Care Bill [HL]
Baroness Finlay of Llandaff Excerpts(11 years, 1 month ago)
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Baroness Finlay of Llandaff (CB)
My Lords, on reading carefully the amendments in the name of the Minister, I hope that he will be able to provide reassurance that his amendments will go further than Amendments 22 and 25 to which I have added my name and that they will be much more about the whole person and the whole person’s needs. I recognise that there are dangers in putting a timeframe around anything; there is the danger that it will be used as a so-called minimum standard, down to which people will drop. I initially wanted to support these amendments and I suppose, if I had a choice, I would have added my name to those of the Minister now, because there is a real problem if care is not adequate in quality and promoting well-being in that it creates dependency rather than reablement towards increasing independence. There is a sense of personal worth that goes along with being able to do things, however slowly, rather than having to accept somebody doing them for you because they are in a terrible rush. I hope that the Minister will provide us with a much wider reassurance than the words suggest at first glance.
Baroness Gardner of Parkes (Con)
My Lords, I was most interested to hear the comments of the noble Baroness, Lady Meacher, and I agreed with every word, but I do think the time limit specified would not be right and I strongly support Amendment 27. However, there are other aspects of this care issue that we have not really thought about.
One that is covered in Amendment 27 is about the well-being of carers. I find it very disturbing that a woman I know who lives in with a person needing pretty comprehensive care every Saturday and Sunday and stays overnight on both nights, is appallingly paid for this because she is self-employed. I said to her that I could not believe she was earning so little when it is such a very important job and so very time consuming. I told her I would look on the internet to see what she is entitled to as a minimum wage. It turns out that there is no minimum wage for a self-employed person. That quite stunned me; there is a great reservoir of people who would be willing to take on self-employed caring positions and do them for quite long periods, not rushing people, but not at her rate of pay, which worked out at a little over £2 an hour for all the hours she was there. I suggested that, since she had done training in care, she should work instead for the people who provide a service for the local authority. She followed that up and it turned out that she would not earn much more, because they are not paid for travelling time. Unless the organisation improved so that her two, three, four or 10 jobs—whatever it is—were almost next door to one another, the unpaid travelling time would constitute much more of her day than the time actually caring for people.
The other point raised by the noble Baroness, Lady Finlay, is that it is more than just physical care. We have heard much in recent days about people’s extreme loneliness, how they can go almost for days with hardly a word with anyone. That is a most essential thing in life, to feel that you have not been abandoned. The woman in the television report talked about taking your coat off, making your booking and going through it all, and how you are left with 10 minutes in the middle and then you book in a final 10 minutes to reverse everything. That is exactly what I remember from when I was chairman of local social services 30 years ago; that was exactly the same problem then.
These are not new problems; because there are so many more older people who need more care, and there is more awareness, with people wanting to stay in their own homes, this problem has grown, and we do not have the solutions to match the need. I strongly support the emphasis on the well-being of carers, which is mentioned in Amendment 27—that is important. People should feel that they are doing a worthwhile job and that what they are doing is helping other people. They should also be reasonably remunerated for it. There is so much that we would all support; I feel that all noble Lords in this Chamber want to see more help and more efficiently used help. Amendment 27 in particular covers a lot, but whatever offers can be made, so much the better.
Lord Warner
I support the important amendment of the noble Baroness, Lady Greengross. I want to do so by telling a story and then putting a suggestion to the Minister. Like my noble friend Lord Hunt and me, he will have done his time touring hospitals as a Minister. We are usually shown the high points of the hospital’s achievements. Life changes a bit when you cease to be a Minister and you visit your friends and relatives in hospital. On visits to hospitals to see friends and relatives, because I am a nosy sort of person I have always looked to see whether there is a date for discharge on the charts. Some of these discharge dates are great works of fiction. When I have asked nurses about these discharge dates, quite commonly they say that managers have told them they have to have a discharge date—so it is something they have done for internal compliance purposes.
