(7 years, 9 months ago)
Lords ChamberMy Lords, I congratulate the noble Baroness, Lady Wheeler, on submitting the same Question for Short Debate as the one that I submitted myself, but clearly she was in front of me in the queue.
This is a very important topic, impacting, as it does, both on the health of individual patients and their families and on the sustainability of the health and social care services. As usual, we see in the PHSO report evidence that we will never achieve sustainability in the health service until we address the shortfalls in budgets and provision in the social care service. Only recently we heard about more social care providers handing back local authority contracts because they are unable to make a reasonable profit while providing an adequate standard of care. One of my colleagues, who is a local councillor, told me that, in fulfilling its statutory duties relating to social care, her council now has to spend 33%—and rising—of its budget and that, if this carries on, the council will soon run out of money.
Care providers are not fat cats who do not think that they are making enough money; on the whole they are caring companies which have reluctantly had to admit that they cannot go on as they have recently been forced to do and deliver the standard of care they want to give. We have also had media stories about the fact that those who are self-funding in care homes are paying a premium of up to £400 per week to subsidise the home’s budget and compensate for the shortfall in local authority payments for publicly funded patients in the setting. From every point of view, this is an unsatisfactory state of affairs, which threatens to get worse, and it backs up the call by my right honourable friend Norman Lamb MP for an independent or cross-party commission on how the health and care systems can be sustainably funded.
I turn to the detail of the report. When I asked an Oral Question about this on 15 June, the Minister’s first Answer was to the effect that the sustainability and transformation plans would integrate health and social care, fill the black hole in funding and solve all our problems. So my first question to him today is to ask him to follow up on that Answer. We have heard in the news recently that STP boards must delay making their draft plans public for two weeks because of the concerns of some Conservative MPs that the plans may involve controversial hospital closures. Is that the case?
That is not the only concern I have heard. I am told that the development of the plans has been very top down and has been led by the acute hospitals, despite the fact that one of their main purposes is to plan how patients can be treated in primary and community care rather than in expensive hospitals. I have also heard that local authorities and community groups have not been involved in developing the plans but have been told that they can comment after the plans are complete. Once the ink is dry on the paper, people can do no more than tweak the plans. Given that these plans need to fundamentally reform the way that care is delivered, and given that the most successful change is bottom up, this is no way to go about it. It will produce the “not invented here” syndrome. I have found that health and care professionals will engage enthusiastically with change that they know will work because they have recommended it, but not when change is imposed on them. Every manager knows that the best changes, and those that are easiest to implement, come from the staff suggestion box.
Also, I have heard that “sustainability”, not “transformation”, has become the over-riding objective. In other words, boards have been told that the books must be balanced, and this has resulted in outrageously unrealistic plans. The Government were wise to call these plans “sustainability and transformation” because, through transforming how services are delivered, we might achieve savings. However, it cannot be the other way round. I also heard a health economist make the very valid point last week that in mental health there has been a transformation from in-patient care to care in the community, but this has taken 20 years. The point he was making was that the timescale for the Government’s STPs is quite unrealistic.
If ever there was a demonstration that this process needs to be carried out properly, it is to be found in the PHSO report on unsafe discharge. The point that I made in my supplementary Oral Question in June, quoting examples from the report, was that there are problems on both sides of the discharge cliff edge: problems in the hospital and problems with the care to which the patient should be discharged. The Minister answered:
“My Lords, there are millions of interactions between patients and consultants and doctors every day of the year, and there will be some mistakes. We cannot draw conclusions from one or two desperate situations. In so far as they reveal systemic problems, it is valid to draw attention to individual cases of this kind, and there are some systemic issues lying behind the PHSO's report. In particular, it states:
‘We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight. …health and social care ... have historically operated in silos’”.—[Official Report, 15/6/16; col. 1216.]
I agree with the Minister that there are millions of satisfactory—nay, exemplary—interactions every day, but the report quoted specific examples only where the ombudsman felt that they did demonstrate systemic issues. That was made very clear in the report. But common sense tells us that mistakes are more liable to be made when people are under great pressure. The Minister also acknowledged that these historic barriers to safe discharge cannot be fixed overnight. So why are the STPs expected to fix them in the health service equivalent of overnight, which is in three or four years?
No doctor or nurse wishes to discharge a patient into unsafe circumstances, but mistakes will be made when the pressure on the service is so great and there is such a shortage of hospital beds, according to the briefing from the BMA. In its submission to the Public Accounts Committee inquiry on this very same subject, the Royal College of Physicians revealed that 40% of advertised consultant vacancies remain unfilled, mostly due to the lack of suitably qualified candidates. At the same time, the Government are telling us that they do not want to bring in doctors from abroad. This is quite unrealistic in the timescale quoted. The RCP says that the,
“staffing crisis is impacting on physicians’ ability to swiftly assess patients… to tailor their care plans and to work across disciplines to achieve safe and timely transfers of care”.
