Wuhan Coronavirus

Baroness Finlay of Llandaff Excerpts

Tuesday 11th February 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Lord is quite right that each of us has a role to play in preventing the spread of infection. At this point, the advice is that, if you have travelled from any of the infected areas or have been part of the contact tracing, you should self-isolate. Should you have any of the symptoms associated with coronavirus—a cough, fever or shortness of breath—you should stay indoors and call 111, even if the symptoms are mild. Outside the question of whether you have had any contact or travelled to the affected areas, the advice from the Chief Medical Officer is that effective handwashing and the “Catch It, Bin It, Kill It” concept—to use tissues when you sneeze or cough and to throw those tissues away—is the most effective way of limiting the passing on of infection, and each and every one of us has a role to play in doing that. However, I am happy to pass on to the House authorities the point the noble Lord has made and ask for communications to be sent from Public Health England with the most up-to-date information.

[Baroness Finlay of Llandaff (CB)]

My Lords, I thank the Minister for bringing the update to the House. Among all those people to whom we owe a debt, we should particularly single out the chief medical officers, led by Chris Whitty, who is an epidemiologist and therefore has an in-depth understanding of the science. We should also thank the owners and crew of, and all those on board, the “Diamond Princess”—a British-owned vessel—who are working with the Japanese authorities and doing all they can to contain the outbreak that has occurred there.

One of the difficulties—this was alluded to by the noble Baroness, Lady McIntosh, who is not in her place at the moment—is that in the early stages this is like the common manifestation of any other viral disease. Therefore, self-isolation and being responsible by staying away from people is everyone’s responsibility with all such infections. Unfortunately, some turn out to be coronavirus. Are the diagnostic kits for Covid-19, which I think is now its official name, available to adequate numbers of hospital laboratories which are under public health supervision? Are those diagnostic kits available across all four nations of the United Kingdom? Are they linked to Colindale so that there is good co-ordination of the way in which the diagnostic procedures are undertaken?

[Baroness Blackwood of North Oxford]

The noble Baroness is quite right. We are aware that there are British nationals on board the “Diamond Princess” in Japan and that six more people have tested positive for coronavirus, none of whom is a British national. We have offered consular assistance to those British nationals—we have been in touch with the “Diamond Princess”—including one who is in hospital. We obviously pay tribute to the work being done in trying to contain the situation there. I identify myself with the thanks and tribute paid to the work of the CMOs, who are doing an extraordinary job right now to make sure that the UK is prepared.

We are one of the first countries in the world to have an effective test; it is working well. Now that the protocols have been sent to the devolved Administrations, testing centres in Glasgow, Edinburgh, Cardiff and Belfast have started testing already. Labs in Cambridge, Bristol and Manchester have started testing today and Birmingham, Newcastle and Southampton will come online shortly. I hope that reassures the House about the capability already available within the NHS.

Access to Palliative Care and Treatment of Children Bill [HL]

Baroness Finlay of Llandaff Excerpts

2nd reading & 2nd reading (Hansard): House of Lords & 2nd reading (Hansard)
Friday 7th February 2020 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

That the Bill be now read a second time.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests in palliative care, including as vice-president of Marie Curie and of Hospice UK and other roles declared in the register. I particularly welcome the noble Lord, Lord Brownlow of Shurlock Row, who has chosen this Bill for his Maiden Speech.

Let me make it clear: this has nothing to do with assisted dying. My Bill aims to solve two problems for the Government. The first is the ongoing variable access to hospice and specialist palliative care, with even less available out-of-hours. The second is to try to avoid some of the very distressing cases that have gone to court where there is disagreement between the clinical team and deeply distressed, loving parents over the best course of action in the management of a child with a serious life-limiting condition.

