Economy: Budget Statement

Baroness Jolly Excerpts

Tuesday 13th November 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I join others in thanking the noble Lord, Lord Bates, for tabling this timely debate and for his excellent speech. I also thank fellow Peers for their thoughtful contributions so far on this topic.

I shall use my time today to discuss the health of our population, a topic that goes hand in hand with a strong economy. There are clear links between good health and good economic performance. We know that when health and social care services are limited, it is the most vulnerable in our society who lose out. When services are strong and the Government fund progressive programmes to improve health, workers are more likely to stay in their jobs, children are more likely to thrive in school and the result is that the economy is made stronger. Not all health interventions need to be large or to take place at a clinical level. There is fantastic work being undertaken in public health by businesses, communities and local authorities across the country, which indirectly helps to support our economy by keeping people healthy and in work.

The headline figure of £20.5 billion by 2024 for the NHS in the recent budget, while welcome and laudable, is not enough to continue to grow this kind of upstream support, which helps keep individuals out of hospital and relieves pressure on primary care. Indeed, I was dismayed to note a cut of almost £1 billion in the non-NHS England parts of the Department of Health and Social Care budget this year, most of which will be felt in public health and social care services. I welcome the uplift to the national minimum wage, but regret the lack of funding for local authorities which have to pay for the increase in the wages of care workers.

The economic implications of Brexit are likely to add further strains to those services, which already face a funding gap far deeper than the most recent commitment will fill. Will the Government follow the Liberal Democrats in thinking strategically and on a cross-party basis about the future funding of help, including how it relates to our economy and workplaces?

To elaborate my point, consider for a moment an issue that affects all of us in our lifetime. One in four of us will have a mental health condition, and that means that someone well known to us or to our family will be affected. Mind estimates that 70 million work days are lost each year due to mental health problems in the UK. This costs employers billions of pounds each year in lost productivity and recruitment costs for those who ultimately feel forced to leave their jobs due to illness. Investing now to protect people’s mental health will pay dividends in future for employers and employees. Although I am pleased that the Government have highlighted this important issue in the Budget, I am disappointed by the funding allocation of £2 billion, which falls far short of the amount that experts say is needed to deliver vital improvements to services and achieve real equality between mental and physical health in future.

Mental health support is also crucial for younger people, who will soon be entering the workforce. The Budget recycles commitments set out in the coalition Government’s blueprint for children’s mental health, which pledged a named mental health lead in schools, as well as a dedicated professional in specialist NHS services. Will the Government consider investigating a similar programme for the workplace, perhaps along the lines of a mental health first aider? We are used to there being a first aider in all businesses above a certain size—I think it is those employing above 12 people. Perhaps we need to consider a mental health first aider. They need not be a professional, but rather someone trained to provide confidential advice and signposting for those who are suffering with their mental health who may not know where to turn. This is in line with existing efforts of employers to support the health of their employees. Let us consider some schemes that already exist which could be adapted.

Here in the Houses of Parliament, for parliamentarians and staff alike, the Parliamentary Health and Wellbeing Service offers mental health counsellors for anyone who needs them, away from their local GP and support network. Big White Wall, which provides emotional support for employees in the workplace, uses a virtual messenger service to provide advice. Fantastic work is being done by employers to encourage people to be open about their mental health and reduce stigma. It is surely also worthy of bolstered government commitment. There are plenty of lessons to learn about how we can improve our health in a cost-effective manner and save on lost work days. Do the Government support that view, especially considering the Statement of the Secretary of State for Health and Social Care on 5 November about prioritising prevention, including strengthening public health initiatives and local authority services to reduce strain on primary care?

We should remember that a lot of health conditions are caused or influenced by people’s work. To help keep individuals in their jobs and happy in those jobs, we need to be open to recognising that. In particular, it is important to fund research into conditions that are often exacerbated by the stresses of the workplace. The Migraine Trust quotes recent research by the Work Foundation suggesting that migraine is the least publicly funded of all neurological illnesses relative to its economic impact. It is estimated that absenteeism from migraine costs £2.25 billion per year in the UK, calculated on the basis of 25 million lost working days.

In addition, there is the phenomenon of “presenteeism”, in which workers attend their jobs, but are minimally productive due to their underlying and often unappreciated health conditions. Clearly, it is difficult under the Government’s current financing to fund some of these asks. But there may be other, creative ways to source funds. Possibly some health components could be funded in future by a system such as a citizen’s wealth fund—if you like, a sovereign wealth fund for the NHS. Under this system, the fund could be used to actively invest in stocks, bonds and physical assets. It would enable the country as a whole to benefit from the returns on investment typically available only to the wealthy. Once the fund became large enough to generate a substantial annual return, it would represent a new source of public funding, which could be used, for instance, to promote underresearched areas of health, or to bolster the much underfunded public health funding. This fund could also be used to raise awareness and identify conditions that are currently underdiagnosed—for example, structural heart disease, atrial fibrillation and bipolar conditions. It could help to normalise and prevent illnesses that affect thousands every year.

Overall, I see the state of the economy, and the state of our health, as closely linked. Tackling health in the workplace, and for the workplace, makes sense. It makes sense at a pragmatic level, a moral level and an economic level. I hope that the Minister can give me a positive response to guarantee the workforce, and so the economy, of the future.

Nursing

Baroness Jolly Excerpts

Monday 14th May 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I join noble Lords in congratulating the noble Lord, Lord Crisp, on calling the debate and on the APPG report. It has been an excellent debate, with informed contributions from noble Lords across the House.