Although the suggestion of the noble Baroness, Lady Greengross, may not be right for the Bill, it is at the very least important for guidance. Planning on admission for discharge is needed. Present arrangements fail to communicate that to the social care world. It is now an internal mechanism for the NHS, not a mechanism designed to get people out of hospital into an appropriate placement as soon as they are ready to go. It would be a good idea to put this in the Bill, but at the very least this issue needs to be covered in some detail in guidance so that the NHS and the social care world are clear beyond peradventure what they are supposed to do when a person comes into hospital. If we went along that path, the world would be a better place and we would deliver some of the objectives of this legislation.
Baroness Finlay of Llandaff
My Lords, I shall be brief since the hour is getting late. This amendment makes a very important point, though it may be better in guidance. One of the problems is that the pinch point is always A&E, and getting patients out is really difficult. At the moment, there is tokenism in planning discharge. It needs to be much more embedded in trying to predict people’s needs and having things in place. Until discharge planning really is part of looking ahead at the aims for the patient we are still going to have backlogs, because we are still going to be waiting for somebody to come in and do something.
Earl Howe
My Lords, I should like to thank the noble Baroness, Lady Greengross, for tabling Amendments 29 and 125, on what is undoubtedly an extremely important issue, not just for the system but, most importantly, for the patients themselves. When someone is discharged from an acute care setting, care and support must be joined up to prevent unnecessary delays and readmissions that can be distressing to patients and their families and carers. The noble Lord, Lord Hunt, was absolutely right on increasing pressure on acute trusts, not least in A&E.
There is a mixture of reasons why this is occurring: the weight of patient demand; the acuity of patients who present at A&E, more of whom have to be admitted; workforce issues in some A&E departments; hospital discharge practices that may not be as efficient as they should be; an absence of follow-on care in certain locations or, indeed, adult social care services; and delays in installing home adaptations. One cannot generalise about this problem. One can say only that in many areas it is very real.
I will just correct the noble Lord on one issue: the £250 million that we have allocated to ease the pressures on A&E. Those moneys went to 53 NHS trusts before the end of September. They went to trusts that were most at risk of breaching the A&E standards. They were not chosen by Ministers or the Government. The process was led by NHS England and Monitor, so it was done on a structured and objective basis.
Cigarette Packaging
Baroness Finlay of Llandaff Excerpts(11 years, 4 months ago)
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Earl Howe
I am sure that we could get into an interesting conceptual discussion about the difference between strategy and policy. The key point is that Mr Crosby has been very clear in his public statement. He has said:
“At no time have I had any conversation or discussion with or lobbied the prime minister, or indeed the health secretary or the health minister, on plain packaging or tobacco issues”.
That is very clear.
Baroness Finlay of Llandaff
What assessment do the Government intend to make in the coming year of the appeal of current packaging, given that some of the slimline packaging is particularly attractive and enticing to young women and that some of the chunky packaging is particularly enticing to the macho side of young men?
Earl Howe
The noble Baroness gives me the opportunity to make clear that plain packaging of tobacco is very much still in our sights; we have not decided to reject that option. I am sure that the psychology of marketing is one very important area that we will continue to focus on.
NHS: Accident and Emergency Services
Baroness Finlay of Llandaff Excerpts(11 years, 4 months ago)
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Earl Howe
We have been taking action in several areas. We released additional money to ensure that immediate pressures were relieved in the health service in the spring and, as I have said, that was successful. We are encouraging, and have ensured, the setting up of urgent care wards, which amount to the kind of discussions across the system in local areas that are needed to ensure that there are no blockages in that system. More fundamentally, we have tasked Sir Bruce Keogh to undertake the work that I referred to earlier, looking at the root causes of why there have been these pressures on A&E. There is no single answer to that question.
Baroness Finlay of Llandaff
My Lords, I declare my interests, including that my daughter is an A&E consultant in London. Are the Government planning specifically to put in some additional resources to support A&E departments now, given that the consultants need more infrastructure support, including people at a much lower grade—clerical staff, care assistants and alcohol support workers—to cope with the peaks that occur of those who have come in having abused alcohol, who take staff away from the other very sick patients, who are often in resus and whom they are also trying to look after at the same time?
