Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Committee stage & Lords Hansard - Part 1
Tuesday 11th January 2022 Lords Chamber

[Lord Patel (CB)]

My Lords, my knee-jerk reaction was going to be, “I don’t agree with what Lord Lansley says”. However, I have put my knee hammer back in my pocket, because I do agree with him about the importance of using outcomes indicators as a measure of the performance of health in patients. In that respect the outcomes framework has always been a good development. Although Clause 4 focuses on cancer—and I hope we do not change that—it is an example of how it can be used for other conditions to improve healthcare.

The noble Lord has also identified one key omission in this Bill, which I hope we can find a way to fill: who will be responsible for making sure that there is continuous improvement and development in healthcare that measures the outcomes? That is not in the Bill. I hope we might find a way to do that, whether through the mandate or other ways. That is all I have to say.

[Baroness Finlay of Llandaff (CB)]

My Lords, I must declare an interest, because a lot of the outcome measures that are now used are in place at Cardiff University. I will expand a little on and support what my noble friend Lord Patel said about outcome measures, particularly for something such as cancer. That is in part because the disease process itself is marching on all the time. It is different from many other diseases, where there might be a chronic condition and other things happen as a result of it. If you do not intervene rapidly with some cancers, you miss the boat and go from being able to cure it to a situation where you certainly will not be able to.

The other group of outcome measures that I do not think we should forget has just now been developed: family-reported outcome measures. That is the impact on the family. We know about the number of carers that there are. There are child carers and many unpaid carers. Having somebody in the family with a disease process, waiting for something to happen and seeing that disease process getting worse and worse in front of their eyes, has a major impact on the health of others and stacks up problems for the future in the health service.

That is why, when I was on the All-Party Parliamentary Group on Cancer, I strongly supported John Baron in all his efforts to look at the one-year survival times in cancer. Looking at outcomes can be far more informative than looking simply at process targets, which is what we have been looking at too much to date rather than looking at the overall impact of disease.

[Baroness Thornton (Lab)]

My Lords, I will speak to Amendments 7 and 9 in my name. I thank the noble Lord, Lord Lansley, for introducing this debate and I look forward to supporting the noble Baroness, Lady Walmsley. I think we are about to see harmony breaking out between the four walls of the Chamber. The noble Lord, Lord Lansley, and I are I think in accord over these amendments.

Historically, the mandate is part of the attempted change—I think that is probably the right way to put it—to distance the role of government and Ministers from the sound of bedpans dropping, if I might put it like that. Unfortunately, as the noble Lord, Lord Lansley, said, despite the mandate’s intentions, recent Ministers have still tried to micromanage and otherwise interfere with NHS managers. During the passage of the 2012 Bill, the Government had to concede that the Secretary of State remained politically responsible to Parliament for the NHS.

I think it would be fair to say that laying the mandate before Parliament in each year, as was intended, has not brought about energetic debates and wise reflections in either House of Parliament. But the mandate is not without merit. It is good that the NHS knows what is expected of it and should be free from sudden announcements and other surprises. Without something of this nature, it is wholly unclear how accountability works. So we accept that, at least until the next reorganisation happens, there has to be a mandate, and the important thing is to get this right.

For that reason, we support the two amendments from the noble Lord, Lord Lansley. If anybody knows how the mandate ought to be used, it is definitely him. Trying to have clearly stated objectives in the outcomes framework, or some equivalent, and ensuring that the mandate is objective, evidence-based and publicly accountable must be correct.

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[Lord Kakkar (CB)]

My Lords, I support the objectives of this group of very important amendments. In so doing, I remind noble Lords of my interests as chairman of the King’s Fund and of King’s Health Partners. I have seen this work directly in King’s Health Partners through a programme defined as Mind & Body, which proposes to promote pathways of care across the entirety of our health economy that look in equal measure at physical and mental health for all patients, irrespective of their principal clinical presentation. Initiatives such as that important programme could be brought to fruition only because of the emphasis in the 2012 Act regarding parity for physical and mental health. It demonstrates very clearly that legislative intervention can have a profound impact. I very much join in congratulating my noble friend Lady Hollins on her relentless commitment to these issues in your Lordships’ House over the past 10 years, which have had and will continue to have a profound impact.