We are here to talk about the all-encompassing importance of investing in nursing around the world. As serendipity would have it, a Minister’s response to a Written Question popped into my inbox this morning. This was the Question:

“To ask the Secretary of State for International Development, given the UK Government’s recent recommitment to defeating malaria, if her Department will increase investment in community-based primary healthcare programmes in remote, rural communities”.


This was the response from the Minister, Alistair Burt:

“DFID supports low income countries to make faster progress towards universal health coverage, with a particular focus on improving access to good quality primary care in poorer, very often remote areas. This support to strengthening health systems helps to ensure that countries are better able to prevent, detect and treat all causes of ill health”.


I am sure that noble Lords will agree that this came as quite a useful prologue to thinking about the debate.

Who better to deliver these changes than nurses? Nurses are an integral part of the global health workforce. Universal health coverage promotes the notion that, despite where one is in the world and the economic situation people find themselves in, each global citizen has the right to quality healthcare. As a country proud of its NHS and its irreplaceable facilities, this notion is close and dear to our heart. Yet nurses around the world, including here in the UK, face 21st-century obstacles. Health systems remain fragmented and endure systemic troubles that impede the quality of care. Communities are experiencing disengagement from participating in elevating their own health. Funding is often mismanaged, misplaced or misguided. Our own health obstacles surrounding Brexit pose a challenge to staffing. Research into universal healthcare has brought to light issues that affect most, if not all, countries with a healthcare workforce: their training and education, staff shortages, problems with recruitment and retention and limited accessibility to proper resources. Some of those sound quite familiar to us here at home.

Of course, countries vary greatly from an economic, social and political perspective. That is why, to combat such issues and signal nurses’ irreplaceable status to the world, the All-Party Parliamentary Group on Global Health published a critical report on nursing’s unique Triple Impact. I congratulate the noble Lord, Lord Crisp, on again putting his finger on the pulse. The report claims that investing in nursing globally progresses gender equality, builds strong economies and improves the health of all. Equality, prosperity and health: three fundamental legs that nursing strengthens. As the noble Lord said, that is a no-brainer.

On fortifying the equality, wellness and wealth of not just our own country but countries around the world, the report sets out several detailed recommendations and the practical applicability of each: nurses as policymakers; nurses developing their own potential through the Workforce 2030 initiative of the World Health Organization; nurses as leaders; nurses driving research, and nurses being empowered and therefore empowering other women.

Let us not forget the “global” aspect of investing in nurses globally. The UK must be a willing, active and successful participant when working with, and learning from, leading global health organisations. The exchange of health knowledge only improves Britain’s soft diplomatic power with nations of the world.

The noble Lord, Lord Crisp, mentioned gender; the noble Baroness, Lady Bottomley, mentioned prescribing. I wonder whether the noble Baroness was a Minister or Secretary of State at the time, but I remember two key changes which transformed the dynamic among health professionals and improved healthcare in my home county of Cornwall. The first was the de-medicalisation of community hospitals in the 1990s, turning them into effective, nurse-led step up, step down units; and, a bit later, the establishment of effective minor injury units in those hospitals. With those two changes came the impact of nurse prescribing.

GPs, predominantly men, were suspicious of both innovations, but now, 20 years on, nurses, predominantly female, have proved that with appropriate training and support they can lead healthcare in a local setting. Thinking of a global parallel, I remember several years ago the noble Lord, Lord Ribeiro, and I joining a party to Zambia. We visited a hospital out in the bush. Much like our community hospitals in Cornwall, they were then nurse-led very effectively, with not a doctor in sight. Doctors are great, but we do not need them all the time.

I return to the global agenda. Next month, we celebrate 70 years of the NHS. Twenty years ago, I was at the NHS Confederation conference to celebrate 50 years of the NHS. One of the most impressive speakers was the Health Minister from South Africa, who implored us not to poach her nurses. That country invests a significantly higher proportion of its GDP than us in training nurses. She asked us to desist and let them develop their strengths and health services in country. That is as important 20 years on as it was then.

Sponsored by the World Health Organization and the International Council of Nurses, Nursing Now takes these recommendations and works towards creating a world community that offers nurses more acknowledgment, security and authority. Nursing Now reminds us that the great power nurses hold, especially in this dynamic and cautious time, is unmatched and has a long reach. I would be grateful if the Minister told us how DfID intends to engage in this way, and what might be the timescale and the short-term and long-term investment.

Mental and Physical Health: Insurance

Baroness Jolly Excerpts

Tuesday 12th September 2017 Lords Chamber

[Lord Bates]

First, welcome back. It is good to see the noble Lord in his place. I do not know how long he was away in Bhutan, but there has been quite a bit of movement in this area in recent years. The Health and Social Care Act, led through this House by the noble Earl, Lord Howe, played an important role. It introduced parity and this was a significant advance. The serious discussion in the media now about mental health issues—particularly among young people—and how we respond to them, and the resources which are moving into this, bode well. As to whether we will match the constitution of Bhutan, I can say that parity of esteem is now in the constitution of the NHS.

[Baroness Jolly (LD)]

My Lords, is there any evidence that insurers are dealing with treatment for mental health differently from that for physical health? How many instances have there been, say over the last three years, of complaints about parity to the Financial Ombudsman Service and what were the outcomes?