The RCP also emphasises that more needs to be done to prevent unnecessary admissions, and quotes examples where early access to multidisciplinary assessment led to a reduction of up to 24% in hospital admissions. Patients were given care in more appropriate settings and pressure on hospitals was reduced. That is what we should be seeing across the board.
It also makes the point that better integration between hospital and community settings is fundamental in preventing patient readmission to hospital. That was one of the regrettable consequences of unsafe discharge, according to the report. To be fair, this integration is one of the major objectives of the STPs. Why, therefore, in too many cases, is one partner producing the plan and then showing it to the other for comment?
The Royal College of Nursing, in its briefing for this debate, accepts that poor care is unacceptable, and agrees with many of the findings of the report. It mentions the problems with recruiting and retaining nurses in the NHS and shows a link between shortages and poor patient experience. Can the Minister tell us what impact the Government expect the change in funding for student nurses to have on this situation and what effect this will have on the availability of nursing homes?
The RCN also points out that discharge targets mean little if the resources in social care are not there to meet them. What do the Government plan to do about this? They must surely accept that the small precept for social care which has been allowed to local councils to cover the cost of the increase in the national minimum wage will not do so—and by the way, I refuse to call it the national living wage because no one could live on it. We also know that in the areas where most is needed for social care, because of the predominance of publicly funded patients, the ability to raise extra cash from the precept is the lowest. This is a topsy-turvy policy that the Government are labelling a legitimate solution to the problem.
I ask the Minister what plans the Government have to address the shortfall in funding for social care and the shortage of doctors and nurses, the main causes of unsafe discharge? There are problems with communications and poor interoperability of IT systems, but—although they should be addressed—they are not the great big elephant in the room. We all know what that is. When will the Government address it and stop burying their head in the sand? Even Simon Stevens and a Select Committee in another place have questioned the Government’s claim that they have given the NHS all it asked for. They have not, and the five-year forward view remains an aspiration and not a plan.
Without a properly funded plan, the crisis in health and social care, of which unsafe discharge is very sad evidence, will continue as demand continues to rise. Instead of picking fights with junior doctors and community pharmacists, the Secretary of State would be better advised to tackle this with his usual energy. If he did so, his name would go down in history as the best Secretary of State for Health we have ever had. I await that day with bated breath.
(7 years, 9 months ago)
Lords ChamberMy Lords, I will try to respond to those last three points. First, the noble Lord is right: the NHS is—and I would regard it still as—the highest-value healthcare system in the world. It does have fewer doctors and MRI machines—however you want to measure it—compared to many other OECD countries, but its outcomes, on the whole, are very good. I can, therefore, certainly confirm that the NHS is a very high-value healthcare system. As far as the involvement of the NHS in the plan is concerned, it was very much put together by the NHS and signed by all of the arm’s-length bodies at the time. This is a quote from Simon Stevens about the spending round settlement:
“This settlement is a clear and highly welcome acceptance of our argument for frontloaded NHS investment. It will help stabilise current pressures on hospitals, GPs, and mental health services, and kick-start the NHS Five Year Forward View’s fundamental redesign of care”.
This brings me to my last point, the fundamental redesign of care. That was possibly not really recognised at the time of the NHS review, because it is a fundamental redesign of care. As the noble Lord said, it means moving resources away from acute settings into community settings, very much as mental health care was restructured 20 or 25 years ago.
My Lords, the Secretary of State said that there were going to be another million over-75 year-olds in five years’ time, and I very much hope that I am going to be one of them. May I give the noble Lord a couple of other statistics? The King’s Fund quarterly monitoring report found that, for each month in the first quarter of this year, there were an additional 54,000 attendances at A&E departments and 14,200 emergency hospital admissions compared to the same time last year. All these emergencies are no way to run a health service.
The noble Lord and the Secretary of State pray in aid the five-year forward view as if it were a statement of fact. It is a plan; it is an aspiration, and at the time it was written, the hole in the funding of the NHS was not £4.5 billion, as the Select Committee says has been given to the health service; it was not £8 billion or £10 billion: it was £30 billion. The Government gave about a third of it and suggested, through the five-year forward aspirational plan, that the rest could be done by efficiencies. We have the STPs, which are supposed to find those efficiencies. We have heard many times in this House over the last few weeks about the shortcomings of those, so when will the Government respond to my right honourable friend Norman Lamb when he calls for a cross-party commission on proper funding of social care and the health service?
My Lords, I am sure that the noble Baroness will be here well past the age of 75, and that there are many years to come before she reaches that age.
The noble Baroness is absolutely right: for many elderly people, the worst way to be treated, frankly, is to be blue-lighted in an ambulance into an A&E department of a very busy acute hospital. The whole purpose of the five-year forward view is to deliver care to many more such people outside. I think we all agree with that. The noble Baroness’s party, like ours, agreed with the £8 billion of extra government spending over the course of this Parliament, and accepted the fact that very significant efficiencies could be generated from the NHS. We still subscribe to that view, and the STPs will be the right vehicle for delivering many of them.
