Health and Social Care (Safety and Quality) Bill

Debate between Baroness Finlay of Llandaff and Baroness Hollins

Friday 13th March 2015 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, first, I apologise to the House for not declaring my interest as president of the BMA at the opening of this debate, given that the BMA has briefed about problems with the Bill.

My Amendment 5 focuses on the word “best” in the term “best interests”. I have had a concern about this because of the way “best interests” is now used. I have looked back, thanks to help from the Library, at 147 pieces of legislation in which the term “best interests” has been used. If one looks at those that came after 2005, when the Mental Capacity Act was passed, it is notable that that term has been included when it concerns the best interests of children, young carers, safeguarding, protection of those who lack capacity, or with regard to organisations such as charities—but not with regard to adults, who would be considered to have capacity as individuals. The term is also used in connection with the storage of gametes and the provision of local services and pension funds, which must act out of the collective best interest of people with whom the legislation is concerned.

I have also understood—I stand to be corrected—that in legislation the most recent use of a term supersedes all preceding use of that terminology in legislation. Therefore, the Mental Capacity Act should be the Act we look to. However, here we have a specific decision to be made in the so-called best interests of an individual, who can be assumed to have capacity, about the decision over their data, and that decision is being made by another person. My concern is that we are legislating for one person, the health or adult social care commissioner or provider, to decide that inclusion of the NHS number as a consistent identifier is, or is not, in the individual’s best interest, even though the individual with capacity may, if consulted, feel very differently. My concern is because there are quite serious implications about not including the NHS individual identifier.

I turn to the principle of best interests. For years we have tried to make sure that that term was used properly in both health and social care. We had a very interesting debate earlier this week on the post-legislative scrutiny of the Mental Capacity Act. Strenuous efforts have been made to roll out empowerment of individuals to enhance capacity and not to take paternalistic decisions of one person over another. Indeed, I have been involved in trying to teach the principles of the Mental Capacity Act, and I am fearful that this wording—as in this piece of legislation—could be seen to undermine the laudable intentions of that Act in terms of empowering individuals to take decisions.

I turn to Amendment 6 and how the NHS function of the unique identifier is important. In our society, we have several different identifying numbers—national insurance numbers, bank account numbers, passport numbers and so on. The national insurance and passport numbers are held from within the province of government. Perhaps it would be more honest to state that, if you do not wish your NHS unique identifier to be available to be available to you, you have effectively signed yourself out of NHS services.

Indeed, I am grateful for a briefing that I have only just received this morning, which points out—if I have understood it correctly—that opting out of the use of the NHS identifier opts you out of systems such as “choose and book”, screening programmes and so on. So effectively you are in part removing yourself from services that are available as a public health measure, as well as services that would be available to you as a patient. I wonder whether we should state clearly that the onus is only on you as the individual to explain why you wish such a number to be excluded, perhaps because you are a public figure and wish to use an alias—or should we begin to think about whether there should be the occasional possibility for people to have two numbers to use in different situations, rather as you can, in exceptional circumstances, hold two passports?

The NHS number makes links across the whole system of pathways of care. Indeed, it is there to reduce risk. For example, if you have two patients with a similar name who are going for surgery, the NHS number will be used as a checklist identifier to make sure that the right patient of that name is taken down for surgery. We are all aware that, when patients are in hospital and frightened and feel disempowered, they are less likely to challenge the processes that are happening to them than when they are fit and well.

Another problem concerns me. What about the person who is coerced or pressurised into withholding their NHS number because somebody is badly intentioned or abusive towards them and does not wish that abuse to be revealed? A person may appear in different parts of the healthcare system but, without that NHS identifier number, the dots cannot be joined up to protect them or to detect that there is a problem.

I seek confirmation in summing up from the Minister that I am correct in understanding that, if you decide not to use your NHS number, you are opting out of things such as screening programmes, as well as having to present your NHS number to be able to opt out of systems such as care.data, and so on. At the moment, if you opt out of care.data, you are opting out of screening programmes as well.