[Lord Bates]

I do not have those specific figures to hand. The data on such experiences would be obtained through the Financial Conduct Authority. The Question asked by the noble Lord, Lord Blunkett, shows the importance of raising awareness of insurers’ responsibility to treat their clients equally, as set out under the Equality Act 2010. If people do not feel they have been treated fairly, they should seek redress.

International Development: Diseases of Poverty

Baroness Jolly Excerpts

Wednesday 24th July 2013 Lords Chamber

Asked by

[Baroness Jolly]

To ask Her Majesty’s Government how much of the £30 million allocated to fund the development of new technologies to impact on diseases of poverty, announced in March 2012, has been awarded to date.

[Baroness Northover]

My Lords, DfID is committed to tackling diseases of poverty through supporting the development of new technologies. Business cases for product development partnerships have been prepared and allocated funding is expected to begin this year, as planned.

[Baroness Jolly]

I thank my noble friend for her response, but how much has been spent in the past five years on biomedical and scientific research into HIV/AIDS and TB, and how much is planned to be spent in the next five years? I have tried to find this information; perhaps she can also tell the House where DfID’s 2013 onward research strategy is to be found.

[Baroness Northover]

DfID has provided approximately £60 million for biomedical and scientific research into HIV/AIDS and £39 million for TB research over the past five years. Spending for the next five years is dependent on the results of the ongoing product development partnerships competition. If my noble friend looks online, she will find DfID’s research strategy priorities and commissioning practices, which were published earlier this year as part of the International Development Committee’s annual accounts inquiry. This information is also in the Library.

Care Bill [HL]

Baroness Jolly Excerpts

Wednesday 12th June 2013 Lords Chamber

[Lord Warner]

My Lords, I shall speak to Amendment 77 standing in my name. I have taken a slight different approach from that of my noble friend, but I was out of the traps a little before him. I was trying to do something slightly different, but I am equally happy with his rather more elegant amendment on the duty of candour. Whether I have got the wording of the amendment right is another matter, but I was trying to link the organisational responsibility for a duty of candour to the registration process. Therefore, that right at the outset, as a condition of registration, the organisation had to sign up to the idea of a duty of candour.

When one is in the patient’s position, the duty of candour in relation to the employee becomes very important. The patient sees individual people, not necessarily something called an organisation. On the other hand, for the reasons that the noble Baroness, Lady Finlay, mentioned, one has to provide cover for individuals who operate in that organisation, both to protect them from unreasonable attacks by the victim of the mistakes, but also from attacks by the employer for blowing the whistle on them. In this amendment, I am striving for an obligation on the employer—the provider of the services—to have a duty of candour as part of their registration conditions. At the same time, the employee should be protected against unfair employment practices or unfair criticism. One is then forced along a path—which is not fully explained in my amendment—where the contract of employment between the individual and the employer gives some protection to the employee who blows the whistle.

That is quite complicated stuff and this is a complicated area, but we have to strive not just for organisational candour, but for some protected way for the employee to level with people when things have gone wrong. I think the secret lies somewhere in the contract of employment. We do not want that routed only through doctors. In a care home, for example, it will not be the doctors talking to the residents, their families or whoever. We need to do more work on this. Given that this was such a high-profile issue in the Francis report I, like my noble friend Lord Hunt, find it surprising that we are not trying to deal with it in the Bill, complicated though it is. We need to put some wet towels around our heads to try to find a way of capturing this in the Bill, so it is both fair to the employer and to the employee. That is what I am trying to do. Whether I have succeeded in my simpler version in Amendment 77 I am not sure, but that is the thinking behind it.

[Baroness Jolly]

My Lords, I welcome the debate on the duty of candour. It almost seems as though we are rewinding to 18 months ago, when we had similar debates during the passage of the Health and Social Care Bill. Although I would not have wished the events at Mid Staffordshire Hospital on anybody, I am really pleased that as a result the Francis report recommended a duty of candour. I therefore welcome the Government’s intention to implement that duty. However, as we have seen over the past 20 minutes, nothing is as straightforward as it first seems, so a lot of hot-towel work needs to be done to get this right.

I shall not detain the Committee long, but there are two sets of choices that the Government have made and I am curious why they made them. The first is whether the duty of candour is on the individual or on the organisation. The second, to which the noble Lord, Lord Warner, has just referred, is whether it is going to be in the Bill or in secondary legislation.

The duty of candour will cause a large change in people’s behaviour and it should be a game changer in lots of ways. As an aside, I think that complaints will fall. If somebody turns around and says, “I’m sorry”, people are less likely to complain. Certainly, those of us who have been involved in complaints will know that on many occasions patients just want someone to say that they are sorry and to explain why and how it went wrong, because they do not want it to go wrong in the same way for anybody else. So there might be an unintended consequence there.

When the Minister sums up, I would like to know why the decision was made not to put the duty in the Bill. Is that decision irrevocable?

[Baroness Masham of Ilton]

My Lords, I support Amendments 76B and 77. There has been so much said that there should be a change in the culture in the NHS after the scandal of Mid Staffordshire Hospital. Amendments 76B and 77, dealing with the duty of candour, might help to do this. For years, relatives of patients who have died or been badly damaged have not always been treated in an honest and open way; many times, the causes have been covered up and there has been much suffering by those who need to know the truth and have an apology. It is also terrible that when people who fear for patients’ safety speak out to warn of unsatisfactory and dangerous situations, they are silenced and gagged. Surely, we should do something about that. It is our duty to speak out now and make patients’ safety a reality.

