Long-term Plan for the NHS

Baroness Hollins Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord Hannay of Chiswick]

My Lords—

[Baroness Hollins (CB)]

My Lords—

[Baroness Manzoor]

My Lords, it is the turn of the Cross Benches.

[Baroness Hollins]

My Lords, there is much concern in this House about social care. Can the Minister confirm that the now-promised social care plan will address not only the needs of older people but the needs of all vulnerable people of all ages? It is a little-known fact that the cost of meeting the needs of people with learning disabilities will soon overtake the cost of care of the growing number of older people. It is really important to address that.

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight the care for this vulnerable group of adults. As she knows, there has been a parallel work stream alongside the work for the Green Paper. Those are two allied but separate pieces of work. At this point in time I do not have a specific date for when that work will emerge into a report or a review, but I will write to her with the details because the Government agree with her that this issue is of equal importance.

Health Inequality: Autism and Learning Disabilities

Baroness Hollins Excerpts

Thursday 10th May 2018 Grand Committee

[Baroness Hollins (CB)]

My Lords, I, too, have a family interest. My son has a learning disability and is on the autistic spectrum.

The Learning Disabilities Mortality Review report was discussed briefly following an Urgent Question last night, and the Minister made some very reassuring comments about training, on which I hope that he will expand today. The mortality review is an extremely important programme, but it cannot change entrenched discriminatory attitudes on its own. Equally important is what action Ministers, NHS England and NHS trusts take to prevent avoidable deaths, given this important evidence.

Interestingly, the recommendations in the recent report are almost identical to recommendations made in 2007 Mencap’s game-changing Death by Indifference report: make sure that hospital staff understand about people with learning difficulties. Make sure that hospital staff work together with other agencies, including families, and that they understand the law on capacity and consent. They are the same recommendations every time, but we do not seem to be able to do anything about it.

It is critical that tackling health inequalities faced by people with a learning disability and/or autism is a priority among Ministers. NHS England must continue the funding of the mortality review programme beyond its current one-year extension and continue the good work of its learning disability programme beyond next March. Other confidential inquiries are permanent. Why is this group being treated differently?

In addition, individual NHS trusts must take urgent action in line with the recommendations of the review, not least in improving learning disability awareness training and practice in relation to the Mental Capacity Act. Doctors and nurses probably need a lower threshold for admission and to understand that sending a person with a learning disability home and suggesting that they come back if they are worried is inadequate. That may be one reason for the episodes of sepsis which underlie 11% of the deaths reported by the learning disability review.

The third sector is campaigning effectively, but it needs the Government and the NHS to commit, too. Mencap launched the Treat Me Well campaign in February, an aim of which is to ensure that no health professional sets foot on a hospital ward without learning disability awareness training. Dimensions, another national learning disability provider, is launching an initiative to offer training within primary care, and we have heard about SeeAbility’s report.

In my time at St George’s at the University of London, the most effective training for medical students was co-delivered by people with learning disabilities. Sadly, it ended on my retirement, because it depends on having a learning disability expert on the staff. If it was mandated, it will be different.

We know that involving people helps health professionals to understand what it is like to have difficulties communicating or understanding complex information. I look forward to working with the noble Lord, Lord Touhig, who has raised this important subject today, and other noble Lords, including the Minister, on this agenda.

Learning Disabilities Mortality Review

Baroness Hollins Excerpts

Wednesday 9th May 2018 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I declare my interest as the chair of a social enterprise that creates communication resources for people with learning disabilities. My own research more than 25 years ago uncovered very similar shocking inequalities. The noble Lord has responded to a question about education but is it not now time for there to be mandatory education for all healthcare professionals? This is not a specialist matter. Does he agree that such training should be co-delivered by people with learning disabilities in order to reduce the fear and lack of understanding among health professionals when it comes to making reasonable adjustments? What action will be taken now?