I will start with palliative care, which the Conservative manifesto committed to support. Last year, over 492,000 people died in England. It is estimated that, at any time, about 0.75% of the population will have palliative care needs, because the majority of those dying will have a significant terminal phase to their illness. Yet about one-third do not receive palliative care when they need it, particularly those with non-cancer diagnoses, or who are from marginalised communities, LGBT+ or of black and ethnic minority heritage. Those facing death are not just older people. Currently around 49,000 children and young people under 18 and over 55,000 young adults aged 18 to 40 are living with a life-limiting or life-threatening condition; almost 13,000 are aged 18 to 25. Even excluding oncology patients, this prevalence had risen by one-third in a decade, yet palliative care support for these young people is even more patchy than for older adults or small children. That is why the Bill covers all ages.

We know what to do, but we are just not doing it. I am grateful to the Minister for meeting me. I fear she will say that the Government feel they can achieve improvements without legislation, but it has not happened for decades. Major health improvements sometimes need the jolt of legislation and this is one of them. Two examples are smoking cessation, which needed a ban on advertising and smoking in public places, and wearing seat belts in cars. In recent years, many reports have highlighted deficits in palliative care provision, referred to in the many briefings which have been supportive of the Bill. The ombudsman’s report, Marie Curie’s research into inequitable care, and the BMA’s qualitative, in-depth study into end-of-life care are examples. Despite 20 years of strategies and policies, my own inquiry five years ago revealed a 40-fold variation in indicative budgets from clinical commissioning groups, ranging from under £50 to almost £2,330 per palliative care patient per annum. Yet almost half the respondents had no plans to update or review their palliative care provision.

Now it is no better; the End of Life Care Coalition found that 18 of 44 sustainability and transformation plans do not even mention end-of-life care, let alone how they would improve it, and only 40% of clinical commissioning groups provided Marie Curie with data on fast-track packages of care. Following Second Reading of a previous iteration of the Bill, the Minister kindly wrote to me confirming that there is a statutory duty to provide maternity services. Indeed, the duty is far wider than only for the ubiquitous experience of being born. In Section 3(1) of the NHS Act 1977 the general duty on the Secretary of State to provide

“to such an extent as he considers necessary to meet all reasonable requirements”

has a list which includes

“such other facilities for the care of expectant and nursing mothers and young children as he considers are appropriate as part of the health service.”

A notable aspect of the way this list is written is that it focuses on the diagnosis, treatment and aftercare of those who have suffered from an illness. In 1977, there was a deep culture of death denial. When services only strived for cure, death was a failure. Indeed, only 10 years earlier Cicely Saunders had opened her hospice—St Christopher’s—and had begun to shine a bright light on the need for medical research to improve the care of the dying. From that beginning, the hospice movement came about outside the NHS and gradually, as the benefits of all it does became evident, the specialty of palliative medicine was recognised in 1989, 12 years after the 1977 NHS Act mandating maternity care. Now it is time to update the obligations of the NHS and end excessive reliance on voluntary donations to provide care for the only other universal experience after birth, which is death.

Hospices renowned for excellent care have sprung up across the UK. Outreach teams go into people’s homes and hospital support teams transform patients’ experience when faced with a terminal illness. All too often, that is at the time of diagnosis. We all recall our much-loved colleague Lady Jowell and her powerful advocacy for research moving the frontiers of knowledge to improve care and outcomes. Systematic reviews, including one I co-authored, have shown the outcome benefits and cost efficacy of palliative care teams. These services are concerned with far more than just the last days of life.

NHS England has estimated that improved recognition of palliative care needs and services outside hospital could improve care and reduce hospital costs by £180 million a year. Previous iterations of this Bill contained more detail—detail that is better in accompanying guidance. The Bill would ensure that those commissioning services meet the duty to reduce inequalities, as required in Section 1C of the National Health Service Act 2006. It reinforces current strategies, such as the “Ambitions” framework, to meet the Government’s commitment, in “Our Commitment to you for end of life care” and the comprehensive personalised care model, to end variation by 2020. It fulfils the pledges of the NHS constitution and the rights of patients to care appropriate to their needs.

Last August’s announcement by the Prime Minister of a welcome £25 million to be administered through sustainability and transformation partnerships is a one-off grant. Unless changes are incorporated in strategic plans, as Clause 4 of the Bill requires, improvements will not be sustained. Clause 2 would ensure that a hospice with in-patient beds can access supplies from the drug tariff. There is a wide variation in how hospices access the medication and supplies they need, especially out of hours. Hospices with adequate pharmacy support can provide expert advice on medicine management, particularly for complex treatment regimes, reduce prescribing errors and ensure safe medicine supply and disposal.