One elderly Member of your Lordships’ House told me yesterday that she was frightened in case she might have to go to hospital. How many people throughout the country must feel like that? The culture of fear and neglect must be changed. I hope that the Government understand that.

Global Fund to Fight AIDS, Tuberculosis and Malaria

Baroness Jolly Excerpts

Tuesday 4th June 2013 Lords Chamber

[Baroness Jolly]

My Lords, I, too, thank my noble friend Lord Fowler for securing this well informed and timely debate. I realise that I am a newcomer to this field, and recognise that I am among experts with a wealth of experience. However, I hope that what I lack in both experience and expertise I can make up for in strength of feeling and enthusiasm.

I will take this opportunity to build on what the other speakers have said and emphasise the importance of the global fund in the fight against tuberculosis. Ninety per cent of international donor funding to fight TB comes through the fund, mainly because it is such an effective institution but also because TB does not get the profile or attention warranted by the devastation it causes. It is a disease closely associated with poverty, and 90% of cases are in developing countries. In 2011 there were almost 9 million cases of TB and the disease killed 1.4 million people. That is scandalous when you think that the majority of cases are curable with a course of cheap antibiotics. There are 22 high TB-burden countries in the world today, of which six are totally reliant on funding from the global fund, while two-thirds of the budget for the other 15 comes from global fund financing. Let us be clear: for many countries there would be no response to TB without the global fund’s support.

Last summer I was lucky enough to visit one of the projects supported by the global fund in Zambia. We visited St Luke’s Mission Hospital in Mpanshya, which serves a population of over 30,000 people and receives funding from the Churches Health Association of Zambia, or CHAZ, for its work on malaria, TB, HIV/AIDS and preventing mother-to-child transmission of HIV. CHAZ receives a grant from the global fund and is one of two principal recipients of such funding in the country. Through the grants that the global fund has distributed, CHAZ has brought about catalytic change in Zambia. Global fund-supported programmes have diagnosed and treated 44,000 new cases of TB, distributed 1.6 million bed nets to protect families from malaria since 2003, and provide lifesaving antiretroviral treatment to over 450,000 people living with HIV.

On our visit we heard from community health workers who included TB and HIV treatment supporters, traditional-birth attendants and former TB patients. These comments also reflect the observation of the right reverend Prelate the Bishop of Derby, because these people were church-based workers. They were based at this religious foundation, some 200 kilometres east of the capital. They carry out their work entirely voluntarily, covering long distances on foot in order to reach patients. Their commitment to improving the health of their communities was truly inspirational; but this is only one part of the global fund’s portfolio. It really brought home to me the important work that they do and the hope that the projects that they support brings to millions.

It is essential that this work continues in Zambia but also elsewhere. This replenishment year is critical for the future of the fund’s work. It announced in April that it will need $15 billion to tackle the three diseases for 2014-16. Speaking about the call for new pledges, the executive director of the global fund said:

“Innovations in science and implementation have given us a historic opportunity to completely control these diseases. If we do not, the long-term costs will be staggering”.

These costs are not just financial; they are costs in lives.

If this goal were achieved, it would mean that 17 million patients with TB and with multidrug-resistant TB could be treated, saving over 6 million lives over the three-year period; I cannot do the sums, but per day those numbers run to four figures. Some 1.3 million new HIV infections could be averted each year and 196,000 additional lives saved from malaria.

Of the money needed by the fund, the United States has signalled that it could pledge an unprecedented $5 billion. However, according to US law it cannot donate more than one-third of total contributions to the Global Fund. For the US contribution to become a reality, other donors must increase their contributions to commit the remaining funds. I echo the comments of my noble friend Lord Fowler: the UK Government have a key role to play. They can exert leverage on other donors by demonstrating their continued support for the Global Fund with an increased contribution of £1 billion for this replenishment period. An early summer announcement of increased UK funding at this key moment would lay down a marker for other Governments to follow.

This is just not my view. It was shared by the International Development Select Committee last year when it urged the Government to do all possible to commit funds early, and at a time that raises the most amounts of money from other donors. I urge my noble friend the Minister, for the reasons that I have just outlined, to do all in her power to ensure that the Government bring forward this anticipated increased contribution, ahead of the Summer Recess.

National Health Service (Clinical Commissioning Groups—Disapplication of Responsibility) Regulations 2012

Baroness Jolly Excerpts

Tuesday 29th January 2013 Grand Committee

[Baroness Jolly]

My Lords, I shall be brief. The main purpose of this secondary legislation is to transfer responsibilities for patient care and commissioning from the PCTs and SHAs of the old world on to the CCGs and the National Commissioning Board of the new. It seems complicated, but it is relatively straightforward. I note as well that some individuals are actually covered by the board, and I welcome developments such as the board’s responsibility to fund fertility treatment for members of the Armed Forces. I shall be asking the Minister for assurance and clarification in a few areas.

I note that care needs to be taken at the borders of Wales and Scotland as far as residence is concerned so that the appropriate arrangements are made with the NHS bodies in Wales, Scotland and Northern Ireland.

I note that my noble friend said that the commissioning groups would be responsible for commissioning ambulance services and accident and emergency services. If there is a major disaster in a CCG area, how is that covered? It would certainly be a big, unexpected hit on a CCG’s budget so I would assume that the board might pick that up. I would welcome clarification on this.

I note, too, that the board has responsibility for those in immigration removal centres, secure training centres and young offender institutions. My noble friend also indicated that some services might actually be commissioned by the Home Office. Can she give the Committee some assurance that in all these areas the mandate will be adhered to and reported, that health inequalities will be addressed and that governance will be transparent, so that reporting would be available on an annual basis as to what is commissioned in each of these establishments, and the outcomes?

