Care Services: Elderly People

Baroness Masham of Ilton Excerpts

Wednesday 17th October 2012 Lords Chamber

[Earl Howe]

Yes, I firmly agree with that. It bears upon the point that I alluded to very briefly, which is that the risk assessment process should not just be a tick-box exercise. It should assess the suitability of the individual and their own characteristics, the environment in which they will be working, the kind of people for whom they will be working and whether they have the right skills and characteristics as the people required to do that job.

[Baroness Masham of Ilton]

My Lords, does the Minister agree that it is not only the elderly who are vulnerable but also some very disabled people, including some with learning disabilities?

[Earl Howe]

Yes, like the CQC, we are very clear that when providers are assessed for the recruitment processes that they undertake in relation to those groups of patients and service users, no corners whatever should be cut in the requirements for vetting those people.

NHS: Walk-in Centres

Baroness Masham of Ilton Excerpts

Thursday 11th October 2012 Lords Chamber

[Earl Howe]

My Lords, the Government’s clear policy is that people should be able to rely on high-quality, 24/7 urgent and emergency care that is right for them, when they need it. That is our starting point.

I say to the noble Lord that since walk-in centres were invented the array of services available to patients has been considerably enhanced. It is not just a case of going to an A and E department as an alternative. There are now many GP health centres, minor injuries units, urgent care centres and, in the extreme case, ambulance services, so I do not necessarily accept the premise of the noble Lord’s question.

[Baroness Masham of Ilton]

My Lords, is the Minister aware that I have a colleague who went to the Victoria walk-in centre and found it closed? She went, in the end, to St Thomas’s. The whole procedure took her four hours. She had a urinary infection. Many of the people who go to these centres are working people who come up to cities and are away from their home environment.

[Earl Howe]

My Lords, I am sorry to hear of the experience of the noble Baroness’s friend. I asked my officials to let me know which walk-in centres were available within striking distance of this building. There are, in fact, five NHS walk-in centres in or very near central London. I am aware of another privately run centre as well. A quick search on NHS choices will bring you to a menu of options.

Health: Diabetes

Baroness Masham of Ilton Excerpts

Wednesday 25th July 2012 Lords Chamber

[Earl Howe]

My advice is that type 1 diabetes is not a particular issue in ethnic-minority communities. We are talking about type 2 diabetes, which is five times more common in black and ethnic-minority groups, six times more common in south Asian ethnic groups, and three times more common in areas of social deprivation than in the rest of the population. There are particular clinical risks associated with those from ethnic minority communities who have diabetes. Complications include particularly heart disease—south Asian people are 50% more likely than the general population to die prematurely from coronary heart disease—and the prevalence of stroke is also much higher in African, Caribbean and south Asian men.

[Baroness Masham of Ilton]

My Lords, can genetic problems be a cause? Are not exercise and getting fit an important part of stopping diabetes?

[Earl Howe]

Exercise is recommended under the Change4Life programme and under the advice given by NICE. However, the noble Baroness is absolutely right to mention a possible genetic cause. The cause of diabetes is not fully understood and is multi-factorial. Healthy eating, weight control and exercise can help reduce the risks, but that is not the full picture. It is suspected that there is a genetic component in the case of black and ethnic-minority communities.

NHS: Specialised Services

Baroness Masham of Ilton Excerpts

Wednesday 18th July 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I thank the noble Baroness, Lady Jolly, for this timely debate on AGNSS. There is no doubt in my mind that there are many really concerned and frustrated people who are involved in highly specialised conditions, be they patients, relatives or doctors treating them. With so much insecurity and with PCTs running down and the national Commissioning Board not operational yet, there is a limbo situation.

When a rare disease strikes, it is the individual who matters. The correct treatment is vital, but with rare conditions risks have to be taken if there are to be improvements. The Chief Medical Officer, Dame Sally Davies, has recently endorsed the value of research into rare diseases by the National Institute of Health Research as a significant source of benefit for patients with rare diseases. The role of AGNSS is to advise Ministers. Does the Minister think that the national Commissioning Board members will be infallible so that they will not need advisers? We have come to a shocking situation when staff in St George’s Hospital, a teaching hospital, neglected a patient of 22 who had suffered a rare condition, following a brain tumour, that required daily drugs. He died of thirst because staff failed to read his notes. Patients with rare conditions need extra-special treatment; they should not be neglected and ignored. What has gone wrong? We need transparency and confession and a fool-proof system for all vulnerable patients. When the Government say that everything is fine when it is not, it is a cover-up.

AGNSS is an independent advisory group providing advice to the Secretary of State for Health regarding the commissioning of services for very small populations of patients—fewer than 500 patients in England. Will the Minister make clear what the future of AGNSS is? To cover all specialised services adequately, the Commissioning Board will have a mammoth task.

