. As the noble Baroness, Lady Kingsmill, pointed out, across the UK there are more than 1 million paid care workers. But they are in the minority compared to those who do this work for no pay. It is estimated there are 6.5 million unpaid carers; three in five people will take on this role at some point in their lives. These selfless people are estimated to be saving the state £119 billion a year, and they can be anyone of any age who provides unpaid care to family or friends who could not manage without this help. But these carers need care themselves to be able to continue in this role. They are twice as likely to be permanently sick or disabled from their demanding work. Many face depression. There is a clear moral and economic case for supporting carers, and this support usually comes from paid care workers.

Voluntary carers are the first line of prevention. It has been well documented that they experience disproportionately high levels of ill health, but increasing support for them improves their health and well-being, as well as the health outcomes of the recipients. I am proud to be part of a Government who have initiated the Better Care Fund, which is integrating health and social care across health sectors; but we must have a joined-up approach for our voluntary carers and paid care workers. Research shows that providing good-quality support for voluntary carers prevents an escalation of demand on statutory services. Local authorities can reduce spending on care by more than £1 billion per year by spending on breaks, information and support for carers. When support is required, voluntary carers depend on high-quality care for recipients with care needs. They will forego assistance from care workers unless they feel the care received is of the high standard expected.

Anecdotally, I was told about care workers who went from appointment to appointment by bus. They had no access to a car and were frequently up to two hours late, causing distress to the person they were looking after, and, where present, distress to relatives. So it is imperative that paid care workers have the right attitude, are well trained and supported, and given the right tools for their job; that they know the needs of the person they are caring for, and are paid appropriately for their time and not the cheapest rate possible.

Under a new scheme that came into effect from October 2013, it is now simpler to name and shame employers who break national minimum wage law. But cases from the care sector can take longer to investigate than comparable cases from other sectors because of issues around travelling time and on-call pay. I am pleased to see that the Department of Health is clear that social care employers should pay home care workers for travel time between clients. The department is looking to ensure that the statutory guidance that accompanies the Care Act states that local authorities must have evidence that conditions and fee levels are appropriate.

The challenges faced today to give high-quality care are enormous. The care certificate for new healthcare assistants and social care workers is being introduced from 1 April 2015. This surely will go some way in developing the required behaviours, competences and skills, to enable them to provide high-quality, compassionate care.

We all want the most vulnerable in our communities to receive the best possible care, and this will be possible only if the authorities are committed to making sure that the care workers they employ are of the highest standard. For this to be the case they must value them by the training they are given, the information given on the recipient of their care, and the financial reward they receive for their work.