In Committee on the Health and Social Care Bill, and elsewhere, we were all very concerned to ensure that everybody was going to be covered by CCGs. There was a lot of debate about people who are at the margins: Gypsies and Travellers; those who are homeless; people with chaotic lifestyles, substance dependence, mental health issues, and so on. I am sure that these groups are now swept up into these regulations.

I welcome the clarification on temporary patients. In Cornwall, our population rises by several hundred thousand during the summer and it is welcome news that it is really clear how that is going to be commissioned.

In conclusion, clearly much work has been done in this piece of secondary legislation to ensure that everybody is covered. The way that it is laid out is very complex. I would be grateful if my noble friend could explain who is the arbiter in future should either a category of person or a certain individual not fall into any of the areas covered in this secondary legislation. Who should decide who should commission these services?

[Lord Hunt of Kings Heath]

My Lords, I, too, thank the noble Baroness for her explanation of the two statutory instruments that are covered in the Explanatory Memorandum that we have received. I particularly noted her reassurance in relation to temporary arrangements, which is very helpful, as I do not think the instrument itself is particularly easy to follow.

As far as the affirmative instrument is concerned, perhaps I could ask the noble Baroness about the situation with regard to patients from Northern Ireland. Indeed, some of my remarks would apply to patients from Scotland and Wales as well. Regulation 2(2)(a) refers to,

“a person usually resident in Northern Ireland who is provided with primary medical services by a member of the CCG”,

and says that for such a person,

“a CCG does not have responsibility in relation to its duty to commission services”.

But what if the person who comes from Northern Ireland, Scotland or Wales needs services that a GP cannot give—for example, in a hospital—and this is regarded as secondary care? Who has responsibility for commissioning secondary care services in such circumstances?

I would like to ask the Minister about abortion services, because I have asked a number of questions recently about the eligibility for abortion services in England of people normally resident in Northern Ireland. On 8 January, I received a response from the noble Earl, Lord Howe, which referred to the fact that the Secretary of State,

“has a duty under Section 3 of the National Health Service Act 2006 to provide a variety of secondary care services to such extent as he considers necessary to meet all reasonable requirements. This duty is delegated to primary care trusts … in Regulation 3(2) of, and Part 2 of Schedule 1 to, the National Health Service (Functions of strategic health authorities and primary care trusts and administration arrangements) (England) Regulations 2002”.

The noble Earl went on to say:

“Regulation 3(7) of the regulations sets out who a PCT is responsible for exercising functions (including the Section 3 duty) in respect of. Under Regulation 3(7), there are two sets of limited circumstances in which PCTs would be able to exercise their delegated functions to provide abortion services to women resident in Northern Ireland. The first is set out in Regulation 3(7)(a)(iii), which provides that a PCT shall exercise its delegated functions in so far as those functions consist of the provision (or securing the provision) of certain services to ‘qualifying patients’ resident in Scotland, Wales or Northern Ireland who are present in its area and do not fall under the responsibility of another PCT. This essentially covers persons resident in the above countries with serious mental illness who are present in a PCT’s area. The second is set out in Regulation 3(7)(b)(i), which provides that a PCT must exercise its delegated functions in so far as those functions consist of the provision (or securing the provision) of accident and emergency services for the benefit of all persons resident in its area”.

He then said:

“A PCT’s functions under Regulation 3(7)(a)(iii) will clearly be exercisable only in respect of the limited number of women who fall within that provision. A PCT’s functions under Regulation 3(7)(b)(i) will be exercisable in respect of any person present in the PCT’s area”.

He then went on to say, I think rather controversially:

“There is no absolute right for a patient to receive particular treatment under the NHS. A PCT has delegated powers to provide abortion services to a woman who is ordinarily resident in Northern Ireland but present in the PCT’s area in so far as that provision falls within Regulation 3(7)(a)(iii) or (b)(i) and is considered by the PCT to be necessary to meet all reasonable requirements”.—[Official Report, 8/1/13; cols. WA 1-2.]

I am well aware that of course the noble Earl was referring to the current legislation and that the 2012 Act made amendments to the 2006 Act, including changing the words around “reasonable requirements”. However, I hope the noble Baroness will be able to reassure me that women coming to England from Northern Ireland for an abortion service will continue to be able to be eligible to receive that service. I would be very grateful for any reassurance she can give me on that.

I now want to come on to the standing rules. The noble Baroness said we were not debating these this afternoon but I must confess to being a little surprised, because the two had been put together in one Explanatory Memorandum and the noble Baroness has referred to them, so I had assumed we would be able to discuss them. I will ask four questions and see how we go.

First, there is the issue of consultation. Paragraph 18 of the standing rules says that the board “must consult” persons specified, including Healthwatch England. The noble Baroness will probably know what is coming. She will know that, in a week or so, we are debating the NHS bodies and local authorities partnership arrangements. This relates to the issue of whether local Healthwatch organisations can campaign. There has been some controversy. Healthwatch England has not made any public comment on the regulations. Did it respond to them? If so, why did it not publish its response? The noble Baroness responded for the Government and said that there was a great deal of debate. She assured us that Healthwatch England, despite coming under the CQC, would be independent. So far, we have seen very little sign of that independence. Will the Minister reassure me that when the board consults the CQC, CCGs, Healthwatch England, Monitor, the Secretary of State and such other persons as the board considers it appropriate to consult, those submissions will be published?

