Health: Medically Unexplained Symptoms

Baroness Jolly Excerpts

Tuesday 4th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I am certainly happy to investigate CCG practice and commit to write to the joint panel to make sure it understands both the nature of the classification of the illness and the fact of the NICE guidelines. Of course, those are guidelines for clinicians; they are not mandatory in themselves.

[Baroness Jolly (LD)]

My Lords, the commissioning of mental health services has a chequered past at best, particularly when involving many agencies such as in this case. However, good commissioning practice exists. What training is available for commissioners of such complex services and what opportunities are there for sharing innovative practice?

[Lord O'Shaughnessy]

Of course, a suite of training is available for those treating illnesses such as this one, which affects about 220,000 people in England. It is not a rare disease; unfortunately, it is far too common. That treatment is there and also a number of networks exist, such as the Academic Health Science Networks, to spread innovation and best practice for treatments around the NHS.

Queen’s Speech

Baroness Jolly Excerpts

Thursday 29th June 2017 Lords Chamber

[Baroness Jolly (LD)]

My Lords, as the Liberal Democrat defence spokesperson, I would usually have spoken in response to the Queen’s Speech last week. However, I have a social care issue of which I have given the Minister prior warning and would be grateful for a response, so I am speaking now and understand that I will get no feedback on the defence element.

Last week’s defence debate revisited issues that we have raised again and again these past two years: the 2% of GNP spend; concerns about our shrinking fleet; insufficient equipment to maintain capabilities in the face of growing threats; and all this against a backdrop of concerns over Britain’s diminishing position on the global stage.

Whenever our fleet is reduced, whenever a key military capability is lost, there are howls of indignation from all sides of the House. However, the gradual hollowing out of the Armed Forces through reductions in the numbers of personnel must also be of great concern. Last year, there was a deficit of full-time, trained personnel of about 6,400 individuals, a trend which has seen little sign of abating under the current Government. This means more pinch-points in operational capabilities. This pinch is already felt in specialties requiring key skills such as engineering, but it will be felt right across the Armed Forces should the decline continue. This week, HMS “Queen Elizabeth”, our magnificent new £3 billion pound aircraft carrier, put to sea for the first time. But how valuable an investment will she be if we cannot crew her or her supporting fleet?

For the service men and women still serving, the cuts have been felt acutely. The results of the Regular Armed Forces continuous attitude survey published last month painted a picture of low morale, both personal and within units, which, along with the impact on family and personal life, were the key reasons cited for leaving the service.

The recent report of the Armed Forces Pay Review Body noted that this is due to a “perfect storm”—those are its words, not mine—of pay below the private sector, increasing national insurance, changes in tax credits and increases in rental charges under the new combined accommodation assessment system. Beyond that, service personnel feel the pressure of having to perform difficult jobs without sufficient capacity, which leaves them feeling undervalued and undersupported by the establishment. It is small wonder, then, that there has been a deterioration in perceptions of the Armed Forces offer, as compared with that of the private sector.

The Government’s solution, announced in the Queen’s Speech, is the proposed Armed Forces (Flexible Working) Bill, which would enable flexible working arrangements for regular service personnel. This includes part-time service and limited geographic employment within the Regular Armed Forces. The Bill might go some way to stem the loss of service personnel and it might provide measures that would make the Armed Forces a more attractive prospect for some, but the proposals will not necessarily allow the Armed Forces to maintain current levels of functionality.

I would be interested in seeing the evidence that suggests that the measures in this Bill will be effective. Do any NATO members have similar schemes? Is there a great call for this from families? Furthermore, the Bill does not address the major causes of the lack of manpower. As such, it provides measures only to treat the symptoms of Britain’s ailing defence capabilities but fails to address their causes. Failure to address these deficiencies puts more and more pressure on our service men and women, who make sacrifices for our defence, risking their health and well-being. This truly threatens the security of the nation.