Earl Howe
The answer to the noble Baroness’s question is yes. We are looking very carefully at workforce issues and the mix of skills needed in those A&E departments that have been struggling. I refer not simply to A&E consultants but also specialists in their field—perhaps alcohol is a good example—who can deflect the pressure away from staff looking after acutely ill patients.
Smoking: Cigarette Packaging
Baroness Finlay of Llandaff Excerpts(11 years, 4 months ago)
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Baroness Finlay of Llandaff
To ask Her Majesty’s Government what is the basis for the decision not to proceed with standardised packaging of cigarettes.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
Standardised packaging remains a policy under active consideration. The Government have not ruled out its introduction. However, we want to spend more time assimilating information about the likely effect of such a policy in this country and learning from experience abroad. Let me be clear: we are not going soft on tobacco, which is a leading cause of premature death. We have an ambitious tobacco control plan and will press ahead with tobacco control policies, including removing tobacco from displays in shops.
Baroness Finlay of Llandaff
I declare my interest as president-elect of the BMA. As 200,000 11 to 15 year- olds start smoking each year in the UK, what are the criteria and time frames that the Government will use to judge the outcomes of standardised packaging in Australia? The high mortality rate does not appear until about 25 years after these youngsters start smoking. As this is fundamentally a child protection issue, how will the Government now prevent vulnerable children—particularly those in local authority care—from starting smoking, given that the Department of Health’s own systematic review showed that current packs are particularly attractive to youngsters and that they mislead them into thinking that some brands are less harmful than others?
Earl Howe
My Lords, we want to keep a close eye on what is happening around the world before making a decision. We are keeping standardised packaging under active consideration. It has been newly introduced in Australia, and other countries are intending to follow suit, so it is sensible for us to see what we can learn from other countries’ experience. The impacts could be several. They could include, for example, health benefits, as well as impacts on businesses such as retailers and tobacco manufacturers, and could possibly bring about a change in attitude to smoking.
On the risk to children, the noble Baroness is of course absolutely right. Evidence suggests that action needs to be taken to reshape social norms around smoking so that tobacco becomes less desirable, less acceptable and less accessible, particularly to the young. That is why we are committed to ending tobacco displays in shops. We have a TV-led marketing campaign to encourage smokers not to smoke at home or in cars and we have banned the sale of tobacco in vending machines, which has removed a source of cigarettes that underage smokers could access as often as they liked. There is a range of work going on.
Health: Prescription Drugs
Baroness Finlay of Llandaff Excerpts(11 years, 4 months ago)
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Earl Howe
My noble friend will be encouraged to know that Public Health England has published a commissioning guide for the NHS and local authorities which sets out its expectation that support should be available in every area for people with a dependency on prescription or over-the-counter medicines. Local authorities are now, as she is aware, responsible for commissioning services to support people to recover from dependence in line with local need. Most of the support available for people who are addicted to prescription drugs is with their GP and not in services treating those addicted to illegal drugs, but there is a range of services available.
Baroness Finlay of Llandaff
To better understand the size of the problem, will the Government consider adding a box to the yellow card, which has been successful in reporting adverse drug reactions, to state that the doctor suspects that this person may have dependence on the drug? That would provide ongoing epidemiological monitoring.
National Health Service (Licensing and Pricing) Regulations 2013
Baroness Finlay of Llandaff Excerpts(11 years, 4 months ago)
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Baroness Finlay of Llandaff
I have a short query, which I hope that the Minister can clarify for me. It relates to the cross-border flow between England and Wales, either of providers or patients as users of services where NHS Wales is paying for services provided by NHS England or a provider in England. I would like reassurance that there will be no way that the experience of patients going from Wales into England, or the ability for providers from Wales to provide services to patients along the border, are in any way jeopardised within these arrangements and that they have equality within the provision.