Some 27 years ago my hospice was the second in the UK to take on a part-time pharmacist; in her first two years she saved more than the cost of her salary. Now, although many hospices have pharmacy support, the arrangements with CCGs are very variable, ranging from nil to more than 67 hours a week, but many cannot access GP or hospital records. I have been given examples of hospice drug costs being halved when supply was transferred from an FP10 model to a full hospital pharmacy supply.

I turn to the difficulties and tragedy of children who are imminently dying, where conflict results in an application to the High Court under the Children Act 1989. The wording of the Bill has been developed following several publicised cases where the parents of a child with a life-limiting prognosis sought other treatment options. Sometimes, communication broke down to such an extent that court action was instigated over proposed treatment or treatment-withdrawal decisions, or to prevent transfer of the child’s care to another reputable provider. I am grateful to Chris Gard and Connie Yates, here today, who generously shared their experience to try to prevent others going through what they experienced, when a polarisation of views made it all the harder for clinicians and Charlie’s parents. They had sought a three-month trial of an oral supplement costing £3,000, with a suggested chance of success of more than 50%. They knew it could fail, yet legal fees of more than £l million, a media circus and acrimony ensued. Three years after Charlie’s death, his mum says, “I just wanted to know we’d done everything we could.” Such grief does not fade.

Legal action has many detrimental effects. It exacerbates failures of communication, increases stress and has long-term mental health sequelae. Clause 2(2) states that independent mediation must be offered early by the hospital when views are diverging before proceeding to court. Mediation, voluntarily undertaken and with information shared openly between clinicians and the parent or parents, can ensure that parents feel listened to and are less intimidated by the power differential of clinicians with complex medical knowledge. Options for a second opinion can be discussed. Of course, if mediation fails for whatever reason or the child needs urgent life-saving interventions or abuse is suspected, subsection (2) would not apply.

Some major clinical decisions are terribly difficult. Overall, treatment or an intervention is ceased because no therapeutic goal is being achieved or the intervention has become excessively burdensome. Similarly, a proposed intervention that poses disproportionate risks of significant harm would be withheld or the risks minimised by transferring the child to a more suitable setting. However, often things are far from clear-cut. They must be carefully weighed in the balance of harms against benefits, but risk aversion must not deny realistic hope. Prognosis is an inexact science and the ways a child adapts to progressive disability are unpredictable.

When deciding the best interests of the child, all aspects of the child’s life and experience must be considered. When the child can express wishes and feelings, these are paramount. When they cannot, it is the parents who normally know the child extremely well, and are aware of the child’s wishes and feelings, aspects that comfort the child and the way that the child feels valued. While the child is alive and therefore has interests, those interests are unique to that child; but all interests cease on death.

Clause 2(4) would give appropriate weight to parental views in the court process, in line with societal and medical norms, in the weighing up of the benefits and disbenefits of a proposed course of action. I am most grateful to the noble Baroness, Lady Jolly, for sharing with me a draft amendment that may help clarify this in relation to disproportionate risk of significant harm and improve this subsection, which I know has caused some concern. The subsection does not form a court direction. It is compatible with the Children Act, which emphasises the crucial importance of the child’s interests, wishes and feelings. It allows the healthcare provider to have the chance to show that a different treatment plan is in the child’s best interests. It does not give precedence to one parent’s view over another; the court must decide on an individual basis, as at present.

This Bill solves two major problems for the Government. First, it can show that they are determined to ensure good palliative and end-of-life care for everyone, everywhere, at all times of the day or night. Secondly, it would resolve some distressing disputes between loving parents and clinicians, rather than proceeding to court. I beg to move.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, I thank all noble Lords who stayed behind on a Friday to contribute and who have done so much research behind the speeches they gave in support of my Bill. I can confidently say that the first part of the Bill has full—from many, completely overwhelming—support. I am extremely grateful for that, as will be all those who are trying to provide excellence in end-of-life and palliative care. I single out the noble Lord, Lord Brownlow, for his amazingly warm maiden speech, in which he showed his understanding of vulnerability and of the fundamental principle of the duty of people in society to look after each other. All noble Lords gained a great deal from it.