[Lord O'Shaughnessy]

The point that the noble Baroness makes about the involvement of people with learning disabilities in this process is critical. I did not respond to a question from the noble Baroness, Lady Jolly, about communications with people with learning disabilities. Having written a manifesto in the past and having had it translated into the Easy Read format, I know that this is critical. I know that there are attempts to make sure that communications are made in that format where it is helpful to do so.

On the noble Baroness’s question about training, we have a really good template which my honourable friend Caroline Dinenage mentioned in the other place yesterday, and that is dementia training. It is tiered, with tiers 1 and 2, and it has been rolled out very broadly across the health and care sectors with great success. Therefore, I think that we have a template for doing this, and I know that my honourable friend is taking that forward. It was a specific recommendation in the report by the University of Bristol. My honourable friend committed to take forward with NHS England all those recommendations, and that is what we will endeavour to do.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Hollins Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Hollins (CB)]

My Lords, unlike the noble Lord, Lord Saatchi, I cannot see into the future, but I remember the past. In 1980, when I was a senior trainee in psychiatry, the Reith lecture series was given by Sir Ian Kennedy, who addressed the fundamental problems with healthcare in this country at that time. High among the problems he identified was the value we place on acute hospitals. He argued that prevention was always better than cure but that, unfortunately, spending was always on cure, not on prevention. That was 38 years ago, and despite numerous transformations in the NHS, we are still having the same debate and reaching similar conclusions today. The noble Lord, Lord Prior, commented earlier that too little attention has been paid to prevention in the last six years. I suggest that it has been longer than that.

A consensus is forming today around the need for a more coherent and non-party political long-term strategy, with more robust community healthcare, social care alongside healthcare, and for the same value to be given to mental health as to physical health. In paragraph 34 of this game-changing report, the Royal College of Nursing is quoted as saying that we must consider health and care services and budgets as “fundamentally connected and interdependent”. However, we also heard today about the gap between these aims and what is actually happening on the ground.

I worked as a psychiatrist in the NHS for over 30 years, and will focus my remarks on my own areas of expertise in mental health and learning disability. These services should be at the vanguard of a new sustainable health service. Most practitioners in mental health work in community settings rather than hospitals, and I recall from my own practice my team’s endeavours to prevent the admission to hospital of people with learning disabilities who also have mental health problems, unless absolutely necessary for short-term specialist intervention. The services I developed and had the privilege of working in had close links to social care, with workers working alongside mental health and learning disability workers in community teams. They worked with some of the most vulnerable, isolated people in society who not only struggled with their mental health but had poor physical health outcomes and died much younger than their non-disabled peers. Such close working seems less possible today.

The learning disability Transforming Care programme is due to end in March next year without having changed the all-too-common factor of a one-way hospital admission in crisis being the only option available. I left the debate briefly today to discuss the case of a young autistic man who has spent the last nine years in a private psychiatric unit. He was detained under the Mental Health Act on grounds of learning disability and aggressive behaviour. A recent attempt under the Transforming Care programme to discharge him unfortunately resulted in readmission after only three months. This was because of inadequate support in the community. Funding disputes were central to that failure. The social care support provider has still not been paid a penny, and the local NHS failed to take any responsibility for him. This local failure, still repeated around the country, is priming a boom in private hospital care, costing the NHS as much as £8,000 a week per person. Long-term admissions are good for business but not good for patients. I conclude from this that the barriers within the bureaucracy currently in place are making it well-nigh impossible to provide skilled, effective personalised care for people like the young man I have mentioned.

The Royal College of Psychiatrists highlights that, despite the Government reporting “record” levels of mental health spending, mental health NHS trust income is lower than it was in 2012 once inflation is taken into account. Referral numbers are going up, while the ability of trusts to provide services is going down—the exact opposite of a sustainable system, despite a more confident and competent discourse about mental health and the promised commitment to parity with physical healthcare. According to a freedom of information request reported in the Independent, nationally 50% of clinical commissioning groups say that they are planning to spend less of their total funding on mental health during the current year. How can this be right?