In the Queen’s Speech there is a commitment to improve social care and bring forward proposals for consultations. I am sure many noble Lords here today await these eagerly. I declare my interests as set out in the register. For the last 18 months I have been chair of Hft, a long-established charity which provides services to over 2,000 adults with learning disabilities and employs over 3,000 staff. We pride ourselves on our quality service provision and quality approach to staff. To put this in context, I remind noble Lords that one-third of social care expenditure is on adults with a learning disability—a significant number.

That sector is under threat due to the unintended consequences of a series of employment tribunal rulings, coupled with HMRC enforcement activity, relating to the treatment of sleep in shifts for the purposes of the national living wage. This is forcing employers to fund back-payments for a number of years when everyone involved funded on the understanding that sleep-ins are not covered by national minimum wage legislation.

Many in the sector, including charities and personal budgetholders, do not have the money to fund these payments. The total cost to the sector will be around £400 million. My charity is the first to be called to pay, going back six years, and it has a deadline of 1 September this year. The payment will exceed £5 million. Once this has happened, the issue will go past the point of no return and any solution will be very complex and difficult to achieve. As other providers are required to pay, many will be forced into insolvency and have to return contracts to local authorities. Unlike Southern Cross contracts, these will be unattractive to other providers, as they will contain the six-year back-pay liability.

The key issue is timing and the urgent need to seek a suspension of current enforcement action to allow space for a considered solution. This would prevent the failure of a significant part of the social care sector but requires swift action from government. It cannot wait until the promised November Green Paper on funding social care or the Government’s proposals for consultation. Can the Minister give the sector some assurance that this issue is very high on the list of urgent actions for each of the four ministries involved, and that there is an understanding that this cannot wait until after the Summer Recess?

Learning Disabilities: Transforming Care

Baroness Jolly Excerpts

Thursday 9th June 2016 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I declare my interest as chair of Hft, a learning disability charity delivering such services across England. It is really very difficult to plan at the moment. We anticipate an element of growth, but we are not sure where or when that will come. The Minister outlined issues such as that. Could the NHS learn from some local authorities that are charged with managing their markets so that when they are ready to discharge such patients they have already established settings for them?

[Lord Prior of Brampton]

All the transforming care partnerships will comprise both CCGs and local authorities, so all the experiences learned by local authorities should be paid into the process.

Social Care

Baroness Jolly Excerpts

Thursday 15th October 2015 Lords Chamber

[Lord Prior of Brampton]

What the noble Baroness says is absolutely right—the two are linked closely, although it is interesting that the main concern coming from the CQC report is around safety, which is not directly related to the point that she raised. The better care fund is a start on this road. The devolution in Manchester is another point along the journey. Increasingly, over the next five or 10 years, we will see a coming together of the health and social care system.

[Baroness Jolly (LD)]

My Lords, I am sure we all welcome a living wage being paid to care workers, but when this was announced, did either the Treasury or the department do an impact assessment of this new expenditure on the sector?

[Lord Prior of Brampton]

The impact on the sector is very clear: it will push up costs in the sector. How those costs are funded will be part of the spending round discussions that are going forward at the moment.

Jimmy Savile: NHS Investigations

Baroness Jolly Excerpts

Thursday 26th February 2015 Lords Chamber

[Baroness Benjamin (LD)]

My Lords—

[Baroness Jolly (LD)]

My Lords, we have a 20-minute time limit.

House adjourned at 4.01 pm.

National Health Service

Baroness Jolly Excerpts

Thursday 8th January 2015 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, it is a privilege to be able to open this debate on the future of the NHS. It comes at a time when we are gearing up for the election and when it seems entirely possible that the NHS will be of some interest to the electorate. I will try to set the scene with a broad brush and leave it to other noble Lords to focus on various specific aspects.

We are going through a time when the media are full of one NHS disaster after another; with reports of cancelled operations, GPs and A&E departments being overwhelmed and waiting lists rising. We have not been short of media analysis in the past few days. That this is not simply the usual media hype is pretty obvious. We have had a number of careful reports from the Nuffield Trust and the King’s Fund, for example, that make sobering reading, with titles such as Into the Red? The State of the NHS Finances and Is General Practice in Crisis? suggesting that all is not well and that we cannot continue as we are.