I know that the hour is late and we all want to move on, but I will turn briefly to the concerns expressed over Clause 2(4). I am delighted that so many noble Lords want to discuss it. I am more than happy to do so, and to amend it. We have to get things right; this was my humble start. We have fantastic expertise. I reassure the noble Lord, Lord Hunt, that I am in conversation with Together for Short Lives. The noble Baroness, Lady Jolly, has been incredibly helpful to date and I am sure would join me when I say that we should expand the discussions to include the noble and learned Baroness, Lady Butler-Sloss, the noble Lord, Lord Hunt, the noble Baroness, Lady Brinton, and my noble friend Lady Hollins, all of whom have enormous experience. There is no conflict; the wording in the Bill is not right. However, we do need to rebalance the way that the voice of the parent who is genuinely concerned can be heard—probably in the pre-court time—and is then represented by barristers speaking on their behalf.

I take slight issue with the noble Baroness, Lady Meacher, over parents always wanting their child to stay alive. I have had in-depth conversations with parents who have said: “Enough is enough. Can we withdraw? Can we stop?”. I have been involved in extubating children and looking after them as they die peacefully and gently in their parents’ arms. I have helped parents lay out their child after death. It is such an anguishing time, but their overriding concern is to prevent the suffering of the child they love and to have their views and culture respected in the way that that is done.

I am grateful, too, to the noble Lord, Lord Berkeley of Knighton, for highlighting the need for open conversations. I declare an interest in Dying Matters; it is part of Hospice UK and I was part of the group that set it up. It has done an enormous amount to lift the lid off the taboo. People now talk openly about dying. If you go in to any out-patient department, people will sit and talk openly with clinicians about their death and dying. In the gap, the noble Lord, Lord Kerr of Kinlochard, rode into the debate like a shining knight to blow apart the reasons for not legislating for access to palliative care. I would welcome further advice from his vast experience on how we drive this forward. I am sure that that will be in conjunction with the noble Lord, Lord Ribeiro, who brought his experiences and salutary tales of how it used to be. He and I know how awful it was and how it does not need to be like that.

On mediation, the noble Lord, Lord Balfe, made a point about the great importance of listening. Nearly always, things go wrong when people have not listened early on—listened to what people say, listened to their expectations and tried to understand things from their point of view. How true that is. If only people spent 80% of their time listening instead of talking, we might have less misunderstanding.

The noble Lord, Lord Sheikh, brought his experiences of the hospice world and his wide support for it, and also his experience of mediation, to support this. I do think a pilot would be most welcome, as the noble Baroness, Lady Stroud, said in talking about the need for mediation. In fact, there is a Court of Protection pilot going on at the moment over mediation, run by a group of solicitors. There is something to be said for the complete independence of somebody coming in, rather than the clinical team that is already involved and can be perceived as having already taken some kind of stance. Certainly, any kind of pilot needs evaluating, so all those comments were very welcome.

Finally, the noble Baroness, Lady Brinton, highlighted that resources are not just money but also people, and the noble Baroness, Lady Thornton, pointed out that you need people to address the variations: money does not do it, you need trained people. She asked about the number of people in palliative medicine. I just sound a tiny note of warning because, as the shape of training changes, there will be fewer doctors for a time, unless we put the numbers up: they will be doing a lot more in acute medicine and supporting acute medical services, bringing their skills there—but we cannot think that, just because the numbers have gone up from the early days, we have got there yet.

I hope that I have adequately paid tribute to the fantastic contributions of everybody in the debate and I look forward to discussions with the Secretary of State and the Minister with responsibility for this area, because I feel we are at the point where sometimes it needs a jolt. I go back to the analogy with seat belts and tobacco control. Perhaps I have still got too much in the first part of my Bill; I am happy to take it down. But laws send messages, and the variation, as seen in the atlas, despite all the work that so many of us have done over decades, shows that it is now time for that jolt to happen. I beg to move.