It therefore seems counterintuitive for Her Majesty’s Government, in bringing forward this important legislation, to move away from the opportunity to emphasise the importance of this parity. Is it sensible to move away from this position? Why not use the opportunity afforded by this important legislation to emphasise once again the importance of parity between mental and physical health in every respect—not only funding but the organisation and supervision of services and the construction of organisations within the NHS—so that, step by step, we can achieve what every Member of your Lordships’ Committee who has spoken in this debate has emphasised?

Will the Minister, in replying to the debate, reassure your Lordships that not proceeding with these amendments does not undermine what has been achieved so far and that what is proposed in the Bill can without the amendments achieve the continued momentum and concentration of focus on this vital issue, to ensure that we continue not only to develop mental health services but to ensure that they can be integrated more broadly into physical health, and that physical health services can be developed to ensure that the mental health consequences of physical conditions can also be appropriately addressed? In taking this holistic approach, we will achieve the objectives of better well-being and health for all our fellow citizens—one of the most important aspects of the triple aim.

[Baroness Finlay of Llandaff (CB)]

My Lords, I should declare my interests as having worked with liaison psychiatry extensively in the cancer centre in Cardiff, and as chair of the National Mental Capacity Forum for England and Wales.

One group that has not been mentioned yet—I appreciate the noble Lord, Lord Warner, mentioning some—is those with impaired capacity and learning difficulties. We should not underestimate the importance of access to psychiatry for those people who develop mental health problems as a result of their physical health problems. To view the two as separate is a fallacy because they are completely integrated in many people. Many people present initially with a physical illness but develop mental health problems which, if ignored, become really major. The opposite also occurs, of course. Those people with learning difficulties and impaired capacity at different levels often have a raft of quite serious physical medical conditions that might be particularly difficult to diagnose because their mental health problems get in the way of their ability to express themselves.

If we are really to drive up the health of the nation at all, we would be completely misguided to ignore the importance of this group of amendments. Like others, I urge the Government to grasp this nettle, put this in the Bill and make sure we finally address this severe imbalance, which has left so many people never accessing the care they need. That applies both to mental health care and to those with mental health difficulties who then fail to access the physical healthcare support they need because they just cannot express their needs properly.

Care Workers: Professional Register

Baroness Finlay of Llandaff Excerpts

Monday 10th January 2022 Lords Chamber

[Lord Kamall (Con)]

As the noble Baroness will appreciate, many people who work in social care are employed by private care home owners and other bits of the sector. If she looks at the minimum wage, there has been an announcement of 6.6%, effective from 1 April, which means that workers will be paid more, but one of the bases of some of the additional funding that we have announced is to convince local authorities to put pressure on private care home owners and others to make sure that they pay staff more.

[Baroness Finlay of Llandaff (CB)]

Given that the Government have clearly expressed the view that social care must be adequately valued, which is to be welcomed, and the comments about pay scales, what is the Government’s attitude to those employers in the private sector who do not hand on pay at time-and-a-half on bank holidays and so on, to their front-line staff? These front-line staff feel exploited and do not receive any pay or reimbursement for travel time between clients, even though they may spend quite a lot of time on the road. They are paid only while they are actually in somebody’s home in the community.

[Lord Kamall (Con)]

Issues such as the way private care home owners treat their staff are all part of the consultation that we launched on 6 January. We are working across government and with the devolved Administrations to seek views on the proposed criteria on which the profession should be regulated, whether there are regulated professions that no longer require statutory regulation, and whether there are unregulated professions that should be brought into statutory regulation. The consultation will run for 12 weeks until 31 March, when we will look at the results before taking further action.

Hospital Beds and Social Care

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Thursday 6th January 2022 Lords Chamber

[Lord Kamall (Con)]

We have been looking at different pathways out of hospitals, and one of the discharge pathways is step-down care. One issue that the task force has looked at is how we improve and increase accessibility to appropriate step-down care when a patient is unable to go straight to their home.

[Baroness Finlay of Llandaff (CB)]

I will follow on from the question from the Labour Front Bench. Who is taking responsibility for actively recruiting staff so that any step-down beds can be staffed and managed? We have a workforce problem; without actively recruiting back into the workforce people who have experience but currently have left, we will not bridge that gap in manpower and womanpower provision.