My second question relates to the issue of commissioning and relevant bodies in paragraph 34. This concerns the duty of any relevant body in respect of the funding of the commissioning of drugs and other treatments. The noble Baroness will know that this can often be a controversial area. She will also know that there is continuing concern about the local accountability—or lack of it—of clinical commissioning groups. They can, in accordance with the Act, make judgments about whether a treatment will be available to local people. Will the Minister consider amending the rules to make sure that when a member of the public wishes to appeal against a decision of the commissioning body, a panel must be convened to hear the appeal? I noted from paragraph 23(3) of the standing rules, which relates to decisions about continuing healthcare that are equally controversial, that panels must be established to hear appeals by people who do not agree with the decision reached about their eligibility. Why is it not considered necessary that a similar arrangement should be put in place when it comes to commissioning decisions either by the CCG or by the NHS Commissioning Board?

CCGs are about to start work formally. In Birmingham, I have been very impressed with the leadership of the two CCGs with which I am in contact. However, nationally I do not think that the public have heard very much about them. I do not get any sense that clinical commissioning groups feel that they are accountable to the local population when it comes to making commissioning decisions. If a CCG turns down a request for a certain drug or treatment to be given to a patient, surely there ought to be a way in which that member of the public can challenge the decision.

My fourth question relates to paragraph 39, which covers the important issue of patient choice. Can the Minister say anything about how that choice is to be exercised? In particular, what information needs to be given to any member of the public to make a choice, and who will be available to offer advice to that patient? It is all very well talking about patient choice, but we all know that that is very difficult to exercise unless there is a mechanism by which a member of the public can obtain help and advice in exercising it.

My final question relates to Schedule 5, which I am sure all noble Lords have studied with great care. It relates to the panels that must be established to review decisions about continuing healthcare. Schedule 5(1) disqualifies a number of persons from being a chair, CCG member or social services authority member of a review panel, including a Member of Parliament, a Member of the European Parliament and a member of the London Assembly. Can the noble Baroness tell me why that is so? Why is it deemed okay for Members of the House of Lords to serve on such a panel while Members of Parliament may not? I would be grateful for a response to that.

Care Services: Abuse of Learning Disabled

Baroness Jolly Excerpts

Thursday 13th December 2012 Lords Chamber

[Baroness Jolly]

My Lords, I start by echoing the words of the noble Lord, Lord Touhig, in thanking the noble Lord, Lord Rix, for bringing this important issue to the attention of the House. His personal expertise and wisdom have informed the House for many years, and long may it continue.

It is vital that we make public this failure in care and act swiftly to ensure that vulnerable populations in society are treated with dignity and afforded quality, compassionate treatment. Today, I want to touch on a few distinct aspects of this issue. Systemic and, perhaps, societal issues need to be raised. As evidenced by the 11 individuals prosecuted and sentenced for providing shockingly abusive care, the actions taken by these staff at Winterbourne View were criminal. There is no excuse for this appalling abuse. I am pleased to note that the criminals have been brought to justice and that larger investigations into more than 150 other hospitals have not found similar abuse and neglect. However, where were the safeguards within this hospital to identify failures in care and correct them? Where was the management of this organisation in monitoring abuse and establishing the quality of care?

Culturally, I am concerned that this event reflects a fault in how we value our vulnerable populations—those with mental health problems, the disabled and the elderly. Our respect for these populations is apparent in whom we charge to care for them and we undervalue them when we pay little attention to how their carers are trained and managed. However, we do little to respect the ill treated if we do not change the culture of care to prevent these crimes from happening again.

We were all rightly shocked when the BBC “Panorama” programme uncovered this systematic abuse of patients at Winterbourne View Hospital. Vulnerable patients were bullied, pinned down and tormented, not once or occasionally, but systematically. This would be appalling even if this treatment was limited to one staff member. What escalates the abuse at Winterbourne View to a national scandal was the culture of neglect and ill treatment that was fostered throughout the hospital. Even with this widespread negligent culture, the existing accountability safeguards did not detect the abuse.

I see two areas of concern. First, the patients who received ill treatment in the hospital should not have been in the hospital setting to begin with. The noble Lord, Lord Rix, made that point very clearly. Similar stories of misplacement into the wrong care settings have been found all across England, so greater scrutiny must be called for in the determination and monitoring of treatment plans for the vulnerable. In particular, we should explore every option for them to live close to their families and the people who care for them. The provision of less institutional and more local care can be a great safeguard against abuse.

Secondly, the abuse was found in a private, foreign investment-backed firm. As we move towards a system with greater diversity in how health and social care is provided, will the Minister tell the House what oversight is being put in place to ensure that these new forms of care delivery are fit for purpose and free from repetitions of this kind of abuse? In these settings, good management is key to setting the standard for institutional practices. Clearly, there was a failure to lead and train staff effectively and eliminate unacceptable behaviour. In these new methods of care delivery, with less direct government oversight, how can we ensure that management is effective in setting behaviour standards and being held to account?

There is a cultural issue that I would like to raise around training, appraisal and professional development of care staff. Clearly, there was neglect at many levels of the organisation, but in particular I believe that how we value front-line care workers reflects how we value vulnerable populations. The following example has been used before in your Lordships’ House. A very high-profile department store and grocery chain will not let a new employee on to the shop floor without providing basic training on the job in hand and on the corporate culture—and this takes weeks, not days. It is accepted and common practice that staff at all levels are given close monitoring until a probationary period is over and that they are part of an appraisal scheme. This is not overkill; it is to ensure that employees know what they are doing and that employers know what employees are doing and can take appropriate action if there is a problem.