Another problem for the NHS is that hospital episode statistics rely on the NHS number, which is effectively how the hospital is paid. If there is no number, the only identifier that the hospital has is your name and address, which is a far greater threat to privacy in the system than is the NHS number.

With those comments, I await the Minister’s response to the questions I have posed. I emphasise again that I have real concern about how the term “best interests” is being used. I seek clear clarification in his answer so that we can have clarity on the record about how the term is used in the context of the Bill.

[Baroness Hollins (CB)]

My Lords, Amendment 7 in my name focuses on the proposed duty in Clause 3 to share information between health professionals and social care professionals. I apologise that I was out of the country during Second Reading and was unable to speak. I congratulate the noble Lord, Lord Ribeiro, for championing the Bill through the House. I also thank the noble Lord, Lord Hunt, for supporting this amendment, together with the noble Lord, Lord Low, who unfortunately cannot attend today.

From my own research and the work of the confidential inquiry into the premature deaths of people with a learning disability, I know that there are some appalling patient safety outcomes for people with learning disabilities, where improved information sharing has a real prospect of helping. Data scaled up from the confidential inquiry show that 1,200 people with a learning disability die avoidably in NHS care every year. In many cases this is due to poor or inadequate care or diagnostic overshadowing, where, put simply, professionals fail to see past the learning disability to what is really affecting the patient, may not recognise that the person has a learning disability, or may have had no training on what a learning disability is.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Baroness Hollins

Monday 19th March 2012 Lords Chamber

[Baroness Finlay of Llandaff]

I am grateful to the Minister for meeting me with the President and Vice President of the College of Emergency Medicine and for listening so attentively to the concerns raised. This amendment comes from those discussions and aims to resolve the potential lacuna around the commissioning and the provision of unscheduled urgent and emergency care at all times of day and night.

Emergency medicine departments—commonly known as A&E—see 15 million patients a year, of whom about a quarter are children. About 7.5 million patients arriving in A&E are not ambulant. Typically one-third of these on a stretcher need to be admitted, most frequently into an acute medical bed. The extent of seriously ill and injured attendees is illustrated by the fact that one in 50 will need high levels of care. A quarter of all intensive care admissions come through A&E and seriously ill patients go straight to coronary care and high dependency units from the resuscitation room in the emergency department.

The full spectrum of integrated services has to involve acute medicine, acute surgery and orthopaedics, paediatrics, obstetrics and gynaecology and is crucially underpinned by critical care and anaesthesia.

These very seriously ill patients need integrated services along the whole care pathway; care cannot be broken up. The full spectrum of back-up services with radiology and laboratory services needs to be there 24/7. The best outcomes—and we were talking just now about patient outcomes—for trauma and stroke victims are absolutely reliant on immediate cross-sectional imaging, ideally co-located in the emergency department.

There is a need for closer integration and improvement of the services needed to care for emergency department patients. For example, those with mental health problems, both acute suicidal ideation and acute psychosis, and those with drug and alcohol problems, need a comprehensive integrated psychiatry service, as they are a very vulnerable group. Improving primary care, both out of hours and alongside emergency departments, is essential if departments are to deliver the best care and not be overwhelmed. This will require close collaboration, integration and accurately informed commissioning.

Emergency departments are the 24/7 final safety net for all other services in the healthcare system and they are the last open-access point of call. Escalation of a problem, failure in community care and inadequate out-of-hours primary care support all result in urgent presentation out of hours. Such patients often arrive at night, are unstable clinically and cannot be sent home again, as they are alone or unable to monitor the condition reliably. These 7 per cent to 8 per cent of attendees need to be observed for up to 24 hours in a clinical decision unit, where there is twice daily consultant input, either until they are stable enough to be sent home, or until deterioration indicates admission and ongoing management.

Emergency departments are busy places, providing 24/7 care, looking after patients with wide-ranging needs from resuscitation to reassurance, and interacting with many specialties to ensure the best care. The seriously ill initially need the close interaction of typically three to four specialties; any fragmentation threatens the quality of care.