I must declare an interest as I have a cousin aged six who has relapsed neuroblastoma. The treatment his parents are trying to access is likely to become available on a trial basis in the UK, but not in time for Jamie. It has been internationally recognised as being one of the most promising therapies with encouraging results against neuroblastoma. I think it is available in Germany. There are only about 100 patients a year in England with this aggressive type of child cancer. It desperately needs research. Parents will do anything for their children. This family is appealing to the North Yorkshire PCT.

I am president of the Spinal Injuries Association, which is concerned about tetraplegics and paraplegics who are not being admitted to spinal units. One case is still residing in St Mary’s, Paddington, on a respirator after a ski-ing accident. He has been waiting to go to the spinal unit at Stanmore for months. This is not good. Correct specialised care means good quality for patients. The noble Earl is Minister for Quality. Does he agree that there should be a special fund for very rare cases so that they are not passed over? I, who have every admiration for our hard-working Minister, do not want the system to give him the reputation of being a Pontius Pilate. Even with AGNSS, there are improvements to be made. There is a black cloud hanging over the NHS: the £20 billion that has to be saved. With so many demands on healthcare, this challenge may just be too great.

NHS: Primary Care Trusts

Baroness Masham of Ilton Excerpts

Tuesday 17th July 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, will the noble Earl find out to how many cases the PCT in North Yorkshire has denied treatment in the past year? Is he aware of how distressing it is for very ill patients to have to appeal?

[Earl Howe]

My Lords, I do not have the figures for North Yorkshire in front of me but, as the noble Baroness is aware, there is a process for patients to make an exceptional case application to their primary care trust where the circumstances are deemed to be exceptional. We had a short debate about this matter the other day. However, there will inevitably be variation around the country in the extent to which treatments are seen as a priority for the local population in a given area.

NHS: Definition of Exceptional Case

Baroness Masham of Ilton Excerpts

Monday 2nd July 2012 Lords Chamber

Asked by

[Baroness Masham of Ilton]

To ask Her Majesty’s Government what is the definition of an exceptional case needing surgical and medical care through the National Health Service, and who makes the decision.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the department has not issued definitive guidance on this difficult issue. Indeed, there is a paradox in the whole concept of defining an exception. However, good practice in the NHS suggests that a patient can be considered for treatment which is not normally provided locally if the patient has exceptional clinical need or is likely to derive exceptional clinical benefit. The decision is made by the local commissioner.

[Baroness Masham of Ilton]

My Lords, I thank the noble Earl for that reply. However, is he aware that there is a young doctor in Northallerton, North Yorkshire, whose PCT has denied her a vital operation for a genetic pancreatic condition? If she does not have this operation, she will remain in excruciating pain all the time, she will not be able to work, and there will be a risk of cancer.

[Earl Howe]

My Lords, I hasten to reassure the noble Baroness that I have every sympathy with the individual in question, and I was aware of this particular case. The chief executive of the NHS will shortly be writing to her clinical tutor to suggest a possible way forward. However, I should put on record my view that the commissioner is acting reasonably in insisting that its decision on exceptionality should depend solely on the clinical need of the patient, and not on any broader social factors. If there is now good clinical evidence to support the use of this particular treatment, commissioners should be considering whether to make it available to all patients with similar clinical needs, and not just to a few individuals.

NHS: Liverpool Care Pathway

Baroness Masham of Ilton Excerpts

Wednesday 20th June 2012 Lords Chamber

[Earl Howe]

My Lords, I am pleased to hear that the noble Baroness’s mother was well looked after with the benefit of the Liverpool care pathway. I take the point about the name. Indeed, the noble Baroness, Lady Finlay, can probably give us some instructive examples from Wales, where the word “pathway” has not been adopted and the process has, I believe, been refined.

[Baroness Masham of Ilton]

My Lords, is the noble Earl aware that some relatives and loved ones have to fight to stop their loved ones being on the Liverpool care programme? Can he think of anything worse than dying of thirst?

[Earl Howe]

My Lords, no one should be denied basic care at the end of life. However, that is a different question from whether artificial nutrition and hydration should be withheld. Relatives should always be consulted.

Health: Local Healthwatch Organisations

Baroness Masham of Ilton Excerpts

Monday 11th June 2012 Lords Chamber

[Earl Howe]

We are working with the Local Government Association and the Care Quality Commission to provide support for the implementation of local Healthwatch organisations. As I mentioned, the LGA is running a series of master classes for local authority commissioners. It has published 15 case studies taken from the 75 Healthwatch pathfinders, and a small number of Healthwatch experts will be available to help spread learning. As regards making the public aware, it will be very much for local authorities to decide what is appropriate in their particular areas in order to ensure that patients and the public are engaged in the important work of Healthwatch and understand what the statutory remit of local Healthwatch consists of, because that is the only way in which local Healthwatch will make its voice truly heard.