This brings me to registration. I know that the Government are reluctant to regulate for the registration of care workers but, with a large population in all areas of health and social care, the failure to register looks like a failure to value their work. When we start setting a precedent of lower value for these workers, it shows in their professional behaviour. If this vital cohort of workers were part of a registered body, that would send a signal to any companies that see the health and care business as a cash cow. Care workers do a valuable job. They are a resource to be valued and their training is not a cost—something to come off the bottom line—but an investment.

Finally, I applaud the action plan set forth by my honourable friend Norman Lamb. At the same time as we embrace innovative forms of care delivery, we must complement this flexibility with accountability from all levels of care organisations: owners, boards of directors, managers and care workers. We need to stop patients being inappropriately placed in the hospital as their primary care setting and instead design personalised services enabling them to live in communities closer to their families.

Again, I reiterate: how we value care workers reflects how we value the populations they care for. Universal professional standards for care workers should be developed and implemented to create a culture where their work is professionally valued and appraised. We need to know, too, that they will be registered. By moving quickly to implement these reforms, we can make what was a horrible failure in care into an opportunity to prevent its repeat.

Health: Neurological Services

Baroness Jolly Excerpts

Tuesday 20th November 2012 Lords Chamber

[Baroness Jolly]

My Lords, I thank the noble Baroness, Lady Ford, for bringing this important issue to our attention, especially at a time when decisions are still being formulated by the NHS Commissioning Board. We know that neurological conditions and epilepsy in particular are great challenges facing the NHS. The efficient and effective provision of these services is crucial to the good care of the estimated 8 million people in England who have neurological conditions and the 600,000 of those who have epilepsy.

We know that good treatment of these conditions is vital. However, my comments today focus less on the method of treatment than on the commissioning of the care. Under the coming system of healthcare commissioning through GP-run clinical commissioning groups, will the Minister guarantee the training and resources to support GPs in these new roles for the commissioning of neurological care? Specifically, what is the NHS board doing adequately to prepare clinical commissioning groups to commission high-quality, appropriately targeted epilepsy and other neurological services?

I shall separate my concerns into three areas. First, I am concerned that neurological conditions have not been made enough of a priority within the Government’s objectives for the NHS. Secondly, I welcome the national network, but am concerned that our current approach to neurological care lacks focus, including, as it does, dementia and mental health. My third and perhaps greatest concern is that the board should help create and sustain local or regional neurological networks to support the commissioning process within CCGs.

On my first concern, what are the Government doing to ensure that there is adequate emphasis on and measurement of neurological care? Are these conditions being recorded by GPs? If they are not being recorded, we do not know where they are and we cannot plan properly

Some groups have come forward citing that only three out of the 60 outcomes within the 2012-13 NHS outcomes framework were neurological. Without appropriate outcome measures driving change, key problems with diagnosis and treatment may not be resolved. For example, Epilepsy Action notes that the epilepsy misdiagnosis rate is 20% to 31%—that is, between one-fifth and a third—meaning that around 138,000 people are currently misdiagnosed each year. What have the Government done within the new mandate to react to these past criticisms? How are decisions made about the relative focus among different conditions and how can we be sure that this is adequate?

On my second concern, recent reports from the National Audit Office and the Public Accounts Committee have cited some areas within neurological care as being in need of improvement for increased co-ordination of care, to address delays in diagnosis and to address recent increases in emergency hospital admissions. For example, 66% of patients with epilepsy presenting at an emergency department have not seen an epilepsy specialist in the previous 12 months. It is important that the Government develop a consistent national strategy and then help co-ordinate efforts in order for the board to bring this to the local level.

Lastly, I ask the Government what has been done to support local clinical leaders within neurological care, to connect them and to leverage this network to inform CCGs in their commissioning. This is the greatest concern that I have and the one that I am most anxious to see addressed.

Neurological care as I see it, especially in the case of epilepsy, fits within the spectrum of diseases for which GPs are now responsible for commissioning care. Many of the diseases for which clinical commissioning groups will commission care carry a level of familiarity with GPs—for example, various cancers, diabetes and kidney failure—but neurological conditions are not seen so frequently.

While I have confidence in the expertise and scientific knowledge of our GPs, my fear is that neurological disorders require a special understanding of prevalence and societal factors, and this leads GPs to having less familiarity with neurological conditions than with more common ailments. These networks could contribute to commissioning by helping demonstrate pathways of care for epilepsy and other neurological conditions.

While I am pleased to see the commissioning of treatment of specialised neurological conditions being carried out by the board—as has been said earlier, that is really good news, meaning that commissioning of really rare conditions will be the same across England—I believe that the board should also support and maintain local networks of neurological experts.

For commissioning under the new Health and Social Care Act to be effective for all with a neurological condition, the following three objectives must be reached. First, neurological disorders must become a priority in the measurement of clinical outcomes. Secondly, a national plan should be set out for addressing neurological conditions and, thirdly, networks of expertise should be created to inform the commissioning of CCGs and sustained support be given to them. I look forward to the Minister’s responses and the Government’s call to action on these specific issues.

Health and Social Care Bill

Baroness Jolly Excerpts

Monday 5th December 2011 Lords Chamber

These are very important amendments, and I hope that my noble friend will consider them seriously and see how in this very important area he can enhance the status, security and confidence of directors of public health.