Bill read a second time and committed to a Committee of the Whole House.

Coronavirus

Baroness Finlay of Llandaff Excerpts

Monday 3rd February 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Baroness asked that question last time and I did not forget. At the moment, Foreign Office travel advice is that anyone who has travelled to the UK from anywhere in China other than Wuhan or Hubei province, but not including Macau and Hong Kong, in the past 14 days and has developed symptoms should immediately self-isolate, even if symptoms are minor, and call NHS 111. Macau and Hong Kong are not included because those territories do not have evidence of sustained community transmission, as has been observed in mainland China, to date. They are therefore not currently included in the same travel advice as mainland China. However, the epidemiological situation in Hong Kong and Macau, as indeed in the rest of the region, is kept under constant review and will be considered in travel advice as we go forward, and reported to this House accordingly.

[Baroness Finlay of Llandaff (CB)]

My Lords, I am most grateful, as is everybody, to the Minister for updating us. She spoke about person-to-person transmission not having occurred in Hong Kong and those other areas. Will she confirm that to date there has been no evidence of person-to-person transmission outside China? That is, it has come from contact within China and people who have the virus leaving China. Do we have that information?

Also, in modelling for the worst-case scenario that might occur, how many negative pressure room beds do we have across the whole of the UK for those patients who develop severe acute respiratory infection and therefore have to be hospitalised and possibly ventilated in the event of this becoming severe? What evidence is there about the length of time that the virus survives on different surfaces outside the body? Because of the incubation and asymptomatic periods, when it appears that people are still infectious, there is a concern that the virus has quite a long survival time on surfaces, particularly those that may be warm and damp.

[Baroness Blackwood of North Oxford]

There were a few questions there. With regard to transmission, this is an evolving picture, so the best thing would be for me to send the most up-to-date information to the noble Baroness and put a copy in the Library, as I am sure it will be of interest to the whole House.

On ECMO beds, since April 2013, NHS England has commissioned a total of 15 adult respiratory ECMO beds from five providers in England. There is further provision in Scotland. But in periods of high demand, the capacity can be increased. For example, in the winter of 2018-19, when there was a significant risk associated with flu, the capacity was increased to over 30 beds and similar arrangements are in place for paediatric services. In addition, there are eight commissioned high-consequence infectious disease beds and around 500 infectious disease beds, and at the moment NHS England is confident that it has enough capacity, which I hope is reassuring for the noble Baroness. Obviously, we are keeping that under constant review as the situation evolves.

On the question about surfaces, that is one of the specific reasons why advice has been given regarding personal hygiene—washing hands and using tissues when sneezing—to avoid any forms of transmission that may create the kind of risks referred to by the noble Baroness.

NHS: A&E Waiting Time Target

Baroness Finlay of Llandaff Excerpts

Tuesday 21st January 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

My noble friend is absolutely right. We need to improve access to community care to make sure that people are diverted away from inappropriate visits to A&E. We have said that we will recruit over 6,000 doctors in GP practice, and we are working on that as we speak. We are also increasing the number of GP practices within A&E so that people can be diverted into appropriate care when they go to A&E inappropriately. The evidence is that already around 10% of those attending A&E are streamed into those GP practices, and we are currently trying to increase that provision.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest in relation to the Royal College of Emergency Medicine. Do the Government recognise the data from the weekly monitoring of 50 EDs that report to the Royal College of Emergency Medicine that shows that, in the first two weeks of January this year, an average of almost 6,500 people waited more than 12 hours in emergency departments, the figure having risen from just over 3,800 in October? These long waits represent risks to the health, and indeed to the very lives, of these patients. The president of the college, Dr Katherine Henderson, has urged:

“Rather than focus on ways around the target, we need to get back to the business of delivering on it.”