[Lord Kamall (Con)]

All noble Lords will appreciate the work and dedication of all our social care workers, especially in these challenging times and with the extra pressure that omicron has brought. Throughout the pandemic, we have provided different types of funding. In December 2021, we announced an extra £300 million to support local authorities working with care providers to recruit and retain staff throughout the winter. This funding is in addition to the £162.5 million announced in October 2021. We recognise the issue, and it is about working with local authorities and others to make sure that this money gets into the system and achieves what it is intended to do.

Breast Screening

Baroness Finlay of Llandaff Excerpts

Tuesday 14th December 2021 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for raising the importance of co-ordination and sharing information across the devolved Administrations. I have meetings scheduled with health Ministers from the devolved Administrations, and I will make sure that my office puts this on the agenda.

[Baroness Finlay of Llandaff (CB)]

My Lords, following on from the question of the noble Baroness, Lady Ritchie, will the Minister tell us how the stage of presentation of breast cancer has altered over the past two years? How many women presenting with stage 3 and stage 4 cancers had never been screened?

[Lord Kamall (Con)]

I thank the noble Baroness for giving me advance notice of the question, and so giving me the chance to get some information. Data on cancer stages is currently published only annually, and NHS Digital is publishing the data from 2019 on Thursday 16 December. The latest data from 2018 shows that nearly 86% of breast cancers were diagnosed at stages 1 and 2, meaning that about 15% were diagnosed at stages 3 and 4, but this was pre-pandemic. I will make sure that I get the updated data as soon as possible.

Medical Schools: Training Places

Baroness Finlay of Llandaff Excerpts

Monday 13th December 2021 Lords Chamber

[Lord Kamall (Con)]

The noble Lord raises an important question, but the fact is that we are training more doctors, and we are recruiting internationally where it is ethical to do so. On retirements, we are looking at a scheme that lasts until 2024 to allow doctors to come back without it affecting their pension.

[Baroness Finlay of Llandaff (CB)]

My Lords, I should declare that I am a fellow of the Royal College of Physicians. Do the Government accept the report from that body, Double or Quits, which has shown that we need 15,000 medical school places annually? Doubling the number of medical school places to that number would cost £1.85 billion, which is only one-third of what hospitals currently spend on agency and bank staff. Therefore, an increase is an investment to save.

[Lord Kamall (Con)]

I thank the noble Baroness for that question and for the advice and expertise that she has passed on to me in my short time in this place. As part of the expansion, we have opened five new medical schools across England, in Sunderland, Lancashire, Chelmsford, Lincoln and Canterbury. Sometimes we have the training, but it is difficult to find doctors in certain locations. We have tried to move training as close to those locations as possible.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests in medicine and physiotherapy and as a Bevan Commissioner. Like others, I welcome the noble Lord, Lord Stevens of Birmingham, who clearly brings a veritable wealth of experience.

In the debates during the previous health and social care Bill, there were two references to the Titanic, and it felt as if we were commissioning different lifeboats. The lifeboats never arrived. We have two separate systems, health and social care, both of which are creaking under current pressures and severe workforce shortages. Integration is essential and complex. Integrated care boards need comprehensive membership, with a broad overview for patients and children.

Specialist palliative care services, like maternity services, must be commissioned as core. Would you depend on fundraising events for a woman to be able to have a caesarean section in obstructed labour? No. So why do we allow distress in severely ill people to go unaddressed because there is no specialist palliative care service commissioned? I do not mean after-care, as was suggested in the other place. Good specialist palliative care must be commissioned to be integrated across the trajectory of a person’s serious illness, to deal with problems in a timely way when the prognosis is unknown, not just when people are actively dying.

Children and young people need to be considered in all parts of the system, with integrated services and early mediation for disputes between clinicians and loving parents. Abuse, alcohol and drug addictions, the promotion of cosmetic procedures, dental caries and nutritional problems are all part of the public health emergency for children and young people we now face. Underpinning all of this for children is data. There is a desperate need for a unique identifier for a child that goes across health and social care. Some 46 years ago, I admitted a child who had been dipped in boiling water. The case went to the Old Bailey. This week, we heard of a child being brutally assaulted and killed. Has nothing changed? We cannot continue to have social care data kept separate from healthcare and not linkable to education and police records. To improve life chances, we must have relevant information rapidly available. Across the UK, transferable and comparable data is also imperative for decisions in devolved Administrations to be made in the best interests of the patient. This Bill needs to show that.