(7 years, 10 months ago)
Grand CommitteeMy Lords, I, too, would like to focus on the patients—the 2,500 British people who are expected to die each year of mesothelioma, most of whom have contracted the disease as a result of exposure to asbestos. The use of asbestos in industry and construction, although now banned, was a practice that has had a detrimental effect on many lives, and it is our duty now to offer sufficient aid to those it has affected.
Asbestos lurks in many strange places, including, as we have heard from the noble Lord, Lord Alton, this very building. My husband and I recently demolished an old cottage on our property, and we discovered that there was asbestos in the floor tiles with which my late mother-in-law had been living for 40 years. We had to have them removed by specialists. In the 1970s, when I lived in an old farmhouse, I used an asbestos product to fill the rather irregular holes that I used to drill in the walls to hang pictures and bookshelves, having no idea that there may be a problem with it. Concerns about the dangers of asbestos were first raised early in the 20th century, but its use was not outlawed until 1999. For the thousands of cases now arising 40 or 50 years after first exposure, it is our responsibility to ensure that they are given the compensation and support they require. Unfortunately, the median survival time for pleural mesothelioma, once it has taken hold, is 12 months from diagnosis, but this time, and beyond for the dependents of those affected, must be made as comfortable as possible for those who need help.
Over the years, there have been many shortcomings in the handling of asbestos-related cases across the globe, one such case being the fire at the central ordnance depot in Donnington, Shropshire, in 1983. The blaze which released a huge cloud of asbestos into the air has had a huge repercussion which is still being felt today. Paula Ann Nunn, Ellen Paddock, Susan Maughan, Richard George and Marion Groves are just five local people who contracted mesothelioma and unfortunately passed away as a direct result. Mrs Maughan died only last October. Her daughter told the inquest that it took the local authority five days before they told the community so they were exposed to asbestos for all that time. The ash cloud which spread over an area of 15 square miles attracted many small children who played in it as if it were snow which fell in local gardens for days before people were told it was unsafe. We have heard from the noble Baroness, Lady Finlay, how very harmful that could be to those children. My colleague and noble friend Lady Pinnock has told me about many cases in her area of Kirklees, resulting from working for a brake linings factory, long since closed down.
Mesothelioma is generally resistant to conventional cancer treatment. Long-term survival and cures are extremely difficult, but that does not mean that the mistakes of government and industry alike over the past century should not be paid for by compensation to those affected. The current range of available benefits, both lump sums and long-term allowances, must get to the right people at the right time. The Mesothelioma Act 2014, for which we have to congratulate several noble Lords present today, went a long way to help those who had been unable to access compensation because of the passage of time or a lack of effective record-keeping identifying those responsible. Since 2014, a total of £62.2 million has been awarded. However, of those who were unhappy with the result and requested a review of what they were awarded, 25% had their compensation rate altered—I presume upwards. Given that this illness is still an issue affecting thousands of British people every year and that the nature of mesothelioma’s progress means that time is literally of the essence, it is essential that the correct support is awarded without delay in all cases. Given the significant number of cases reviewed since the launch of the scheme, how do the Government intend to learn from those cases and improve the process so that the right decision is made the first time in as many cases as possible?
Can the Minister also outline the ways in which the Government are promoting the compensation scheme, so that those most in need are fully aware of the support available? Given the vital work done by the charitable organisation, Mesothelioma UK, and its invaluable lung nurse specialists, do the Government intend to follow its lead and introduce more specialist nurses into hospitals to support patients?
Finally, to safeguard against mesothelioma cases slipping under radar given the disease’s lengthy latency, are the Government willing to begin actively seeking out those involved in previous incidents, such as the Donnington fire, so as to promote early identification of their disease and to get immediate support to them?
(7 years, 10 months ago)
Lords ChamberI respect the views of the noble Lord but I have looked very carefully at the number of applications coming into medical schools in 2016 compared with the previous year. In 2016, there were 20,100 applications for all medical schools, including in Scotland. The previous year the figure was 20,390, so there is no firm evidence to support the view that the noble Lord expresses. There were some rumours that St George’s was having trouble filling its places. I have investigated that and understand that it was a result not of any lack of demand but of the fact that it wanted to wait until A-level results had come through so that it could choose the best candidates based on those results. So I do not think there is any evidence to substantiate the noble Lord’s point.
My Lords, one of the objectives in Health Education England’s mandate is to reduce our dependency on temporary staff. However, the National Audit Office tells us that we are short of 50,000 clinicians, and that HEE is failing to be sufficiently proactive in addressing the,
“variations in workforce pressures in different parts of the country”.
Is the noble Lord’s department monitoring how well HEE is responding to these challenges?
My Lords, predicting the future requirement for doctors is extremely difficult. It is more a matter of prophesy than science. The fact that we are now going to fund an extra 1,500 doctor places a year, which is a 25% increase, should make a huge difference.