The Government have woken up rather belatedly, with a sudden rash of activities. We have had NHS England’s Five Year Forward View, full of interesting aspirations; the Dalton review, with some ideas about how to go about achieving some of them; a number of crisis funding rescue efforts; and the Prime Minister reportedly sending in his pre-election “hit squad” to try to sort things out. However, it is pretty clear that quick fixes are not the answer and that the nature of the difficulties we face requires much longer-term solutions. It is good to hear that my own party is making some realistic proposals that might make a difference.

The causes of the problems are pretty widely understood. A service designed largely around acute hospital care has ignored for too long the needs of people with multiple long-term illnesses, especially those of the growing band of elderly patients whose needs are much better met in the community than in hospitals. This demand is certainly rising. The number of over 80 year-olds is set to double over the next few years and, for example, the number of people on more than three different pills for their multiple illnesses is growing by the day. I dare say that there will hardly be a Member of your Lordships’ House who is not on at least two pills keeping them in the fine trim that we see today, and I fear that I am no exception.

However, it is not only the growing proportion of the elderly and the worrying rise in the number of people with dementia that is causing difficulties; it is also the pressing demand placed on acute services. We can do so much more for patients than we ever could, and the population increasingly expect that they will be given the most effective treatments available. Many of those treatments are now very expensive. Complex scanners and investigations, coupled with the development of designer drugs produced specifically in response to an understanding of the genetic make-up of smaller and smaller subsets of patients, pose severe problems for a service working within rigid financial constraints.

It is in that financial squeeze where the nub of the problem lies. The fact is that the rate of inflation in health service costs is running way ahead of general inflation rates and certainly ahead of the growth in GDP. So every year the gap between demand and the funds available is widening, and this is what is responsible for the idea so often trotted out that the NHS is a “black hole” into which money just disappears. I do not believe that for a moment, and I will explain why shortly.

You might think that a Government would try to keep pace, if not with inflation then at least with the rise in GDP, small though that might be. In fact, the slice of the national cake devoted to health has gone down from about 8.5% when Labour left office in 2010 to 7% now—that is a fall of 17% in our share of the nation’s wealth. Even worse, predictions by the King’s Fund point to a further fall to 6% of GDP by 2021, on the current Government’s projections. That, I suppose, is all part of their plan to reduce overall public expenditure to pre-1940s levels, despite their protestations about a desire to protect the NHS.

It might be asked why these problems seem to have become much more acute in the past few years. After all, we have not all suddenly become older and sicker. The fact is that when Labour left office five years ago we had managed to get rid of waiting lists, patients were seen on the same day by their GP and patient satisfaction levels were high. It is no coincidence that we had appointed some 130,000 more front-line staff to cope with demand. So what has happened that left us with our current difficulties? Certainly, the distractions of the Lansley reforms did not help, with all the redundancies and re-employment of senior managers and the loss of continuity in leadership that followed. As Maynard Keynes said:

“It is not sufficient that the state of affairs which we seek to promote should be better than the state of affairs which preceded it; it must be sufficiently better to make up for the evils of the transition”.

I fear that we are still suffering from the evils of transition.

Then we have had the Nicholson challenge and the so-called efficiency savings of no less than £20 billion over the past five years. Of course anyone working in the service knows that it is always possible to improve efficiency, but now it is clear that the pips are being made to squeak too loudly as we run out of such short-term measures as wage freezes and the like. The inevitable result is that we are failing to keep up. GPs are overwhelmed, waiting times in A&E departments are rising, waiting lists are growing, social service departments are failing to cope and many such departments are now able to deal only with those in most serious need.

So what is to be done? I shall focus on four specific areas: disease prevention by public health measures; bringing hospital and community services much closer together; focusing on some specific aspects of care where we are clearly failing, namely A&E services, general practice and mental illness; and stimulating much more research and innovation where the potential dividends in health and well-being, as well as economically, are considerable. Of course none of these sounds entirely novel, but the fact is that we have failed miserably to achieve them so far. I want to examine why that is the case and what we should do now to ensure that we do not fail again.