[Baroness Blackwood of North Oxford]

I emphasise that the review of clinical waiting times has been ongoing since 2018. The issues this winter are being addressed with urgent action in this winter. That includes: increasing the provision of same-day emergency care, so that patients can be seen as quickly as possible and are not admitted overnight, if that is inappropriate; reducing the number of patients who have unnecessarily lengthy stays, so that beds are available for those who need to be admitted; continuing to increase the number of urgent treatment centres, with a standardised level of care, so that those who do not need it can be diverted away from A&E—there are now over 140 urgent treatment centres, which can be booked from NHS 111 in most places; increasing the number of GPs in A&E, so that patients can be streamed to appropriate care; and enhancing NHS 111, so that patients can be booked into GPs locally or diverted to pharmacists.

Young Carers: Health and Well-being

Baroness Finlay of Llandaff Excerpts

Monday 13th January 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Lord has asked a specific statistical question which I want to provide an accurate answer to, so I will write to him.

[Baroness Finlay of Llandaff (CB)]

My Lords, do the Government recognise that the shortage of beds which is being experienced across the NHS is having an adverse effect on the ability to provide respite admissions when young carers find that they are literally at breaking point? Funded beds in hospices, nursing homes and other places can be essential to maintaining the cohesiveness of a family unit that is under extreme strain.

[Baroness Blackwood of North Oxford]

Obviously, pressure on the wider NHS and on social care can have a knock-on effect on unpaid carers who provide an enormous and valuable contribution to our health system, and also on those who care for them. I think that many of us in this Chamber will have personal and direct experience of that. That is why we have provided an extra £33.9 billion of funding for the NHS to ease those pressures, why we are working hard to find a sustainable solution to social care reform, and why we want to make sure that we provide carers of all ages with the support they need, first through identification and later by making sure that they have joined-up support right through the system.

National Health Service Infrastructure

Baroness Finlay of Llandaff Excerpts

Thursday 9th January 2020 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests in relation to emergency medicine. Will the Government undertake to look specifically at the problem for emergency departments, given that many of them do not have enough cubicle space for the number of ambulances that arrive and the number of patients who are blue-lighted in? Staff do not have enough space to take a short break from the front line of some of the most harrowing cases that they have to deal with.

[Baroness Blackwood of North Oxford]

The noble Baroness is very expert in this area, and she is absolutely right that the NHS estate must prioritise areas of most need. This is why we have put in a serious amount of investment. NHS Improvement is also conducting a backlog review to understand where the areas of greatest need are and to assist NHS trusts in prioritising capital spending over the next few months and years.

NHS: Nurses

Baroness Finlay of Llandaff Excerpts

Tuesday 7th January 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

The bursary will be available for new and continuing nursing, midwifery and allied health students for courses from September 2020. As I said, students will be able to access both student loan funding and this additional, non-repayable funding from the Department of Health and Social Care while studying. This means that students will have more cash in their pockets than they ever have before, which should attract them. It also means that we will be able to target funding to areas and specialisms that struggle to recruit, which we believe will definitely improve the sustainability of the nursing workforce and reduce its variability up and down the country.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare an interest as chair of the National Mental Capacity Forum. Do the Government recognise that we need to do more than just put more money into nursing for learning difficulties, given that there are now 1,000 fewer such nurses than there were four years ago and given that the mortality and morbidity rate in the population of people with learning difficulties is alarming, in that their life expectancy can be around 10 years shorter than that of the rest of the population? This area needs to be targeted. Given the stresses involved in this type of nursing, it takes more than money to retain people.

[Baroness Blackwood of North Oxford]

As ever, the noble Baroness raises a serious issue. We have introduced a targeted initiative for students who commence loan-funded postgraduate preregistration nursing courses particularly for those going on to work in learning disability, mental health and district nursing—to give them a golden hello, as it were. We have also introduced more clinical placements, where students can gain specific professional knowledge and be attracted into those very specialised and important areas of expertise.

Health Service Safety Investigations Bill [HL]

Baroness Finlay of Llandaff Excerpts

2nd reading (Hansard): House of Lords
Tuesday 29th October 2019 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I am delighted to follow the noble Lord, Lord Ribeiro, who has covered a large part of my concerns about some of the Bill’s powers relating to coroners. I will return to those. I declare my interests as in the register, particularly as president of the Chartered Society of Physiotherapy, as vice-president of Marie Curie and of Hospice UK, and as a clinician in Wales. I know that Wales is outside the Bill’s remit, but I will come to the cross-border flow issue.