[Baroness Jolly]

My Lords, I rise to underpin much of what has already been said, so I will say it very briefly. The appointment of a DPH to a local authority will be critical. Not only will he or she play a key role in something like an outbreak of E. coli, when that sort of expertise is looked up to and expected from the community. They will be absolutely pivotal in delivering and making health plans, both through the health and well-being board and working with the CCGs. There is no way that DPHs could be a shrinking violet; as my noble friend Lady Cumberlege has just said, they really have to be able to mix it and get in there, but what they do has to be totally evidence-based. So it is a really interesting balance for someone who has their hands on all the facts but is not necessarily an introverted individual. One key thing that they really have to have is the support of the chief executive of the local authority. Furthermore, they have to report to them and have exactly the same status as, say, the director of adult social services so that they have that level of authority when going out and talking to various people in the health and social care community. That will be absolutely critical if the localism and local decision-making built into this Bill is going to work.

I have attached my name to Amendments 228 and 229. The person described in the amendments really should be seen as a person of standing, so they should have director status and be responsible to the chief executive of the authority. I was a bit alarmed when talking to my own MP this weekend. He was saying that he had learnt from his conversations with the chief executive of the local authority that the authority was not at all minded to do this with the appointment. That would completely undermine any sort of position that the director might have. They have the key role and need to be a person of standing. Without them having such a position within the council, many of the plans will be totally undermined.

[Lord Warner]

My Lords, I support the thrust of most of the amendments in this group and have added my name to Amendments 226, 259 and 339. As others have said, it is essential to have in the Bill a clear commitment from the Government, and indeed from Parliament, that three things are very clear when it comes to directors of public health. First, we have to make sure that they should be registered public health specialists, with appropriate qualifications and expertise. That seems to me a given if these people are to have standing in the local communities and, perhaps, even in a wider area. Secondly, the director should be accountable to the local authority’s head of paid service and be able to report directly to the local authority itself, particularly when there is an area of great concern in that local community. One does not want people intervening between the director and local authorities’ main committees when a serious incident is taking place locally.

Thirdly, for the reasons that everybody else has mentioned, we have to ensure that a director of public health cannot simply be fired on a whim because they are doing something which is uncomfortable or unpopular, or has brassed off a local interest of one kind or another. That is particularly critical when we see the difference of approach that the noble Baroness, Lady Cumberlege, put very well: between the evidence-based approach of a director of public health and the commitments that local authority members, quite reasonably, have to seek re-election from time to time. That is how the system works, but a different approach is likely to run through some local areas when something is uncomfortable for the local authority but is backed up by the evidence that the director of public health can put in the public arena.

Directors of public health need to be seen to be capable of doing the job and to be able to deliver bad news—as well they may have to. They should be able to expect to be supported and protected locally when they have to deliver uncomfortable news. Amendment 226 is part of that package of armour that we need to wrap around directors of public health. There may be better ways to do that in these amendments than in Amendment 226, but its purpose certainly ought to be in the Bill.

Amendment 259 is an important part of the protective armour that I have mentioned for directors of public health, in that it aims to ensure that they simply do not lose ground financially over time in their pay and conditions of service with NHS medical equivalents. I am not a supporter of creating situations where there are bidding wars between local authorities and the NHS. We have seen that with occupational therapists over the years, where one side decides that it can secure some advantage by upping the ante a bit for a specialist group when there is a degree of local competition for a sometimes scarce resource, so I am not in favour of doing that.



However, my experience—and I have worked six years in local government—is that where there are these bidding wars, usually the NHS specialist is further up the greasy pole in terms of pay and conditions of service, and the specialist at the local level is trying to catch up with what has happened. That is why Amendment 259 is important, in that it ensures that there is a catching-up process. Much more importantly, it tries to ensure that it is not necessary to have a catching-up process, because there is an agreed alignment between the pay of those specialists who are employed by the NHS and those who are employed by local authorities.

In speaking to Amendment 339, to which I have put my name, I should declare an interest, in that my daughter is a non-medical public health specialist, although I hasten to add that I have in no way discussed this with her, so she should not be held responsible for the views I am about to express. It is vital that public health specialists are brought within the purview of the Health Professions Council and that there is a separate register for non-medical public health specialists which comes under the purview of that council.

Increasingly, the behavioural aspects of successful public health policies and their implementation are absolutely critical. This is not an area where we should be relying only on personnel with medical or dental qualifications. If we are to have successful public health policies, it is vital that we have people with the kind of background where they can communicate, understand, and do research on the emerging areas of the behavioural sciences. I hope, therefore, that we can have a register which has public standing and is supervised by the Health Professions Council.

Before I sit down I would like to start this session with a mild chastisement of the Minister. I said at Second Reading that I had a benchmark for the Minister’s flexibility in accepting amendments to this Bill. However, he has been uncharacteristically inflexible in responding to many of the noble Lords’ concerns in their amendments. Of course, he has always been very polite; but we have not seen much evidence of the Government being willing to take away some of these issues and come back with amendments at a later stage. I would say to him that this set of amendments gives him a good chance to turn over a new leaf. They do not affect the Government’s policies in this Bill. However, they strengthen the ability of the Government to deliver those policies in the way that they have strengthened the arrangements around the appointment, the pay and the safeguarding of the independence of the directors of public health. I do hope, therefore, that we will see a different type of Earl Howe appearing in relation to these particular amendments.