Commissioning of services in emergency care is optimised by direct and close working between those specialists responsible for delivery and the local commissioners. Given the size and complexity of urgent and emergency care, this should mandate such a specialist on the local commissioning board.

The challenge to us with this Bill is to ensure that commissioning processes recognise that patient choice in emergency care is inappropriate, as every patient needs access to a quality service that is fully integrated with pre-hospital services such as out-of-hours primary care and ambulance services, and with all the back-up and specialist services that patients are moved to for ongoing management.

The national Commissioning Board must work very closely with the College of Emergency Medicine to ensure that commissioning guidance drives up the standards of weaker departments, that the integration of services is included in the commissioning and that the urgent and emergency service for a population has the full skill set to deal with the full range of undifferentiated clinical problems that arrive at the only open access point of care. It is key to local commissioning that specialists in urgent and emergency care are directly involved. Without that, we will replicate Mid Staffordshire, but it may not be evident until unnecessarily large numbers of lives are lost. I beg to move.

[Baroness Hollins]

My Lords, given the concerns among the medical profession which are still evident, I ask the noble Earl for reassurance that, for those services where commissioning is appropriate, competition will always be on the basis of quality, not price, and that providers will not be able to cherry-pick lucrative parts of the care pathway to the detriment of vulnerable patients, such as people with learning disability or severe mental illness—people that I am particularly concerned about as a psychiatrist. The health and well-being of these patients depends on the effective delivery and co-ordination of complex care pathways.

According to the Guardian, NHS Devon and Devon County Council have shortlisted bids to provide front-line services for children across the county, including some of the most sensitive care for highly vulnerable children and families, such as child protection, treatment for mentally ill children and adolescents, therapy and respite care for those with disabilities, health visiting, palliative nursing for dying children, and so on. On the shortlist for the £130 million three-year NHS contract are two private profit-making companies as well as the Devon Partnership NHS Trust, which has been bidding along with Barnardo’s and other local charities.

The contract will apparently be awarded, according to the criteria, to the most economically advantageous bid, which appears to be possible under current commissioning arrangements. I seek reassurance from the Minister that the new safeguards in the Bill also prevent such commissioning decisions risking the perceived risks raised by my noble friend with respect to the commissioning of integrated care pathways in emergency care. I am referring not just to the emergency care part of the pathway but to the whole care pathway, which inevitably requires stable working relationships across organisational boundaries.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Baroness Hollins

Wednesday 29th February 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, this is a clear example of an iatrogenic condition, very often originating in primary care. When patients have presented with insomnia, instead of being taken through the more complex and time-consuming aspects of sleep hygiene and possibly talking therapies to discover the cause of their insomnia, a prescription has been given all too quickly and readily. If we are looking at responsibility falling back to clinicians in primary care, it seems inordinately sensible that the clinical commissioning group should consider its responsibility to provide support to patients who end up with an iatrogenic problem.

I can see that the Government may feel that this is a very specific amendment targeted at a very specific area, but the guidance that needs to go out to clinical commissioning groups on their responsibility for the behaviour of all those prescribing on their patch may well deal with some of the principles behind this amendment and ensure that the necessary services are provided to patients who, completely inadvertently, fall foul of taking the drugs that they were prescribed and as they were told to take them.

[Baroness Hollins]

My Lords, I pay tribute to the work of my noble friend Lord Sandwich, who has done so much to raise awareness of the often unmet needs of people whose addiction originated in a legal prescription. There is some progress in training doctors—for example, in undergraduate medical education with a new national curriculum on substance misuse. This guidance provides learning objectives on rational prescribing and iatrogenic addiction. The fact that such a curriculum is only just being introduced shows the need for the attention of clinical commissioning groups to be brought to this issue.

There seems to be a special responsibility on the National Health Service to provide better care for people affected by medical prescribing practice, and I hope that the Minister will be able to suggest how such a responsibility could be emphasised in the Bill.