I have a concern, from recognising that the Bill is based on aviation, rail and marine and their investigative processes, as to whether the body will be underresourced in the long term because of the complexity of the NHS. There has been pressure for an open culture of learning. There are death reviews and notification of serious incidents within hospitals, which has been pushed for some time, but unfortunately we do not have the culture of learning that is being called out for loud and clear. The reality works against it. The British Medical Association’s chairman, Chaand Nagpaul, said in the BMJ this week that the NHS now has a culture,

“where blame stifles learning, contributing to the vicious cycle of low morale so staff leave. This unsafe, underfunded environment is as damaging for patients as it is for doctors”.

In an article on fear and medical practice, David Oliver, who is a consultant in geriatrics and acute medicine, describes:

“A continually under-resourced, short staffed system, increasingly unable to meet rising demand”,


that “begins to feel unsafe”. He continues:

“The sheer number of patients … means corner cutting and workarounds. We have to accept, balance, and mitigate risk to patients, even as systems outside hospital are under even more strain. We work on wards facing epic nursing shortfalls, often with inadequate IT or logistics. Even if our … decisions and communication are sound, there’s much else we can’t control”.


I do not want to sound like a whingeing doctor on behalf of medicine, but I am really concerned that, unless that culture of fear and blame is addressed head on, this proposed organisation will not be able to extract much-needed learning.

I am unclear from the Bill what the threshold will be to trigger an investigation, given that the investigations are meant to be thematic rather than going into an individual case. If we are to have a thematic investigation it has to go across boundaries. I echo the concern of several noble Lords about the private sector, where NHS patients might be treated in the private or voluntary sector, such as hospices. If we cannot investigate the whole part of an organisation we would be ring-fencing a patient who goes into that sector and then saying, “All these other problems might have been contributed to on the other side the line, therefore we don’t have the powers to look at it”. If we are to look at thematic change, I do not see how, when we are commissioning services across the nation from non-NHS providers, we can then exclude them from the criteria we are asking for.

My other concern is how recommendations will be audited. How will we know that recommendations made for thematic improvements have been implemented and what are the levers if they are not? It might be that I have missed that, but I do not feel that I am clear on it.

Maternity services have been under HSIB for some time now. There was initially great resistance, but I understand that things have actually been going well and that the trust and confidence of staff and patients have developed so that they feel able to undertake it. In its maternal critical care report, the Royal College of Anaesthetists brought together anaesthetists, obstetricians, midwives, intensive care medicine and the Intensive Care Society. They are very clear that you cannot take maternity services in isolation because they are an integral part of a whole system. They depend on the anaesthetic department being immediately available, on the laboratory infrastructure, on radiology and so on. It cannot be viewed as separate to a whole system. If we are going to have whole system improvement, we must look at it thematically.

In working with others and working across borders, can the Minister tell me whether the memorandum of understanding with Wales has already been written? I have not been able to unearth it. This becomes very important because we have a lot of patients who go from Wales to England for treatment, and a small number who come in the other direction, but for people on the border, thematic changes become very important.

Turning to the safe space concept, this is essential in many ways. In Wales, our revalidation system in medicine is called MARS, spelled like the planet but fortunately not as far away from the realities of this earth. In it, we are asked to describe personal constraints and practice constraints on their practice of medicine. These are visible to the responsible officer in each hospital, who can then analyse them and pick up trends. Everyone was very nervous about this at first, but it provides the beginnings of a safe space, because people are disclosing early warning signals before an incident has happened, rather than once there has been a problem, and they are describing constraints which mean that they are not practising as well as they feel that they should.