(7 years, 10 months ago)
Lords ChamberWe received the report today. We warmly welcome its principles and believe that by combining the great depth of our research base in this country with the NHS, which is the largest single integrated provider of health services in the world, we can create a world-leading life sciences base in this country. The detailed response to the report and the costs attached to it will come in due course.
My Lords, repurposed off-patent drugs often fall in the cracks between the processes of NICE and the processes of NHS England, both of which organisations take the role of approving these drugs. The Accelerated Access Review recognises this problem and recommends that the new streamlined process involve both organisations talking to each other to make quite sure that that does not happen. What will the Minister’s department do to ensure that under this new streamlined process these drugs do not fall between the cracks, because many of them are very useful to patients?
My Lords, I need to consider the report in detail. I do not believe that repurposed generic drugs naturally fall within the AAR streamlined procedures, although it is very important that they do not fall between the cracks. The AAR is largely designed for new products rather than for repurposing old products.
(7 years, 10 months ago)
Lords ChamberMy Lords, in his recent national confidential inquiry, Louis Appleby reported that in 36% of all suicides of people aged under 20, family breakdown or family circumstances were part of the cause. My noble friend is absolutely right that families are critically important. That is very much part of the strategy in our Future in Mind paper. I was horrified by the figure that 43% of all people who took their own lives under the age of 20 had had no prior contact with any agency—no contact with GPs, no contact with CAMH units, no contact with schools—about their condition. Nearly half the people who took their own lives were completely below the radar. That is a shocking figure.
My Lords, I ask the Minister about young people with mental health problems in the criminal justice system, where they are particularly vulnerable to self-harm and suicide attempts. Recent draft NICE guidelines recommend that all staff working in the criminal justice receive training to recognise and respond to mental health problems. Although the NHS is not responsible for the physical or mental health of those in custody, the guidelines recommend co-operation between healthcare and the criminal justice system on mental health, so how will his department respond to them, and who will fund the training?
My Lords, I do not think I can answer the question about who will fund the training; I will write to the noble Baroness to answer it. She is absolutely right that a huge proportion of people who are in the criminal justice system, in prison, also suffer from mental health problems. Tackling the mental health problems of people in prison is just as important as tackling them outside. If I may, I shall write to the noble Baroness on this matter.
(7 years, 11 months ago)
Lords ChamberMy Lords, I too congratulate the noble Lord, Lord Lansley, on initiating this debate. Antimicrobial resistance is a global health disaster waiting to happen, so it could not be more important and it cannot be understated. The report we are debating today is extremely comprehensive and makes a large number of very important recommendations, most of which are practicable and very cost effective. I was glad to see that they focus mainly on reduction and prevention.
Developing new antimicrobial products is important, but it is a bit like closing the door after the horse has bolted. We must shut the stable door and stop the horse bolting in the first place. Global co-operation and a massive awareness campaign about the problem of drug-resistant infections will be essential to tackling it. I have my doubts about whether this could ever really work, but it must if we are to defeat this terrible threat. Given the difficulties and cash shortages of some of the countries that would need to be involved, we would do well concentrate on two things: what we can control within our own shores, and co-operating where we can with international initiatives and funding projects in poorer countries, perhaps with the DfID funding for the Department of Health referred to in yesterday’s debate on smoking.
If we are to be able to reduce the prescribing of antimicrobials to humans, we need to reduce the pressure on doctors from patients who do not really need them. That will take public education and a culture change—and of course we know that a lot of them do not work anyway, so it will save money as well. But we also need to improve rapid diagnosis, as has been said, and develop the use of vaccines and other alternatives to the use of antibiotics.
Vaccine programmes have been very cost effective over the decades, often saving society more than 10 times the cost of their development. But, as the report points out, new vaccines relevant to AMR are more complex and therefore more costly to develop. The report’s authors therefore recommend a greater level of investment in this area with funding from government, charities and international organisations. I do not go back in your Lordships’ House as far as 1998, but this recommendation cast my mind back to the House of Lords Select Committee on Science and Technology report in 2002-3, entitled Fighting Infection. I was a member of that committee. In our report we said:
“We were particularly impressed, when we visited the National Institutes of Allergy and Infectious Disease in the US, to hear about their Small Business Initiatives. Small companies willing to take financial risks inherent in developing a vaccine could apply for up to $100,000 to cover initial development costs. If the company then patented the vaccine they were obliged to make every effort to bring it to market … Pharmaceutical companies invest ten or twenty times less money in vaccine R&D than in therapeutics. They regard the public expectation that vaccines should not have any side-effects as a particular burden. Such public anxiety requires vaccines to be more thoroughly tested than other pharmaceutical products in order to reveal any potential side-effect. This informs companies’ risk-analysis of products to decide whether or not to further develop or to market … Pharmaceutical companies desire clearer guidance from Government about levels of demand”.
We recommended that,
“vaccine development should be facilitated and … that the Government should develop and maintain clear evidence-based guidelines about vaccine requirements and should create financial incentives to enable early research, development and commercialisation of vaccines”.