Funding is now so complex that it is difficult to track how national priorities are being translated locally. In any new long-term funding plan for the NHS, new money must not simply paper over the cracks in the current crisis, shifting the problems just five years further along into the next electoral cycle; nor must the money be sucked into acute hospitals, in keeping with practice over the last 40 years. Instead, it must be distributed with a focus on prevention. Funding for mental health services must be ring-fenced. Most importantly, social care should share in the benefit from any extra resources. The Association of Directors of Adult Social Services is calling for parity of esteem for the social care workforce. Its chair wrote that it is a source of shame that this is a minimum wage workforce and asks for serious consideration to be given to regulating the care workforce and to investing adequately in it.

I commend this important report. I also commend my noble friend Lord Patel for his leadership and, in particular, for his call for better health and care outcomes for everyone, including the young man whose shocking case I described earlier.

Health: Medical Respite for Children

Baroness Hollins Excerpts

Wednesday 21st March 2018 Lords Chamber

[Lord O'Shaughnessy]

Yes, I would be happy to do so. I am disturbed by the picture that the noble Lord has painted. He will know, I am sure, that the Government have set out our commitment to end the variation in end-of-life care, and of course this is a co-commissioned service. I would be very pleased to meet him to investigate that.

[Baroness Hollins (CB)]

My Lords, what measures are being taken by the NHS to check that CCGs have the range of specialist expertise available to be able to make assessments individual by individual? These children’s needs are complex. From my experience, often the assessors may be expert in one area but not necessarily that of the case they are assessing.

[Lord O'Shaughnessy]

The noble Baroness is quite right. Many of the children we are talking about are receiving continuing care to meet all their needs, and delivering that is very complex. A national framework for continuing care is being revised at the moment, and it will provide the picture for the skills mix that is needed at local level to ensure that these children are properly served.

Children and Young People: Mental Health Services

Baroness Hollins Excerpts

Thursday 8th March 2018 Lords Chamber

[Lord O'Shaughnessy]

These are interconnected but separate issues. Anyone can suffer from mental health problems, including a high propensity of children with learning difficulties. A separate line of work led solely by the DfE is providing specific educational support for children with learning difficulties. The point of having specialist staff in all primary and secondary schools is to spot any child, whatever their vulnerability, and signpost them to services.

[Baroness Hollins (CB)]

My Lords, have the Government done any analysis of the numbers? My daughter is a child psychiatrist working particularly with younger children. She points out to me that there is little attention given to the needs of nought to two year-olds and their mental health in the Green Paper. We know that interventions are important in those early years. For the prevention of adverse childhood experiences and interventions after adverse childhood experiences, does the noble Lord consider it wise to ring-fence funds to support prevention and early intervention at that stage?

[Lord O'Shaughnessy]

The noble Baroness makes an excellent point about the importance of that age group. I will write to her giving the specifics of the support available to children and families with children of that age. A significant amount of funding is going into specialist perinatal and mental health services for mothers, which is a big part of the picture, but not the whole. Health visitors are being trained in mental health support. I will write to the noble Baroness with more details but I am sure there is more to be done.

Dental Care

Baroness Hollins Excerpts

Thursday 1st February 2018 Lords Chamber

[Lord O'Shaughnessy]

I recognise the benefits of fluoridation that the noble Lord has pointed out. There is no question about that. But we know that this is a very difficult and vexed issue locally—there are strong feelings either way. That is why the position was reached in the 2012 Act. The noble Lord’s idea of a discussion is a good one. I should point out that it is not a policy area on which I lead so I will have to speak to my colleague in the department, but if we can get that going and think about ways to encourage more action it would be a very clever thing to do.

[Baroness Hollins (CB)]

My Lords, I am sure that the Minister is aware that adults with learning disabilities are also at considerable risk of tooth decay, in part because of difficulties in maintaining their dental health. What measures are being taken to improve their dental health? I declare an interest here because I published a book on the subject. I am concerned too about excessive sugar consumption as a major cause of tooth decay. This is a risk for children and adults with learning disabilities. Will the Government consider introducing a ban on advertising high-sugar products on television before the watershed?