Lord Hunt of Kings Heath
My Lords, I declare an interest as chair of an NHS foundation trust, president elect of GS1 UK and a consultant and trainer with Cumberlege Connections. I am grateful to the Minister for his explanation of these regulations. I want to put a few points to him.
I start with Part 2 on licensing, specifically paragraph 3 concerning monetary penalties. Can I ask the Minister about the logic of fining providers, when all that happens is that worse care will be provided for patients as the organisation will have less money? I think that the figure of up to 10% of turnover would virtually bankrupt most providers. While I certainly accept the need for penalties and consequences for failure, I wonder whether they would be better being not financial, as the reality is that they will not happen in many cases because the people who suffer will be those who get services. I just wonder about the logic of that.
It took NHS England months to wake up to the fact that the A&E problems were to do with the failure of systems, but for months it was pressing CCGs in some parts of the country to fine hospitals for poor A&E performance. I think that NHS England has completely lost the plot when it comes to understanding what is happening in the health service. I cannot think of a more hopeless response to the crisis than to come along and say, “We should fine hospitals”. I worry about this whole approach to fining. I say to the Minister that there are very limited signs that systems understand the winter problems and there is a real reluctance to get to grips with what needs to happen. This is a worry for the future which may not have much to do with the regulations, but my seeing the Minister here represents a good opportunity to raise them with him.
Does the Minister think that fines and targets can lead to some perverse incentives? Of course, it is right to issue targets, but I wonder whether the Minister might comment on a very interesting section of the Chief Medical Officer’s Report for 2013, published earlier this year, where she refers to the low number of instances of MRSA and C. diff. I do not think that there is any doubt that the targets that were set for the health service have been responsible for the focus that has led to this very welcome improvement. My understanding is that part of the response to this by the NHS has been to use antibiotics which should have been reserved for hard-to-treat infections. There is now real concern that the antibiotics that go with those hard-to-treat infections have been used rather widely, which is causing great problems in more general infection control. According to the CMO, while the typical, large, 1,000-bed acute NHS hospital has two to three MRSA bacteraemias per year and 50 to 60 C. diff cases, 400 to 500 bacteraemias involving Gram-negative bacteria can occur in a 1,000-bed-type hospital, 10% to 15% of them being due to strains resistance to those antibiotics for hard-to-treat infections. You can reach a point where individual targets become counterproductive because the focus of the NHS is simply on C. diff and MRSA and not on the wider infections which clearly need to be tackled as well.
Will the regulations lead to more specific targeting which can in turn lead to perverse incentives, or is a more sophisticated approach likely to be taken? It is clear that the Chief Medical Officer is concerned about the way in which some MRSA and C. diff targets are leading to perverse behaviours.
On Part 3, the rationale for each of the thresholds described for penalties, prices and licence changes has not been explained in relation to an evidence base. In other words, why are the thresholds where they are? What work has been done to suggest that those are the right thresholds? Of course, now they will only be tested post-implementation, but it would have been good to have seen a clearer review mechanism that enabled a sensible approach.
In respect of the mechanisms to lodge an objection to the pricing methodology, my understanding is that the Foundation Trust Network has stated throughout the development of the policy that the 51% threshold for an objection, together with the denominator comprising all tariff services, is too high a threshold to be met. Is the noble Earl prepared to look at this? That might be a reasonable approach for general objections to the general approach, but it is insufficiently sensitive to address sections of the tariff that may be inadequately compensated—cancer services, for example. The noble Earl will be aware that there were issues around the tariff for children’s services and women’s services. My reading of that is that if you were a specialist adviser your chances of reaching the 51% threshold would be very limited. Could this be looked at?
If my noble friend Lord Warner were here I am sure he would raise this. It is the question of what happens to non-foundation trusts. I know that Monitor is working closely with the NHS Trust Development Authority, but I would welcome clarity about what will happen to trusts outside Monitor’s remit to ensure that there is an even-handed approach across all providers in the sector. No one is more admiring of the work of Sir Peter Carr as chair of the NHS Trust Development Authority. The noble Earl knows that Sir Peter has held chairmanships under both Governments for many years. While he is a marvellous person, there is a fear that he will hold the chairmanship of the NHS Trust Development Authority for many years to come because of the issue about what on earth will happen to those non-foundation trusts that are clearly not going to reach FT status any time soon.