Seven years after Framework 15, workforce projections remain uncertain. Some 48% of advertised consultant posts went unfulfilled across the UK last year, and there are long-term vacancies on top of that. Unless workforce planning, education and training improve, underpinned by research initiatives and findings, care provision will not improve.

We also need to recognise the appalling work environments, where staff do not feel looked after or valued. Social care will only have the status that it deserves if there is an integrated career path with the NHS, with staff travel time paid for and staff able to access support and advice if they are concerned about someone—with their opinion being valued—without having to go through multiple hoops.

Cancer outcomes at one year are falling behind that of our European colleagues, yet our research is ground-breaking. Sticking with process targets is not good enough. We must not water down the amendments so ably introduced in the other place and accepted by the Government.

Disease does not respect the clock or the calendar. The Bill fails to address the overwhelming number of problems that arise during the three-quarters of the week that is out of hours. The Bill also fails to address the large number of people being treated in inadequate premises because overcrowded emergency units are unable to move sick patients through to wards because there are no beds. Currently, one cannot expect ambulances to offload in a timely way or expect staff to give each patient safe care. Discharging into the community to assess needs in people’s homes makes sense, but where is the workforce to do it? Physiotherapy and occupational therapy are essential in every team to avoid deterioration as well as to restore well-being.

Until health and social care are integrated, we will not solve any of the problems that we face. I believe that the budgetary systems need to be combined. Clause 140 feels like trying to apply an enormous sticking plaster to tackle the underlying chasm: the gap between the current rationing of social care by means-testing versus an NHS free at the point of delivery. The success of the integrated vision in the Bill rests on social care being an equal partner to the NHS, but significant work is required if parity is to be achieved. We have much to do.

NHS: Elective and Cancer Care Backlog

Baroness Finlay of Llandaff Excerpts

Tuesday 7th December 2021 Lords Chamber

[Lord Kamall (Con)]

The Government have announced the NHS long-term plan. We have had a budget increase. We are focusing on a number of different issues. One of the challenges over recent years has been the ageing population. That should be a positive thing and we want to make sure that we look at the new health challenges that we face for the future.

[Baroness Finlay of Llandaff (CB)]

My Lords, do the Government recognise that one-fifth of patients with cancer are diagnosed in emergency departments across the country? When patients are diagnosed late, the nature of cancer and its progressive metastasising behaviour means that, by the time they are diagnosed, the treatment burden is greater and the cost to the NHS goes up. Early diagnosis becomes the only way to tackle the overall problem.

[Lord Kamall (Con)]

The noble Baroness makes a very important point—as did the noble and gallant Lord—about how we reconfigure our healthcare system to make sure that we catch these diseases much earlier in the system rather than waiting for secondary referral. This is not only in primary care but lots more self-diagnosis with more technology now in the home and elsewhere.

Health and Social Care

Baroness Finlay of Llandaff Excerpts

Monday 6th December 2021 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I should declare my interest in relation to medicine, the BMA and the Royal College of Emergency Medicine, and I would like to ask about emergency medicine. The winter flow data from the Royal College of Emergency Medicine has data from 40 sites across the UK. They are reporting that, in November, there were 275,596 attendances. Their long hospital stays had increased by 13% to more than 48,000 patients. Their 12-hour stays in emergency departments were twice as high as they had been in the previous year, and that was equivalent to 7.3% of all attendees. Their four-hour performance is incredibly low, at 62%. I know from one department that was built for 28 patients that, on a Monday in November, it had 108 patients in. This becomes unsustainable, and the overcrowding is a danger in terms of Covid and infection. It is also a danger to the welfare of staff because, in this particular department, even the staff toilets were not flushing, so the staff had to leave the department just to excuse themselves.

The estate takes time to rebuild and be repaired. What is being done with projects now to create additional space for emergency departments to manage this overcrowding? Is there targeted money going to make sure that the departments are in a good condition of maintenance for the staff? Separate, but related, to that, is the pension block, which has stopped doctors from returning from retirement and has pushed some doctors into early retirement, being addressed in the long term? It is important that doctors who have retired because their pension pot has reached its limit can be incentivised to come back to take pressure off in GP surgeries and in hospital departments, particularly out-patient departments, by seeing patients where their long-term experience and wisdom can contribute to the clinical services.