[Lord O'Shaughnessy]

The noble Baroness might send me her book so I can get her ideas on reaching adults with learning difficulties. Most adults with significant learning difficulties are likely to be on a range of benefits. That means that their dental care is free, if not for all, I suspect, then for some. She is absolutely right to point to sugar. We now have the sugar levy, which has had a really big impact. About 50% of drinks that would have been affected have been reformulated to either reduce or remove the application of that levy. That is a really good impact. On her point on advertising, we have very tough advertising rules in this country, including the banning of advertising of sweet drinks, sugary products and so on in children’s media. That is one of the reasons why we are seeing some hopeful signs on, for example, the number of extractions falling in primary care year on year.

NHS and Social Care: Winter Service Delivery

Baroness Hollins Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I remind the House that I am a family carer, retired psychiatrist and a past president of the British Medical Association, whose work I will refer to during my speech. There has been a lot of talk and publicity about the pressures on what are termed acute services. We have all seen the television images of trolleys and the problems in accident and emergency and so on; they make headlines and they are provoking debate—and I welcome today’s debate. One solution will indeed be a focus on the problem of delayed transfers of care back to the community. Without taking attention away from these important areas, I want to highlight similar concerns within mental health services, which seem to me to be as acute in nature as those described in general hospitals—although, in truth, they are not just confined to winter.

The British Medical Association’s bed occupancy report highlighted particular problems with high bed occupancy and delayed discharge in mental health settings. It identified the main reasons for delayed discharge as being a lack of suitable community services or facilities to support patients at home and a lack of available beds within local community or specialist facilities. Of particular relevance, given the ongoing review into the Mental Health Act, the BMA report noted an association between the reduction in mental health beds and the increase in the number of patients admitted following detention under the Mental Health Act, with the balance shifting towards a more acutely ill in-patient population. It seems sometimes that people have to be sectioned to get a service, even if perhaps that might not otherwise have happened.

In December 2017, the mental health charity Mind published its survey of over 1,000 people discharged from mental healthcare facilities and reported that patients found planning for their discharge was rushed and unsatisfactory, and that around half of patients experienced inadequate planning and support with housing and finances before discharge. If I had more time, I would give noble Lords some examples. Given these issues, it is surprising that the framework in the care Act for addressing delayed transfers of care seems to overlook patients with mental health conditions. One of the mechanisms to promote integration and co-operation between the social care sector and the NHS is the system of local authorities reimbursing the NHS for a delay in transferring care. This system is viewed as an incentive to improve joint working between health and social care. However, the provisions do not apply to mental health care, which is explicitly excluded from this framework. In fact, I understand that the only way a mental health patient may benefit from this framework is if they are unfortunate enough also to develop a physical illness that requires treatment under an acute medical consultant, but of course, ensuring adequate care planning for someone with a significant long-term social care need who also has an acute medical condition requires additional time and skill.

By no means do I think that fining local authorities is the sole mechanism for integrating social care and the NHS. The issue is rather more complex than such a blunt measure could resolve. However, that it is excluded from this framework suggests something about the way mental illness is prioritised compared with physical illness. If increased integration and co-operation between the health service and social care is what is needed for physical illness, why is it not also prioritised for mental illness? If the reimbursement provisions in the care Act are felt to drive integration and co-operation for those with physical illness, why not apply it to mental illness also?

While my amendment to the Health and Social Care Act 2012, on parity of esteem, may have helped to raise concerns and awareness of mental illness and parity of service provision, and outcomes are now regularly raised as critical goals in a modern health and social care system, this debate highlights yet another area where it is partly missing. Although I am very grateful to the noble Baroness who initiated the debate for referring to these issues, what worries me when we hear talk of winter pressures, black alerts in hospitals and crisis management is that it is in this environment that those with the most complex health and social care difficulties can be overlooked. Whether we expected such problems in advance or not, this is not an environment where we can deliver the best care for the most vulnerable people. Care services for vulnerable adults need to be part of a long-standing sustainable system. We cannot rush their discharge just because it happens to be winter. In fact, it is at this time when we should be most careful about discharge planning. Do we have more social workers, community mental health workers, community care placements and district nurses during the winter season in order to pick up the work from the overstretched general hospitals, or do we just settle for less robust discharges? If the latter, then clearly, those with complex mental and physical needs will suffer most—the very people who often find it hardest to make their voice heard.