First, with regard to prevention with the aim of reducing demand, no one can argue with the need to try to prevent the many illnesses caused by smoking, drinking too much alcohol and eating too much food. That is why I believe that the Government must get on with the plain packaging legislation, for example. We also know that the most effective measure to reduce alcohol consumption is to increase the duty on alcohol. It is pretty clear that whenever the price of alcohol goes above the rise in the general cost of living, the incidence of death from liver disease goes down—and, let’s face it, the increased revenue generated could make a useful contribution to the Exchequer and the NHS. I will leave it to other noble Lords to go into why the Government are reluctant to use this most effective measure, but the problem here is not that these are not vitally important things to be doing—they clearly are—it is the expectation that we will see financial savings from doing them in any reasonable timespan. Any impact on costs will inevitably take time.

Secondly, I turn to the need to see much greater co-operation and collaboration—what we used to call “integration”—between community-based and hospital services. The report from Sir David Dalton provides some very helpful ideas about how this might be achieved. He, of course, has managed to show how it is possible to integrate services extremely successfully in Salford and his report describes a number of other potential models for collaboration that fit in with different local circumstances. Clearly, the removal of the barriers between hospital and community is highly desirable and the idea of pooling health and social care budgets could be a very supportive measure. However, we have to be sure that current competition laws do not get in the way, and even more importantly, we have to be clear that the funds are available to facilitate this transition. It would be naive to believe that it could be done within existing budgets, even though in the longer term that sort of joined-up service will be more efficient, and of course it will suit patients’ needs much better. But in the short to medium term, it will need transitional funding.

The idea behind the Government’s better care fund was to try to bolster community services at the expense of the NHS, which itself is pretty cash-strapped. Robbing Peter to pay Paul is never going to be popular with Peter, and we now have the lowest number of beds per head of population than anywhere in the western world. If we are to see this vitally important change in the way services are delivered, we have to accept that fresh money will have to be found from somewhere.

Thirdly, I turn to three of the biggest challenges facing the NHS at the moment: problems in general practice, gaps in mental health services, and the troubles in A&E departments. The problems in general practice have been well rehearsed. I had a letter from a young general practitioner the other day in which she encapsulated the difficulties she faced. She said she was increasingly exhausted as her workload just seemed to grow and grow. She pointed to the shortages of practice nurses and care workers, the difficulty in recruiting to those posts, the fact that many of her colleagues were retiring early and that general practice was becoming a very unpopular option for young medical graduates. It seems likely that that is the reason why it has proved difficult for the Government to encourage medical schools to get 50% of their graduates into general practice. It is striking, too, that she said that she had to spend up to 50% of her time in administration. What a waste of her valuable time, which could be much better spent in dealing with her patients.

So there is much to do there. We need to recruit and train more support staff, especially practice and district nurses, who are in such short supply; we should bring together bigger groupings of general practices into multipractices or the like so that there are economies of scale; we need to recruit and train more GPs by making the job much more attractive; and we definitely need to reduce the horrendous bureaucratic burden under which they labour. I am afraid that once again your Lordships will have noticed that none of that can be done without some additional funding.

On accident and emergency departments, which have been in the news so much of late, there is this somewhat optimistic view that once we have stopped people smoking, drinking and eating too much and once primary and community care is up to scratch, the pressures on A&E departments will disappear. But that, of course, is some considerable way off and it denies the evidence from everywhere else in the civilised world that there is a universal rise in A&E visits. So, once again, moving the deckchairs here will not solve the problem and it seems inevitable that more funds will be needed to recruit and fill posts, both medical and paramedical, in these desperate departments. We are clearly wasting far too much money on expensive locums when that money should be directed to permanent posts.

Mental illness, despite much rhetoric about parity of esteem between physical and mental illness, remains a Cinderella service. I suspect that other noble Lords will expand on this, but there can be little doubt that more resources are needed there, too.