However, the concept of a safe space, and access to information in it, must, as the noble Lord, Lord Ribeiro, has so clearly said, be set against a very high bar, with only a High Court judge able to rule that on balance in this exceptional circumstance, such information should be available. Coronial inquests are terrifying for those appearing before the coroner who do not know what is coming, replicating a sense of fear and blame. That has all been worsened by the concepts and accusations of gross negligence manslaughter, for which many of the referrals to the police have come from coroners. That is also aggravated by the fact that there is not a clear definition of what is or is not gross negligence manslaughter. The Williams review asked for it to be clarified. Unless the coroner is undertaking a clean investigation, de novo, and asking questions, if they cannot unknow information that they may have somehow gained from whatever has been in the safe space, they will then be owners of that information, and I fear that what they do with it will completely erode trust in the safe space concept. It sets the safe space up to fail, because those people who have been referred for investigation of gross negligence manslaughter are often so traumatised, having been suspended for one to three years, that they leave medicine, or certainly never practice as thoroughly and as well as they did before.

Therefore, the public interest in having thematic investigations that work well is essential. If I may turn in the last moments to medical examiners, I am glad to see them in place and on a statutory footing. Personally, I wonder whether the Wales system of them being employed through shared services at a national level is going to work better, because they cannot be deemed to have any vested interest in the organisation, the hospital trust or the health board in which they are working. Time will tell. That is going to be one of those interesting experiments where we see what happens across borders with slightly different healthcare systems.

Overall, I welcome this Bill. We have a lot to discuss, and I am glad that it looks as though we will have quite a lot of time to do that in, because we have to get it right.

Drugs: Methadone

Baroness Finlay of Llandaff Excerpts

Monday 28th October 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

No, the Government are suggesting that a PHE review in 2017 found that drug and alcohol treatment services are currently as good as or better than international comparators. They are cost-effective and the outcomes are good. However, we recognise that the number of deaths at the moment is too high, which is why the Home Office has commissioned a review of drugs policy by Dame Carol Black, and there will be a summit in Glasgow before the end of the year to find out what more can be done to improve these services.

[Baroness Finlay of Llandaff (CB)]

My Lords, do the Government recognise that methadone, apart from being an opioid substitute, is therapeutically a useful drug because it hits a different set of receptors from many other opioids? Each individual opioid is unique in its pharmacological profile and action, so there are real dangers in labelling methadone as only an opioid substitute. Patients who need it for symptom control can worry that they are stigmatised by being prescribed methadone, and there can be difficulties in supply therapeutically. In addition, any review of addiction and addiction services cannot look only at substituting one drug for another but must also look at the fundamental underlying drivers to the addiction that has occurred. It must give support in the long term, because these people remain at risk of returning to their addictive habits.

[Baroness Blackwood of North Oxford]

The noble Baroness in her question has outlined her expertise in this. She is quite right that the evidence base for the effectiveness of methadone is robust. It is provided for by NICE guidance and UK drug misuse and dependence treatment guidelines. Those have recently been updated in the Orange Book, which provides clinical guidance to clinicians and was published in 2017. There is also an update coming to NICE guidelines on how to manage drug dependency, which will be published in 2021. Therefore, up-to-date guidance is available for clinicians which ensures that they are able to provide both therapeutic and dependency management to those on prescription but also on withdrawal treatment. I therefore reassure the House that this is being taken extremely seriously by the Department of Health and Social Care, and by all related departments.

Sexually Transmitted Infections: England

Baroness Finlay of Llandaff Excerpts

Thursday 5th September 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Lord is of course an expert in where we should target our research. The NIHR is a £1 billion fund which is not targeted specifically. However, it is right that we should target research into STIs to ensure our response to the challenges. We know that STIs are increasing so we should include research into them.

[Baroness Finlay of Llandaff (CB)]

My Lords, how much is the Department of Health and Social Care doing with the Department for Education to ensure that in schools young people are aware of the emergence of antimicrobial resistance among STIs and to make the use of condoms more fashionable? Many young people feel that they are not the things to use, when they are actually the best form of protection.

[Baroness Blackwood of North Oxford]

The Government have made it clear that we want all young people to be happy, healthy and safe, especially when it comes to relationships. That is why we are making relationship and sex education compulsory for all secondary-age pupils from September 2020. That is intended to equip young people with the skills to maintain their sexual health and overall well-being. The noble Baroness is absolutely right that that will be effective only if it is cool and works well in terms of communication with young people.