That was in 2003, and I fear that the same needs still exist today. What are the Government doing to encourage and enable the development of new vaccines? Do they have a similar scheme to assist smaller research companies to mitigate the risks associated with the development of vaccines and other treatments, such as the company producing reactive oxygen, mentioned by the noble Lord, Lord Colwyn? We have to accept that development will have to be done in the richer countries, of which we are one—and, of course, happily we also have the skills here.
I was glad to see the warnings about the prophylactic use of antibiotics in agriculture because excrement from livestock is subject to even looser waste management practices than human waste. So not only are we taking in those chemicals in the meat that we eat but they are also being flushed away into our rivers, streams, soils and also the sea, where they are picked up by fish. So even careful usage and hygiene on one continent can be neutralised by poor practice on another—hence the need for global action. Of course, this is in addition to the effect of the mass movement of people, referred to by the noble Lord, Lord Trees.
Clearly, the consumer needs more information about the antibiotics used in meat production. If we had that, I am convinced public pressure would reduce their use in food production. I absolutely agree with the comments of the noble Lord, Lord Lansley, and the noble Earl, Lord Selborne, about this. I hope that our departure from the EU will not stop us from banning more categories of use than we have already. But hygiene measures to prevent these products getting into the water we drink and the fish that we eat are also essential. That should include antimicrobials in development, which should be disposed of by pharmaceutical researchers in a way that does not pollute our water. I use the word “pollute” deliberately, because these products can be just as dangerous as the microbeads which have recently been brought to our attention as a great danger to marine life.
There is another danger which I did not notice mentioned in the report. That is the fact that bacteria can swap bits of their DNA with other bacteria—and this is very significant. A drug-resistant bacterium that passes through the intestines of any animal into the local waterway may not in itself be a pathogen that normally threatens human health, but that benign bug can share its drug-tolerating secrets with others. David Cummings, a biologist at Point Loma Nazarene University in San Diego explains in his paper on the subject:
“It’s not necessarily important what species is holding on to the DNA as long as the DNA is held on to and propagated. Then it can later be released to cause disease in an animal, plant or human”.
Of course, course, drug-resistant strains of bacteria—to go back to what the noble Earl, Lord Selborne, said about Darwinism—tend to be the fittest, and therefore survive. Cummings’s research has identified dangerous DNA in the river sediments around San Diego and across the Mexican border. He says:
“These coastal wetland habitats are becoming sinks and ultimately sources for drug-resistant bacteria—more importantly, sinks for the DNA that provide resistance”,
and he points his finger at very common things, such as pet waste, bird faeces, leaky sewer pipes and hospital waste effluent as the likely culprits.
Bacteria are very biologically clever and flexible. Not only are they able to develop resistance to our antibiotics and thrive but they can then pass that resistance on to other bacteria that can harm us. So our focus needs to be not only on pathogens and developing ways of killing them but on reducing the use of antimicrobials as a whole. In relation to that, I was very interested in the section of the report covering the provision of clean water and proper sanitation in four middle-income countries. These simple, fundamental basics of public health, which we take for granted here, can break the chain of infection and reduce the need for antibiotics by up to 60%. This in turn reduces the development of drug-resistant strains.
I saw for myself the practical benefits of improvements in these areas when I visited an area near Calcutta with UNICEF a few years ago. I have never seen more brand new toilets in a few short days in my whole life—and, of course, people were very proud of them, as well they might be. The benefits of clean water to the schoolchildren, with whom I washed my hands with soap before a meal, showed in their smiling healthy faces and their growth charts on the wall of the school. The benefits of proper toilets to the mothers, who earned money by manufacturing them, and then of having them available in their homes, were enormous and obvious. I have mentioned before the UNICEF project in a village where clean water was being pumped up from a well by a pump which was serviced regularly by the women. They may not have realised it, but they were not only saving their children from diarrhoea but were contributing to limiting the global development of antibiotic resistance.
The report also recommends the development of more rapid diagnostics and early recognition of human disease. Obviously, early treatment will require smaller quantities of antimicrobials. The Royal College of Nursing agrees. One key recommendation in its briefing was implementation of rapid diagnostic testing for suspected cases of pneumonia and investment in systems that capture the rationale for prescribing antibiotics to improve practice, reduce unnecessary prescribing and cut the cost to the NHS. The RCN also calls for a national strategy for infection prevention and control, but rightly points out that AMR is not exclusively a hospital or even a healthcare-related issue, and multisector engagement is necessary.
For so long, we have had so many very effective treatments for infectious diseases that we are in danger of being casual about infection control. After all, if we get an infection, the antimicrobials will deal with it, will they not? Well, perhaps not any more. The many factors that we have heard about in this debate that make it easy for micro-organisms to develop drug resistance, all put together, make me feel that the human race has become very cavalier about infection—we have in the West at least. For example, all hospital wards and departments that I have been in now have little machines at the entrance with antimicrobial stuff that you can rub on your hands. But do we always use them? I must admit that I do not always. When hospitals look superficially very clean, as most do, it is tempting to forget the millions of invisible but potentially dangerous microbes lurking in every corner. Of course we do not want to live in a completely sterile environment, because that would not allow our immune systems to develop strongly, and we need that. The human immune system is a wonderful thing but it cannot cope with overwhelming odds. We need to take all the recommendations of this excellent report to heart. As the report says, it will save money as well as lives. Can the Minister tell us how the Government plan to respond?