Finally, I will say a few words about research and innovation in the NHS. The UK has been pretty successful in supporting medical research through both public funds and the research charities—and here I should express my interest as scientific adviser to the Association of Medical Research Charities. Some good things are happening here: for example, with the National Institute for Health Research, under the direction of Dame Sally Davies with the strong support of the noble Earl; the Health Research Authority is streamlining ethical approval; and the MHRA is providing quicker routes for licensing new medicines. However, there are many problems, too, because while we may be good at research, we are too often sluggish in taking up innovations. There are concerns that future funding for NIHR and its invaluable academic health science networks and centres remains uncertain, and there are also worries about the willingness of CCGs to support the Charity Research Support Fund. We are also failing to encourage and support those entering a clinical research career while their conditions of service are being neglected.

A tortuous funding approval process also gets in the way. It may come as some surprise to learn that to get the approval of NHS England for a new medicine to treat a rare disease there are no fewer than eight committees through which it has to go. It has been said that if you want to avoid making a decision, set up a committee. If you want never to make a decision, set up eight committees. That is a case where NHS England needs to look at its own efficiency, and if it is just an example of its committee structures, it has some way to go.

In the pressure for ever more efficiencies, we must avoid being so short-sighted as to leave research and innovation to wither away. The dividends we will lose are just too great. I believe we know what should be done—there is a growing consensus on that. However, it is increasingly clear that without an input of more resources we will not be able to rescue the NHS from this downward spiral. Even Simon Stevens, the chief executive of NHS England, has said as much. The next Government will have to face up to this issue and square with the public about how they intend to protect an NHS and a social service system that is so precious to them and to focus on the sources of the increased funds that are needed. I look forward to the speeches of other noble Lords and to the Minister’s response.

[Baroness Jolly (LD)]

I remind the House that time is very tight, so I ask noble Lords to keep their remarks to six minutes. When the clock shows six, your time is up.

Health: Innovative Medicine

Baroness Jolly Excerpts

Tuesday 1st April 2014 Lords Chamber

[Baroness Thomas of Winchester (LD)]

My Lords, I am grateful to have attracted such a stellar cast for the important matters that we will be talking about in this short debate this evening. I hope that it might build on the interesting debate on 13 March on regenerative medicine, in which my noble friend Lord Willis of Knaresborough said:

“The King’s Fund estimates that by 2070, 20% of the UK’s GDP will be spent managing long-term conditions”.—[Official Report, 13/3/14; col. 1944.]

Such a situation would be unsustainable and unaffordable, and we must ensure that new treatments and technologies are found so that the quality of life of those with long-term conditions is as good as possible.

The very next day after that debate last month, the Government announced the early access to medicines scheme, which offers a way by which unlicensed medicines can be made available to patients before approval of a licence to benefit public health. The scheme has been warmly welcomed by many of us who are involved with rare-disease patient groups and their families. Indeed, with the support of the Muscular Dystrophy Campaign, the All-Party Parliamentary Group for Muscular Dystrophy, in its report last year, highlighted the need for such a scheme. Ground-breaking research for potential treatments for rare diseases is set to grow and this scheme should ensure that patients will, in future, be able to get the treatments that they need at a much earlier stage of the process.

Professor Dame Kay Davies of the department of physiology, anatomy and genetics at Oxford University is leading the development of a potential treatment for Duchenne muscular dystrophy, which is currently in early clinical trials. She said:

“The introduction of a ‘fast-track’ system offers an exciting opportunity to intervene in a safe way and ensure effective medicines reach the people who need them as early as possible. It is good news for families affected by Duchenne muscular dystrophy, who are deeply anxious about the speed at which future potential therapies will reach their children. Several potential treatments are in clinical trials and further laboratory research projects are underway—the prospect of accelerating the progress of approaches that show particular promise is a very welcome one”.

This view is supported by many families of boys with Duchenne, who say that every second counts and time is not a luxury that they have.

Professor Dame Sally Davies, the Chief Medical Officer, said that the scheme would allow drug-makers to demonstrate the value of unlicensed medicines, improving their chances of eventual approval by regulators and NICE. Obviously, allowing patients early access to medicines is not without some risks, which is why the Government were right to be clear that sufficient data must be available to demonstrate safety before a drug can be considered under the early access scheme.