A sustainable health and social care service cannot run at two different speeds: one for summer and one for winter. Careful, considered, joined-up care is needed all year round. This care does not suddenly appear when a winter crisis is identified.

NHS: Winter Funding

Baroness Hollins Excerpts

Thursday 11th January 2018 Lords Chamber

[Lord O'Shaughnessy]

I think that the trust has been clear that there are not going to be delays. If the noble Lord is talking about the story on the front page of the Times yesterday, the trust has subsequently been clear that it will not delay or curtail its treatments. We know that more nurses are required. That is why, as I am sure he will be pleased to know, there have been around 11,700 more nurses on wards in the last seven years.

[Baroness Hollins (CB)]

My Lords, I have heard from clinicians, including an on-call psychiatrist working over Christmas at St George’s Hospital in south London, about the difficulties experienced and the teamwork displayed to manage the exceptional strain and capacity problems hospitals face. Particular concern was expressed about the pressure to discharge patients quickly and the possible impact on people with learning disabilities or serious mental illness, especially given similar pressures in social care. What steps are being taken to prevent this, for example, by targeting flu vaccination to these vulnerable groups, but also to monitor the impact on them?

[Lord O'Shaughnessy]

The noble Baroness is right to pay tribute, as we should all do, to the incredible work that NHS and social care staff are doing during winter. Of course there is a need to discharge patients, but that should be only when it is clinically appropriate. If she has seen or heard of instances in which she believes that that is not the case I urge her to write to me with them. On how we deal with vulnerable groups, one example is clearly flu vaccination. I point out, and this is important, that not only were flu vaccinations offered for all NHS staff for free this year, with 60% uptake, but for the first time they were also offered to care home staff. That is a really important point about making sure we go to the community to prevent infection.

Social Care: Sleep-in Payments

Baroness Hollins Excerpts

Thursday 7th December 2017 Lords Chamber

Asked by

[Baroness Hollins]

To ask Her Majesty’s Government what steps they are taking to support (1) the care sector, and (2) those receiving care, in the light of the retrospective change in guidance on the application of the national minimum wage to sleep-in shifts for care workers.

[Baroness Hollins (CB)]

I beg leave to ask the Question standing in my name on the Order Paper, and I remind the House of my interests.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

My Lords, we recognise that the historic liabilities associated with the national minimum wage for sleep-in shifts present a challenge to the financial position of many care providers. The Government have been working with representatives of the social care sector to understand how liabilities for back pay for sleep-in shifts impact on the provision of care for vulnerable people. We are exploring options to minimise any impact on individuals and the sector.

[Baroness Hollins]

The Minister will be aware of the considerable stress and anxiety faced by people with learning disabilities and their families about the likely loss of service providers. People with personal budgets who directly employ support staff fear being made bankrupt if they are found to owe arrears to them. We have been aware of this issue for some time now. Will the Government commit to funding these historical liabilities for sleep-in shifts and end the stress and anxiety which is now prevalent within this sector?

[Lord O’Shaughnessy]

We absolutely recognise the pressures that this has caused for providers of all kinds, whether they are large providers of social care or those with personal budgets in receipt of direct payments. I should point out that HMRC is working with local authorities where they are providing funding for direct care, so it is not just a discussion between individuals and HMRC. Local authorities are involved as well because they clearly need to look at the budgets they are providing to make sure they are adequate to pay for existing costs. We are looking at all the issues around historic liabilities, but I am afraid that I cannot give the noble Baroness the commitment she is asking for today.