(7 years, 11 months ago)
Lords ChamberMy Lords, last year, the Minister Jane Ellison confirmed that the Government were working on a new anti-smoking plan to be published this summer. I too hope that we are going to hear news about that from the Minister today. Jane Ellison stated that the Government would seek to,
“further empower local areas and support action within them, particularly where tobacco control strategies can be tailored to the unique needs of local populations”.—[Official Report, Commons, 17/12/15; col. 636WH.]
The Government, she said, would also seek to tackle the “stark differences” in health outcomes among smokers from different parts of the country. I strongly support those ambitions but fear that those words have not yet been translated into enough action. Indeed, the Government’s action in making cuts to public health funding for local authorities has flown in the face of those objectives.
The BMJ says that prescription medication and personal support are the best routes to quitting smoking. The Government agree, and yet up and down the country local authorities have reluctantly had to cut these services. The Government, therefore, are relying on the commercial supply of expensive aids to quit smoking, such as patches and electronic cigarettes, in order to achieve further reductions in smoking. I would like to know whether the Government support prescribing more of those aids to the people who really need them but cannot afford to buy them.
The Government have also said that although they believe that e-cigarettes can help smokers quit smoking, they are,
“not harmless and there is a lack of evidence on their effects in long term use”.
I would certainly agree with that. There is massive evidence that e-cigarettes are much safer than smoking, but there is also some evidence that they may have undesirable short and long-term effects, particularly on the heart. It was irresponsible for a national newspaper to claim that vaping is just as dangerous as smoking. There is no evidence for that claim. However, there is still a lot that we do not know. Therefore, I now repeat the call I made during the recent debate on the EU tobacco directive: we need more research. After all, we now have many thousands of users, and I am sure many would be happy to co-operate with research.
It is estimated that over 200,000 children take up smoking every year. I call on the Government to ensure that every child has good-quality PSHE lessons in which the dangers of smoking are emphasised. I welcome the proposed removal of packets of less than 20 cigarettes, which used to be so popular with children, and also the plain packaging and larger pictorial health warnings. I hope that Brexit does not get in the way of all that.
The BMA calls for more measures to protect others from second-hand smoke. This is particularly important for children. Since we cannot ban smoking in people’s own homes, it is really important to help all smokers voluntarily give up smoking or never to smoke when children are present. Those on these Benches fought for the legislation that banned smoking in cars with children present, but the ban is not being properly enforced. Will the Government carry out a public information campaign about this and encourage the police to enforce the law?
(7 years, 11 months ago)
Lords ChamberMy Lords, I thank the noble Viscount, Lord Hanworth, for initiating this debate, and the noble Lord, Lord Lipsey, for what he said at the beginning of his remarks. I think we all have a great deal to thank the NHS for and we should always remember that.
There is no doubt that the 2012 Act was the biggest reorganisation the NHS has ever seen. It was also probably the most controversial. It was opposed by the British Medical Association, the Royal College of Nursing, the Royal College of Midwives and the Royal College of General Practitioners. While accepting the principle that doctors should have a role in commissioning, the Royal College of Surgeons and the Royal College of Physicians were highly critical of the proposed mode of implementation.
I would judge the success of the Act by whether it minimised the health inequalities in this country, whether it treated physical and mental health equally, and whether it made health and social care sustainable for the foreseeable future. Whatever David Cameron and the noble Lord, Lord Lansley, had hoped would be the benefits, I suggest that we are yet to see them fully realised. Experts agree that none of the many reorganisations has really benefited patients in the end, and this was a particularly expensive one. One wonders how many treatments could have been paid for by the £1 billion redundancy bill alone.
The stated purpose was to “liberate” the health service. Well, it certainly liberated a lot of money which is now in the pockets of many private providers who have come into the health service since 2012. I am not saying that I believe any participation of private companies is in itself a bad thing—of course not—if they can provide better services at an equal or smaller cost to the public purse than that offered by NHS providers. The primary principle must always be that healthcare is, as far as possible, free at the point of need and cost effective to all of us taxpayers. The problem is that we are now seeing evidence that the criteria for whether we need the services or not, and therefore whether we get them, are being tightened in both health and, particularly, social care, as some services close down and the rest try to provide for a growing and ageing population, and pay for healthcare price inflation.