The Minister will know that I was bound to mention the dismay of many of us in this field at the fact that AGNSS—the Advisory Group for National Specialised Services—was being disbanded, along with NHS Specialised Services. AGNSS was responsible for the appraisal of very rare drugs, while NHS Specialised Services had responsibility for the commissioning of services for very rare diseases, as well as a ring-fenced fund to subsidise treatments for the drugs to treat these diseases. AGNSS’s duties have transferred to NICE—the National Institute for Health and Care Excellence—while NHS England has taken over the NHS Specialised Services role. However, little clarity was given on what the new appraisal and commissioning processes will look like and there was widespread concern that NICE’s “cost per quality-adjusted life year” approach to the appraising of new drugs will effectively exclude, on the grounds of high costs, treatments for small patient populations.

NICE has now established its highly specialised technology programme, responsible for the appraisal of orphan drugs. Unfortunately, early indications of its outlook on high-cost treatments do not appear promising, although it is still at an interim stage. A current example is the approval that NICE is considering for Soliris, a treatment for atypical haemolytic uraemic syndrome, a rare blood disorder that may be inherited. Before Soliris, there was no treatment available to prevent death or organ damage and up to 25% of patients would die following their first attack. Soliris was recommended for approval by AGNSS, based on its effectiveness in halting the progress of the disease and its low cost per quality-adjusted life year. It was assumed that, as a result of this recommendation, the drug would be available to patients from October 2012. However, in January 2013 the Government announced that Soliris would be subjected to a second assessment, under the new system for specialised services within NICE, and Alexion Pharmaceuticals, which developed the drug, has been asked to explain the high cost of Soliris.

NICE has also asked for advice from NHS England on what considerations relating to the management of its specialised commissioning budget it considers should be taken into account in formulating a recommendation. I hope that the fears that many people voiced when AGNSS was disbanded that treatments for rare disorders might be denied on grounds of high costs are not going to be realised. After all, patients with rare and life-threatening conditions deserve access to treatments just as much as those with more prevalent conditions.

The next matter that I wish to raise is the clinical trials process, which must be speeded up. One way of achieving this could be to authorise a process of study approval whereby various stages of clinical trials can be conducted in parallel with one another. This would avoid a lengthy sequential process. For example, in the case of exon-skipping technologies for Duchenne, each drug or molecular patch will treat only certain specific mutations causing the condition and, under current procedures, future molecular patches would have to go through the same lengthy requirements. Will my noble friend the Minister urge the Medicines and Healthcare products Regulatory Agency and NHS England to consider such a study approval process?

Another important consideration is the clinical trial infrastructure, including additional specialist centres to enable more patients to participate in clinical trials. During the APPG inquiry, we were concerned to hear about the cutting of administrative support by some hospital trusts. It is a false economy to cut back on this infrastructure, such as patient registries. At present, many patient registries are charity-funded, with little or no long-term funding security. With limited back-office support, some centres are finding that there is no one available to input patient data. Consequently, such cuts can seriously damage the ability of centres to carry out large-scale clinical trials. Will my noble friend say what steps the Government are taking to ensure that centres and clinics across the UK have the resources required to manage patient registries and for clinical trials to be carried out?

Finally, in last month’s debate my noble friend said that consideration of the Health Research Authority’s business case to bring together and streamline NHS approvals and local ethics approvals should be completed shortly. Will he update us on that? Will he also endorse the need to streamline NHS approvals so that unnecessary regulation and delays are avoided? We must always look forward with great optimism in the search for treatments for intractable conditions. The early access to medicines scheme is a very welcome initiative, which must not be allowed to fail because of bureaucratic obstacles in its path.

[Baroness Jolly (LD)]

I remind noble Lords that we are tight for time this evening. Six minutes is the limit and, as soon as the clock reaches six, your time is up.