[Baroness Masham of Ilton]

My Lords, will local Healthwatch members be able to support members of the public if they go to a tribunal?

[Earl Howe]

One of the potential functions of local Healthwatch is to act as a support in terms of advocacy for local people and to signpost patients and the public to appropriate services. It is too early to say which local authorities will commission what services from local Healthwatch in an area, but the resources available to local Healthwatch have to be borne in mind in that context.

Health and Social Care Act 2012

Baroness Masham of Ilton Excerpts

Wednesday 25th April 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, does the Minister agree that HealthWatch has been left in limbo? Would he agree to a fast-track legislative scrutiny?

[Earl Howe]

I do not agree that HealthWatch has been left in limbo; in fact, only this morning I was attending a round table of pathfinder local healthwatches and witnessing for myself the tremendous energy and enthusiasm that they were devoting to HealthWatch. So the short answer to the noble Baroness is no, I think the process as regards HealthWatch is very much on track.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Monday 19th March 2012 Lords Chamber

[Baroness Jolly]

My Lords, I have put my name to the amendment. Historically, both parties to the coalition were in agreement that there were too many quangos and that rationalisation was required. This is always difficult when it involves an organisation as well respected as the Health Protection Agency and others.

Its successor organisation, Public Health England, was going to take over the HPA’s and have duties with regard to the new structure of public health at local government level. However, that had no place in the Bill. On these Benches, we welcomed the move to ground public health in local authorities, and we welcome the statements by the Minister about the role, responsibility and duty of this newfound position.

However, we were anxious about public health at a national level. We were not alone, and I pay huge tribute to my noble friend Lady Cumberlege, who took up this cause at Report stage—probably before then—along with the noble Lords, Lord Patel, Lord Turnberg and Lord Warner. The Secretary of State now sees PHE as carrying out his functions. I am grateful for the time that he gave to meet us to explain his point of view and listen. He felt that to make Public Health England an executive agency of the Department of Health would give it a degree of separation and flexibility. It was argued that PHE needed to have not only an independent chair but a board with a majority of non-executive directors if it were to have credibility with professionals and the public, and for the reputation clearly held by the HPA and others to be maintained in England and abroad. It would need to be able to raise funding to carry out its research on both English and worldwide issues. All this has been ably described by the noble Lord, Lord Warner, and we should be grateful for some clarity from the Minister on the research activities proposed for the organisation. There is clearly intended to be a line of accountability from the Secretary of State through Public Health England to the directors of public health, and it would aid understanding all round if my noble friend could clarify Public Health England’s duties and accountabilities at local, community level with the directors of public health and local authorities. The line right the way down needs looking at.

I hope that the Minister will state that the Secretary of State is convinced that all of this is now a shared vision. However, as I stated earlier, none of this is stated in the Bill. My noble friend said that she will not push that, and I certainly will not, but I regret it, as it would be beneficial and make a really bold statement to the world outside that Public Health England is core to the Bill.

Can the Minister confirm the understanding of the Secretary of State’s letter and, perhaps, agree to the wording of the amendment?

[Baroness Masham of Ilton]

My Lords, the Health Protection Agency is held in high esteem throughout the world. It does the most important work in protecting society from infections and epidemics. The National Blood Service can be the blood of life. It is vital. Can the Minister give an assurance that the HPA will not be downgraded in any way? I support Amendment 14 and hope that the Minister will accept it. If he does, that will give some assurance to some of the people who have concerns about the changes. With so many complicated conditions, research should not be restricted and funding for this must be free and seamless.

Will Public Health England work with other countries? Infections have no boundaries. One never knows what is around the corner. The work of the body should be as independent as possible. Otherwise, we will lose some of our brilliant researchers to countries which will give them more freedom.

[Lord Turnberg]

My Lords, I rise to speak briefly, because much of what I might have said has already been said by the noble Baroness, Lady Cumberlege. I, too, am very grateful for the way that the noble Earl has listened to us and spoken and written to us with helpful comments, which I hope that he will reiterate today. I just want to make one point about the research undertaken by the current HPA. It is directed predominantly to infectious disease and bacterial and viral infections. In that area, it is really world-beating. Recently, two of its members of staff have been elected fellows of the Academy of Medical Sciences, which is quite an achievement. The idea that it should do all this research in academic research partnerships with universities is unhelpful. Although collaboration and co-operation with university departments is enormously valuable, it should not be a precondition that it should be able to do research only in collaboration with universities. I hope that the noble Earl will be able to nail that problem.

--- Later in debate ---

[Lord MacKenzie of Culkein]

My Lords, as a nurse I am always delighted to support the noble Baroness, Lady Emerton, and I particularly support this amendment.