[Lord Kamall (Con)]

I thank the noble Baroness for the points she makes. We are doing what we can to support the dedicated NHS staff in healthcare services. This year alone, we have invested over £15 billion on top of the existing NHS annual budget, and that includes funding to help get patients out of hospital, freeing up beds and supporting hospitals to manage Covid-19. In addition, we are looking at how we can tackle capacity issues on NHS 111 and A&E. We are giving NHS 111 £98 million to boost capacity, help people avoid unnecessary ambulance trips to A&E and take pressure off hospitals. We realise that NHS 111 is often the first port of call to provide urgent medical advice quickly and book time slots for people at their local A&E or appointments at alternative services. We are also delivering the largest ever seasonal flu vaccination programme, so we hope to tackle it on that basis. A number of CCGs and others are having conversations about how we can tackle the pressures on A&E.

The noble Baroness makes the point about staff who, during Covid, went way beyond the call of duty, and we managed temporarily to address those concerns. We are very grateful to staff who had retired and returned, and we are looking at whether that can be a long-term solution. We need to make sure that no one who is willing to come back is disincentivised. I do not have the details at the moment but I commit to write to her.

NHS: Primary Care Surgeries

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Wednesday 24th November 2021 Lords Chamber

[Lord Kamall (Con)]

I thank my noble friend for that important question. International engagement remains crucial to tackling the pandemic and ensuring future resilience. In my first few weeks in the job, I have had a number of meetings, at bilateral, G7 and other levels, to make sure that we are fostering international health partnerships. “It is also really important that we understand the contribution the private sector can make towards making the NHS better for all of us.” Those are the words of Alan Milburn, also a former Labour politician.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare that I am a fellow of the Royal College of General Practitioners. Do the Government recognise that, with an increasing number of GPs working salaried and part-time, it is essential that they have security in their contracts? There is a tension when commercial providers need to provide profits to their shareholders, which can work in the opposite direction to the needs of the community, as the medical staff should be working as a co-operative to improve services locally.

[Lord Kamall (Con)]

I am sure that we all want to pay tribute to the work of GPs, who are at the front line and, quite often, are the gateway to many services across the NHS and the wider healthcare system. It is important that we recognise some of the pressures they are under, but also work out how to help them and, indeed, patients. As I have said in the past, I will be a champion of patients and it is important that patients have access to their GPs, as a gateway to further services.

Covid-19

Baroness Finlay of Llandaff Excerpts

Monday 15th November 2021 Lords Chamber

[Lord Kamall (Con)]

I apologise if I have misled the House: I have booked my booster jab but I have not had it yet. I was able to book it in advance but I cannot have it until—perhaps I should not make this public, but they have given it to me one day before the six months is up. This will be all over the front pages tomorrow, it will be a huge scandal and noble Lords will be calling for my head. I understand that.

On the serious point, I share the frustration of all noble Lords who have brought this issue up. I was hoping to be able to announce a date today, but it was scratched at the last minute. I think there was some technical reason, but we hope to have good news soon. I know that will be as frustrating to many noble Lords as it is to me. Believe me, I would rather have good news than to be seen to be avoiding answering the question.

[Baroness Finlay of Llandaff (CB)]

I shall follow up on the question asked by the noble Baroness, Lady Tyler, in relation to pregnant women in particular. There were maternal deaths early on. It would be most helpful if we could have the data on the number of such women, the pattern of vaccination and the pattern of maternal deaths from Covid and severe infection. Women are still worried and hesitant because there was a failure to vaccinate early on, because the data on safety was not there. Having data on the drop in the number of deaths will help to persuade women of childbearing age to pursue being vaccinated, whether they are already pregnant or not.

[Lord Kamall (Con)]

The noble Baroness raises a very important point and I apologise for not spotting it and answering it earlier. Many noble Lords will be aware of the very sad story of a young lady who died because she felt that the vaccine was not safe; her mother is encouraging other pregnant women to have the vaccine. For that reason, we want clearly to communicate that the vaccine is safe and will not affect fertility, so getting the vaccine is the best way to protect yourself. Pregnant women are more likely to get seriously ill from Covid-19, and we know that vaccines are safe for them and make a huge difference. In fact, no pregnant woman who has had two jabs has needed hospitalisation with Covid-19. We need to make that clearer, and I will take this back to the department and the Government to make sure that we communicate more clearly. We all share the same will to share that message more widely.