NHS: Seven-day Working

Baroness Jolly Excerpts

Thursday 6th February 2014 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, in opening this debate I must first record my interests in the register and my chairmanship of the Independent Reconfiguration Panel. I support the introduction of a seven-day service, promoted by Sir Bruce Keogh, medical director of the NHS, but I believe that it should focus on emergency and urgent care, which is currently poorly provided at weekends. The move to a seven-day service has the support of the Medical Royal Colleges, NHS Confederation, NHS Employers and the BMA, but why is it necessary?

When I was a consultant, I often provided an emergency service at weekends, initially every four weekends and then every eight as staffing numbers increased. That was a requirement to go into the hospital to deal with emergencies when they occurred, rather than a commitment to be there all day as I would be during the week. What has changed is, of course, the increasing number of elderly patients with comorbidities requiring care and the findings of the Francis report that patients felt vulnerable at weekends when,

“staff absences and shortages are more noticeable”.

A report commissioned by NHS London in 2011 found that increasing cover by consultants in acute medical and surgical units at weekends could prevent 500 deaths a year in London. Further evidence in the Journal of the Royal Society of Medicine in 2012, analysing 14.2 million admissions in NHS hospitals in England in 2009-10, found that patients admitted on Sundays were 16% more likely to die than those admitted on Wednesdays, and 11% more likely to die if admitted on Saturdays. The Dr Foster Hospital Guide in 2012 reported similar findings, confirming that a higher level of senior medical staff at the weekend is associated with lower mortality. The case for change in respect of emergency admissions has been made and now something must be done.

Despite a reduction of acute beds by a third in the past 25 years, the number of unplanned admissions of those over 65 continues to rise, with some 2 million admissions a year. Length of stay is also important: for those under the age of 65, the average length of stay is three days but for over 65s it rises to nine days and for those over 85 it is 11 days. To prevent unplanned admissions we need more consultants because consultants make the decisions. They are able to decide whether patients can be sent home or need to be admitted. Junior doctors often lack the confidence to do that. We also need the infrastructure and systems in general practice and social care to allow those patients to be treated nearer their home. That must also be available at weekends.

My noble friend the Minister will no doubt point out that “seven-day working”, as this debate is titled, is not the same as a seven-day service. I agree but the public need to be clear what sort of service they receive. When we promise them the same service at weekends as in the week, they will assume that that implies seven-day working. That means that there will need to be a massive expansion of consultant numbers. I have recently heard the figure of 1,800 quoted as likely. Do we actually have enough qualified trainees to fill those posts—and trainees of the right calibre? Over what timescale do we expect to have this expansion? If the service is to be both for elective procedures, including routine operations, and emergencies, then a bigger challenge is funding and the staffing of theatres, X-ray rooms, and pathology and scientific laboratories—all of which must be supplied if we are to provide the same service at weekends as we do during the week.

We should not promise what we cannot deliver. The seven days a week forum report commissioned by Sir Bruce Keogh, which the Library kindly sent round as a briefing document for those involved in this debate, identifies 10 clinical standards that are evidence based. Three of them incorporate standards developed by the Academy of Medical Royal Colleges, whose committee on this was chaired by the president of the Royal College of Surgeons—so I have a slight inside track on what was developed. The standards cover the patient’s experience through to the transfer to the community. They focus mainly on the management of emergency admissions. Of the 10 standards, eight revolve around hospital care. They recognise that a one-size-fits-all solution cannot be applied in this situation and that what will work best is usually based around local solutions. But there is an emphasis on emergency care that does match the rhetoric of providing care for all at the weekend.

The NHS Confederation and NHS Employers recognised that we already work seven days a week, but it is how we do that work that is in question. Changing to a seven-day service could be liberating for many staff. I heard one lady consultant on southern TV last week say how much she enjoyed working at weekends. I think she worked at Southampton General. One reason she enjoyed working at weekends was that it provided a better work-life balance for her family. We should grasp the opportunity that this offers to use our workforce more flexibly. With the increasing feminisation of the workforce, remembering that more than 60% of our medical school intake is female, it is important that we take families, children and women into account when we design our workforce of the future. It is also important that many women with children would find working at weekends helpful because it would mean that their partners were there to look after the family and home while they were away working. I am not against that but will put forward some arguments as to why we should deal with the emergency problems first.