I had hoped that the House might have agreed the need for statutory regulation and registration for healthcare support workers, but the Government should at least accept this amendment. It provides for a code of conduct, for mandatory training, which must be to an agreed standard, and for a requirement to have undertaken an assured training programme before one can enter the voluntary registers that are to be set up. These things should all be in the Bill; they are necessary to protect the patient and the public.

Training, in my view, has to be mandatory; it cannot be left to the whims of employers to decide how much or how little training to give to healthcare support workers. I know from nurses, including my step-daughter, who is a registered nurse, that some of that training is good, some of it is patchy and some of it is shockingly poor. Some of it is supernumerary today, on the team tomorrow; see a procedure today, carry out that procedure tomorrow. That old system of training has no place in the modern delivery of nursing care, but it is what many healthcare support workers have delegated to them.

The Minister knows my views about voluntary registers, but I have no wish to see them fail. If they are to succeed, every effort must be made to ensure that those who are eligible get on to these registers. He will correct me if my memory is playing tricks on me, but I seem to recall him saying at an earlier stage that employers could require someone to be on a voluntary register before appointment or promotion. I have no quarrel with that if we are properly to protect the public, but I want to know whether an employer can do that. If, say, there are two candidates for promotion with very similar training and experience on their CVs, but one is on the voluntary register and one is not, will the employer be able to refuse to see the person who is not on the voluntary register? I wonder what an employment tribunal might make of that.

I hope we can have an assurance that employers will be able to discriminate in this way, because I am concerned that everyone who should be on the register is on it. We know that rogues and rascals and those who are less than suitable are the ones who are not likely to want to be on a voluntary register, which is why I prefer the other course. However, we are where we are and I hope that the Minister can at least reassure us on this point.

[Baroness Masham of Ilton]

My Lords, I have my name to the amendment. During the passage of this Bill, some of us have been trying very hard to improve the care of vulnerable patients in hospital and in the community. I felt healthcare support workers should be registered and regulated, as many vulnerable patients, being frail and elderly or disabled in many diverse ways, have to rely on their carers. Your Lordships have heard that patients have been put at risk or died through neglect or assault in care homes and hospitals up and down the country. Many people wait in anticipation for the result of the review of the Mid Staffordshire Foundation Trust. This must not be covered up; lessons should be learnt in memory of the hundreds of patients who received poor care, were neglected and died. Surely it is our duty to try to help rectify this deplorable situation.

I have every admiration for the Minister, who has worked tirelessly over this Bill, but I do not agree with him that nurses who have been struck off their register can go back to caring for patients as unregistered healthcare assistants. We are exposing the most vulnerable in our society to greater risks and poorer care if we do nothing to prevent struck-off nurses continuing to work in a caring profession. This amendment is a compromise, but even so it has a very important part. Subsection (2) of the proposed new clause in the amendment states:

“The assured training programme shall be mandatory for all new health care support workers from 1 April 2013”.

Not to train people who care for vulnerable patients is deplorable. Last year I was involved in a case of a person living at home and using a respirator. The patient was left brain damaged when the agency nurse turned off the wrong switch. Adequate, appropriate training should be given; in that case, it was a health care worker who was also a nurse.

Many disabled people are living in the community, which is good, but many of them use technical equipment that needs training and understanding, such as hoists, pressure mattresses, peg feeds, catheters, complicated electric wheelchairs, ventilators, nebulisers, diabetic management, colostomies, adapted vehicles and many other complicated devices. An assured training programme should include where to place a patient’s food and drink and to assess whether the patient can feed themselves. If not, the healthcare worker should know how to do this; how to wash and bathe and deal with personal needs such as toileting; how to prevent pressure ulcers; moving and handling; and complications with patients who have problems and may be difficult and have a problem communicating. There are many needs, but kindness and common sense should prevail.

If the Minister and the Government do not agree with this amendment, it will mean they do not understand the needs of vulnerable patients’ care. If training is mandatory, I am sure employers will take notice.

[Lord Cotter]

My Lords, I thank the noble Baroness, Lady Emerton, for introducing this amendment, which I hope the Minister will agree gives an opportunity for a very important issue to be aired. Many noble Lords have aired it in the past; indeed, I raised it on the very first day of the Bill. It is an area that remains of concern, and I have been pleased to hear from the Ministers that they are well aware of this. I recollect at the beginning of the Bill speaking to a nurse who, with an air of concern in her voice, said that when she asked assistants to carry out work the responsibility remained with her if that work was not carried out correctly. I welcome this opportunity for the Minister I hope to give a very strong response to indicate the Bill will cover this issue. As the noble Lord, Lord Patel, said, we are talking about 450,000 healthcare assistants: many people of varying abilities and knowledge.

I will say no more except to thank the noble Baroness for her amendment and, in anticipation, to thank the Minister for his response, which I hope will be robust and clear as to what we are going to do to address this concern.