The noble Earl mentioned the Competition Commission.
Earl Howe
I take the noble Lord’s point about uncertainty and confusion that I know exists in certain parts of the health service as to what all this means. I can tell him that officials in the department have had some very productive discussions with both the OFT and the Competition Commission to ensure that their approach need not set unnecessary hares running as regards apprehensions that a purist competition-based approach will be taken by these bodies. I am satisfied that that will not happen. My advice is that the Competition Commission, in particular, has welcomed the input of departmental officials in terms of the factors that need to be brought into play when making a judgment on what is in the best interests of the health service and patients.
At the same time I am aware that a number of useful events and conversations took place within the health service itself when we clarified with providers the considerations that the OFT and the Competition Commission will look at in proposed mergers. We are ensuring that when proposals are made the benefits of mergers are clearly defined in terms that will resonate with the competition authorities. The noble Lord is right that we are in new territory in many senses, but I am optimistic that the system will work in the way that it should. It is certainly about looking at competition aspects but, more pertinently, looking at the criteria that I mentioned earlier, such as the public interest in the case of licence modifications, the test of appropriateness in pricing methodology, and in the case of mergers, the interests of patients in the health service. The OFT and the Competition Commission must take into account the benefits of a proposed reconfiguration if they consider it under the Enterprise Act 2002. I remind noble Lords that that is the governing Act, so in theory at least, we have been in this situation for more than 10 years. In doing so the competition authorities must consider whether those benefits would outweigh any substantial lessening of competition that they find.
The noble Lord asked about the tariff, and in particular, primary care. We agree that payment mechanisms need to be aligned to drive better outcomes and better value for patients. They also need to be responsive and flexible, for example to enable services to be provided in an integrated way. Monitor and NHS England will work together to move the tariff in this direction. They are best placed to do that given their different roles.
The noble Lord asked me what would happen if the tariff proved to be inadequate. We expect the tariff in future more closely to relate to the costs of providing particular services. If the price payable for a service would make it uneconomic for a provider to provide a service, Sections 124 and 125 of the 2012 Act provide for a process for local modifications of the price payable.
My advice is that NHS England and Monitor are working very well together in this regard. Guiding principles have been defined and six shared principles for pricing have been agreed: that the pricing mechanism should enable and promote improvements in care for patients and taxpayers; that it should enable efficient providers to earn appropriate reimbursement for their services; that it should have regard to sustain the NHS offer in the long run; that it should not preclude the delivery of the Secretary of State’s mandate for NHS England; that it should have regard to the principles of better regulation; and that it should support movement towards a fairer playing field for providers.
I hope that I have answered most if not all the questions, but I undertake to write to noble Lords if I have failed to do that.
Baroness Finlay of Llandaff
I seek a small point of clarification. I take the example of a Welsh provider that is providing services for Welsh patients and that is also licensed to provide for patients coming across from England. In the event of them being deemed not to meet the conditions and therefore a fine potentially being levied at 10%, would that be only 10% of the contract issued on behalf of the English patients? Two very different healthcare systems will be operating.
I realise that this is complex, but the two healthcare systems are becoming more divergent yet the population on the border has to access both sides, I am concerned that these are some of the things that need to be clarified. It is a detail, I know.
Health: Diabetes
Baroness Finlay of Llandaff Excerpts(11 years, 4 months ago)
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Earl Howe
I would be happy to meet the noble Lord. I am aware that the whole area of the cataract threshold and, perhaps more importantly, the interpretation of that threshold, is one that NHS England is now actively looking at to ensure greater consistency around the country.
I do not agree with the noble Lord’s interpretation of the screening figures. The UK countries, I believe, lead the world in the area of diabetes eye screening. This is the first time that a population-based screening programme has been introduced on such a large scale. The latest figures show that up to March 2013, 99% of people with diabetes who were eligible for screening were offered it in the previous 12 months.