We also need to be much more creative about how we utilise some of our older, senior staff. I say that advisedly as I retired at 64 and was doing emergency admissions until the age of 60. How I could have done that between 60 and 64 I do not know; I feel for my colleagues who still do. Between the ages of 55 and 60, you could take most senior doctors off the emergency on-call rota and have them there providing mentorship for more junior consultant colleagues, and perhaps undertaking elective work at weekends if that could be managed.

Much could be done to achieve seven-day care but I am daunted by the cost of implementing both an emergency and elective service at weekends. The seven-day services improvement programme, which I believe was due to start in January this year, is focused in its first year on emergency care and the provision of enhanced recovery pathways and diagnostic and support services. The programme freely admits that its big challenge is how to actually develop those diagnostic and support services. I wonder where it will focus its attention in the next two years of the three-year programme it has set out. In addition, what are the likely costs of staffing a seven-day service in both primary and secondary care? The figures of £3 billion, from the Department of Health, and £32 billion, from the BMA, have been quoted as the cost of introducing seven-day care right across the piece in primary, secondary and social care.

From my experience of service reconfiguration, the public want high-quality care, but are wary of change, particularly if it affects their local hospital. We have seen the benefits of such service change, particularly here in London. Stroke services, acute heart condition services and trauma care concentrated in fewer centres have already delivered improved outcomes, so we have the evidence. A new project in Northumbria to produce a specialist emergency care hospital, which is due to open in 2015 at a cost of £200 million, is an example of a local solution to rural problems. Local solutions driven by clinicians and co-designed with the public can lead to centres of excellence.

It is important that we focus our attention on delivering an emergency service. If we base this on the 22 trauma centre networks that were designed by Profession Keith Willett and Sir Bruce Keogh, the success of the centres will trickle down to the spoke hospitals which are linked to them. By aiming for this low-hanging fruit, we can demonstrate success to the public, and the effectiveness can be translated to elective care. However, I do not think we are yet in a position where we can provide care at the weekend in the way we go shopping at Tesco and Sainsbury’s. Please do not forget the European working time directive, which applies to junior doctors and equally to consultants, because the SiMAP and Jaeger agreements are still there and they will require compensatory rest for consultants who work at weekends.

I have identified barriers to change. I am not a naysayer, but I have concerns about staff and cost implications, particularly with an austerity budget designed to reduce our deficit, GP contracts—will they be asked to work nights and weekends again?—the ability of social services to cope with seven-day working and whether payment by results can be adjusted to take account of the increased emergency work. I support the proposals for a seven-day service, but I have misgivings about implementation and the costs involved. I hope the Minister will be able to reassure me.

[Baroness Jolly (LD)]

My Lords, I remind noble Lords that this is a time-limited debate and, with the exception of the Minister, speeches are restricted to four minutes. When four is on the clock, time is up.

Mesothelioma: Research Funding

Baroness Jolly Excerpts

Thursday 16th January 2014 Grand Committee

Question for Short Debate

[Baroness Jolly (LD)]

My Lords, this is a time-limited debate and time is going to be very tight. We have one speaker who has asked to speak in the gap, for a short amount of time, so it is really critical that noble Lords keep their comments to the time given in the list. Thank you.

NHS: Out-of-Hours Services

Baroness Jolly Excerpts

Monday 29th July 2013 Lords Chamber

[Earl Howe]

My Lords, I can give the noble Baroness that reassurance, because we want local commissioners and doctors involved in the process to be confident in the service that they are commissioning. We did not ignore the warnings from Dr Buckman and others in the BMA. Indeed, on the strength of that we allowed a six-month extension to those providers who felt they needed it to ensure that they were confident in providing a good service. Only two providers took us up on that, which seemed to indicate that our confidence in the service was not misplaced.

[Baroness Jolly]

My Lords, this is an issue around commissioning. As we have heard, CCGs can now commission NHS 111. Can my noble friend tell the House what support CCGs are likely to receive in commissioning these new services, and from whom?

[Earl Howe]

CCGs, where relevant, are receiving support from local area teams of NHS England.