Of course, one cannot attribute all the cost inflation to the profits made by privatised services. Some of it is attributable to the increasing cost of the research that underpins the development of wonderful new drugs and treatments. That of course is something that I, like the noble Lord, Lord Kakkar, welcome, although there is always room for effective price negotiation at a national level. However, the fact remains that the NHS is struggling in a way that we have not seen before, and this is surely unsustainable. The NHS budget for this Parliament, as we heard from my noble friend Lady Tyler of Enfield, will be short of £22 billion by 2020, and the solutions outlined in the Five Year Forward View are not yet showing convincing results. It is right that all services are scrutinised as to their efficient use of money, and I understand that millions could be saved if the least efficient took several leaves out of the books of the most efficient. However, as with many other things, you need money up front in order to save costs down the line, especially if you are going to replace face-to-face consultations with digital communications and home testing kits.
On top of that, the Government promise £8 billion extra for the seven-day NHS, which even Simon Stevens says is not enough. A majority of acute hospital trusts are in deficit, and many GP practices are ceasing to take new patients because of unacceptable waiting times for appointments. Everyone knows how concerned the junior doctors are about all this. Although I believe that the planned series of five-day strikes should not go ahead without a further ballot of all BMA members, this historic reaction of the doctors to government policy does indicate that the dispute is not just about the detail of their weekend pay or training structures. They are worried about the survival of the NHS as we know it. Clearly, they have made their judgment about the effects of the 2012 Act.
Sustainability was a key word in the noble Viscount’s Motion for this debate, and it has to be one of the key criteria for judging the 2012 Act—apart, of course, from whether it improves services for patients. Nobody I have talked to believes that the current proposals for economies and efficiencies will deliver what is needed, especially given the continuing rising demand. There is evidence that the preparation of the sustainability and transformation plans is not going well. The STP process has been very top down and has become focused on short-term savings rather than longer-term sustainability. This could lead to fragmented care and wider inequalities. Neither has it been very transparent.
A current example of short-term savings is the recent closure for three months without consultation of the 12-bed ward at Rothbury Community Hospital in Northumberland. The hospital is only nine years old, purpose built to serve this very rural community, and is a valued resource. It serves a remote and ageing population, providing care to patients whose families would have enormous difficulty visiting them if they had to go to the nearest general hospital. There are serious concerns about whether due process has been followed. I am not sure, frankly, whether it is part of an STP, but it certainly does not sound like the result of a thoughtful, long-term review of local need, and is opposed by the local people and the local GP practice. Would the Minister care to comment?
Accountability is another issue which has not been well served by the 2012 Act. Even when the Bill was going through Parliament, there were concerns about this. Senior figures from the King’s Fund said at the time:
“At a national level, it is difficult to see who, if anyone, will be in charge of the NHS”.
It is still unclear how the five national bodies interact with each other, and where the Secretary of State comes into the picture. Does the buck stop with the DoH and Jeremy Hunt anymore, other than providing the money? It seems that when it is inconvenient for him to take responsibility Mr Hunt relies on the fact that powers have been delegated to these five agencies.
At local level, fragmentation, as we have heard from other speakers, makes accountability difficult. Although the principle of clinicians having a role in commissioning is one which most of us would support, there are concerns about the abilities of some of the clinical commissioning groups and about the fact that their very existence means a postcode lottery. Devolution to a local level has its advantages, but there are dangers, such as to patients with rare but expensive diseases which may not be funded by their local CCG. This is where national strategies come in, but they need money too.
Mental health, as we have heard from the noble Lord, Lord Lansley, is still a work in progress. Only today, my right honourable friend Norman Lamb has published evidence of the shambles in CCG provision for psychosis.
My greatest hope for the 2012 reorganisation was the local health and well-being boards. I hoped that they would bring together local services and resources and make the most appropriate provision for public health and social care in their areas with the involvement of the local authorities. Sadly, repeated cuts in public health funding have got in the way of local authorities’ realising their potential in making a difference to the health of their local communities. When public health funding is cut, and cannot be subsidised by cash-strapped local authorities, prevention suffers, leading to increased costs in the long term. We have seen preventive services being cut all over the country. In addition, local council representation on the boards is in the minority. The boards’ powers are not really broad enough for them to influence matters such as housing and air pollution, both of which have major consequences for health. Colleagues on health and well-being boards believe that the cultural divide between the self-determination of local government and the top-down NHS is a huge hurdle to these boards achieving better health and social care integration.
I strongly believe that the public do not want to be treated by more and more doctors on more and more days of the week. What they want are services to help them remain well for longer and for appropriate services towards the end of their lives, and they want that period of acute need to be as short as possible. Sadly, this country falls behind others in that respect. In the Scandinavian countries, the period of high-level need for health services at the end of life is, on average, much shorter than it is here. People remain well longer. Why is that? I would judge the 2012 Act on whether it promotes the Scandinavian standard. In order to do so, it would have supported more preventive services. I for one would have cheered. But it did not, so I have not.
What we need now, as has often been said by my right honourable friend Norman Lamb, is a genuine cross-party debate on how much we need to spend on health and social care and the fairest way of raising the money. I encourage all parties to consider this proposal seriously.