Baroness Finlay of Llandaff
My Lords, given the importance of prevention, have the Government been monitoring the progress of access to insulin pumps for children with diabetes, in order to prevent eye problems later in life, given that they have better control with insulin pumps?
Earl Howe
My Lords, that tends to be a matter for provider trusts, working in conjunction with clinical commissioning groups. I am aware that there is concern about the variability of access to insulin pumps. Of course, they are not a universal remedy for every diabetic patient, but where they are appropriate they should be commissioned. If I can give the noble Baroness the latest information on that, once I have consulted NHS England, I would be happy to do so.
NHS: Accident and Emergency Units
Baroness Finlay of Llandaff Excerpts(11 years, 5 months ago)
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Earl Howe
My Lords, the noble Baroness is absolutely right. There is no doubt from Sir Bruce Keogh’s urgent and emergency care review, published this month, that attendance at an A&E department often reflects the lack of availability or the lack of awareness of alternative sources of help. Some patients may default to A&E departments when they are unsure about which service is most appropriate to their needs. That has to be addressed and is being addressed in Sir Bruce’s review. It will look at the entire system of emergency care and how we can make sure that it provides the right care, in the right place and at the right time.
Baroness Finlay of Llandaff
Will this review include an audit of the number of patients who are in A&E but cannot be sent back to their normal place of residence, whether that is their home or a care home, because of the lack of immediate transport and an absence of immediate referral systems to community services that could monitor and review the patient back in the community?
Health: Children's Heart Services
Baroness Finlay of Llandaff Excerpts(11 years, 5 months ago)
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Earl Howe
My Lords, I pay tribute to the work done in Newcastle in this extremely complex area of surgery. The noble Lord knows that hospital better than anyone in this House, and I understand the disappointment felt in Newcastle about this decision. Nevertheless, I would slightly qualify the comment that he made at the beginning. Although I agree that the decision must depend on outcomes and the quality of care, it must also bear in mind the sustainability of the service into the future. While we can recognise good care when we see it now, we must be sure that the service is capable of being sustained on that level into the future.
Baroness Finlay of Llandaff
Is the Minister able to tell us how many vacancies currently exist among highly specialised staff in children’s heart units and what NHS England is doing to monitor vacancies? During a time of uncertainty, when staff do not know what their future will be, recruitment problems can arise, and where vacancies occur at a very senior, highly specialised level, that in itself can threaten the quality of the service and indeed jeopardise long-term sustainability.
Earl Howe
I do not in fact have any statistics on vacancies, although if I can acquire them I shall certainly pass them on to the noble Baroness. However, the central point that she makes is of course right, and the second recommendation made by the IRP relates to the need to have sufficient staff in place to deliver a safe service. It says that patients should receive this service,
“from teams with at least four full-time consultant congenital heart surgeons and appropriate numbers of other specialist staff to sustain a comprehensive range of interventions, round the clock care”,
and, interestingly,
“training and research”.
I think that that sends a signal that will resonate with many noble Lords in the context of debates that we have had in the past about centres of excellence in the NHS.
Medicine: Experimental Drugs
Baroness Finlay of Llandaff Excerpts(11 years, 5 months ago)
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Baroness Finlay of Llandaff
My Lords, in light of the proposed EU directive that is being led by MEP Glenis Willmott to facilitate clinical trials and the work done by Empower: Access to Medicine, led by Les Halpin, are the Government working with the Halpin protocol, which aims to overcome the legal barriers—real or perceived—to early access to, and development of, medicine in the UK?
Earl Howe
My Lords, the Medicine and Healthcare Products Regulatory Agency is at the forefront of the negotiations at European level to ensure that the new clinical trials regulation, which will replace the current directive, is much more conducive to companies directing their clinical trials towards Europe, in particular, we hope, the United Kingdom. This needs to happen. The trend over the past 10 years has been in the wrong direction and we want our own market share to increase; there are already signs that it is doing so.