I would also propose that one of your Lordships’ excellent ad hoc Select Committees should do post-legislative scrutiny on the effects of the 2012 Act, along the lines of the very useful report of the committee chaired by the noble Baroness, Lady Deech, on the impact on disabled people of the Equality Act 2010, which was debated in your Lordships’ House on Tuesday and was a very useful exercise.
Will the Minister consider supporting proposals for such a committee on the impact of the Health and Social Care Act 2012? It would be able to take evidence in a way that has not been possible for noble Lords preparing for today’s debate. I think that we would learn a great deal from it.
(7 years, 11 months ago)
Lords ChamberMy Lords, the noble Lord has raised many questions in his response to our Statement. He may well have read the article published earlier this week in the Times by Sir Simon Wessely, the president of the Royal College of Psychiatrists, which goes to the heart of what I would call the non-contractual issues that have bedevilled, coloured and provided the context for this dispute:
“Changes to the way that doctors are trained means that juniors face switching not just jobs but addresses every few months without much say about where they end up and when. Many seem condemned to spending years rootlessly shuffling from one place to another like lost luggage. Without any familiar faces, long hours are endured in relative isolation and managers who change all the time provide little or no recognition, let alone reward”.
This in a sense is what lies behind much of the dispute. The fact is that we had a contract that was wholeheartedly welcomed by Dr Ellen McCourt, now the president of the BMA, and by the association itself. The issues of difference in the contract were pretty small.
We have been discussing this contract for three years now and the Government have made 103 concessions. The Secretary of State’s door has been open throughout that time. The new contract is due to be introduced in October and at some point we really have to get on and introduce it. There is provision within it to review aspects as it goes forward. We have committed to looking at the gender pay issues that have been raised by the BMA and today HEE has published the work that it is doing on non-contractual issues with the BMA when the association is prepared to talk to it. The Government are bending over backwards to meet the BMA, but there comes a point where we just have to bite the bullet and go ahead with the contract that has been agreed, and that is the place we are in now.
The noble Lord referred to a lack of trust in local management and in the Secretary of State, but we now have the guardians of safe working hours built into the contract. They have a contractual commitment to report every quarter to the boards of trusts and to the GMC and the CQC every year. Plenty of independent safeguards have been built into the new contract. So while of course I understand many of the issues raised by the noble Lord, the Government have gone the extra yard every time they have been asked to do so and now we must get on and introduce this contract.
My Lords, I apologise to the Minister for not getting up quickly enough to add my questions from the opposition side before he gave his last response. We on these Benches welcome the fact that the strike planned for next week has been postponed. I think we have all taken very much to heart what was said by the GMC this morning. I hope the Minister can give an assurance that the Secretary of State will take this breathing space as an opportunity to get back around the table with the junior doctors not only to explore the details of the contract, which may not yet have been hammered out to everyone’s satisfaction, but to get to the core of the reasons why they are so up in arms.
I am very impressed by the fact that when junior doctors are marching along the street, they are not shouting, “Save our weekend pay” or “Save our training structure”, they shout, “Save our NHS”. That is what every single doctor in this country is committed to. The reason why doctors are so concerned is not the Government’s intention to make tests or more frequent investigations available on Saturdays and Sundays for patients in hospital, it is the fact that there are gaps in the weekday rotas now. The Minister is saying that there will be extra money and extra doctors. Where are they going to come from? Does he know how many doctors have investigated the possibility of emigrating or have even actually emigrated since the beginning of this dispute? I ask this because I am hearing about it all the time. I wonder where the new doctors will come from in order first to fill the gaps in the weekday rotas and then to provide extra services at the weekend. The £10 billion mentioned in the Statement is clearly not enough when we already have a £22 billion black hole in the NHS.
Over the Summer Recess we had so many news stories about units being closed, not just to reconfigure the services and provide better service for patients, but to save money, because the system is desperate to do that in the short term. The sustainability and transformation plans clearly do not have the confidence of the doctors, partly because they are very opaque and partly because they are very short term. They are picking up on any short-term economies they can make, rather than looking at the very long-term savings that might be made and bring better provision for patients. Will the noble Lord say where the extra doctors are coming from and how the Government plan to convince existing doctors in this country that they will be fully supported if they are to implement the Government’s policy?
My Lords, the noble Baroness made a valid point when she said that when she meets junior doctors on their demonstrations or marches, they are concerned about the NHS—rightly so; it will be a sad day when doctors are not concerned about the future of the NHS—but that is no reason for going on strike over this contract. We are perfectly happy to have a debate with them. We will disagree and agree on some things, but to launch a wave of strikes over this cannot be right. As the noble Baroness indicated, it is not the contract that they are worried about at all; they are worried about much more general things than the state of the contract.
Staffing is a big issue. There is no question but that after the Mid Staffordshire tragedy, we saw a huge increase in agency staffing. We saw that increase because we did not train enough of our own doctors and nurses. That is a long-term issue about increasing training numbers, but, in the meantime, part of the £10 billion of extra money we agreed to put into the NHS, which the noble Baroness’s party agreed to do at the last general election, has to go towards increasing staffing in our hospitals.