NHS: Food Banks

Baroness Walmsley Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the people running the schemes in the two hospitals in Birmingham and in Tameside are to be congratulated. I am not sure that there is a similar scheme in Newcastle. I know from experience of homelessness how difficult it is, for example, to discharge patients when they have nowhere to go, with the risk of discharging people onto the street who will then come back into hospital. The work they are doing in those two hospitals is to be applauded. We have a welfare safety net in this country. Tragically, anywhere around the world there will be some people who fall through that net. The fact that there are voluntary groups and charities prepared to help pick those people up is a cause for celebration. It is that combination of a state welfare net with an active civic society which makes this country as good as it is.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that the location of food banks should not be at the top of the priority list of cash-strapped NHS hospitals, most of which are in deficit at the moment? Does he also agree that food banks need to be conveniently located so that those who need them can visit them regularly? I would rather hope that those people would not have to visit hospitals regularly.

[Lord Prior of Brampton]

I do not think that anyone is saying that the food banks in the hospitals in Birmingham and Tameside are their top priority, I just think that it is a very human reaction of people working in those hospitals who want to help very vulnerable people who are being discharged.

Health

Baroness Walmsley Excerpts

Thursday 26th November 2015 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been an excellent debate with some fascinating speeches. I shall certainly go on the website. There were three interesting maiden speeches. I was fascinated by my noble friend Lord Foster of Bath’s examples of how business and the arts can contribute to our health. Of course, I would say that as a founder member of the Parliament choir—although I am not sure that last night’s excellent concert has particularly enhanced my health.

Last September at the Liberal Democrat party conference, I made a speech about the future of health provision in the UK. I did not spend all my time talking about the NHS because, like the noble Lord, Lord Crisp, I believe that the crisis in the health service cannot be resolved by the NHS alone. The noble Lord and I are clearly on the same wavelength, so I very much welcome this debate.

As many have said, health affects everything: how long we live and our well-being, achievements, family life, contribution to society and, of course, happiness. Yet the NHS is struggling. Some say it has become a sickness service rather than a health service, spending a huge amount of resource fire-fighting preventable diseases, dealing with the complex needs of an ageing population and providing ever more wonderful, but expensive, treatments.

The pressures on NHS staff are enormous, and it seems that no matter how hard they work, how much they care and how much the Government spend, it is never enough. However, it is incredibly cost effective. Despite spending less per capita on health than most developed nations, the NHS is top in most rankings but next to bottom on living “healthy lives”. So unless we can turn around our public health problems, the pressures on the NHS will continue.

So I agree with the noble Lord, Lord Crisp, that we must stop dealing with health policy in isolation when its implications are so broad. Health should be a “whole government” responsibility, not just the job of the Department of Health. As I said to my party conference, suggesting that health is just the responsibility of the NHS is like expecting the goalkeeper to win the match on his own without the help of the other players. It should be very obvious that the rest of the team have to play their part, too.

The keys to the sustainable future of the health and social care systems are prevention, integration, innovation and “getting it right first time”. If 40% of ill health is due to diet and lifestyle, it is therefore preventable. New ways of working are also vital, and the vanguard sites, set up in response to the NHS Five Year Forward View, demonstrate that better care can be delivered for less if people will only work together. However, we need to ensure that competition legislation does not get in the way of providers working together. They also need the £3.8 billion announced this week to achieve that transformation, yet the Treasury says that the money will be spent on more treatments. Either the money is there to cover part of the shortfall in NHS budgets or it can be used to initiate new ways of working which will bring cost benefits in the future. It cannot do both—you cannot spend money twice.

“Getting it right first time” is the mantra of a number of ground-breaking hospitals that have shown that it is cheaper in the long run to provide excellent services first time round rather than have a lot of readmissions. We also need a complete overhaul of patient discharge and transfer arrangements, which cause bottlenecks and waste money. I am delighted that former Health Minister Paul Burstow is leading a commission on behalf of NHS providers to identify and disseminate best practice on transfers of care. More efficient working will enable the NHS to fulfil its important ambition in the wider picture of sickness prevention, and it should start at the very beginning.

A good start for a baby depends on the health and well-being of its mother and her ability to bond with her child, but perinatal mental health services are patchy—yet this is health creation at its most basic. We need a new standard, delivered everywhere, to promote the future health of the baby and the well-being of the mother. Academics believe that UK children are at a higher risk of premature death than their western European counterparts because of the growing gap between rich and poor and a lack of targeted public health policies. But if a child is born into a low-income family, he is not automatically on a pathway to ill health, as several imaginative interventions have already shown. A new, holistic approach to child health would tackle health inequalities at source.

Moving beyond the NHS’s own role in the health-creating society, it is clear that poverty is a major cause of poor health. According to Sir Michael Marmot’s recent book, 200,000 people die prematurely every year in the UK simply because they are poor. Dealing with the economic divide would go a long way to improving the health of the country and address health inequalities.

Since the foundations of a healthy life are laid in childhood, the Department for Education has a role to play. Liberal Democrats support mandatory personal, social, health and economic education in all state-funded schools, but we still fall far short of that. Children need to know about a healthy diet, the importance of physical activity, how to recognise a respectful relationship as opposed to an abusive one, and about the dangers of tobacco, drugs and alcohol, and so on. Therefore they need good-quality PSHE.

A love of sport is often developed at school, and this can stand a child’s health in good stead in the future. I really commend the daily mile, run or walked by every child in St Ninians primary school in Stirling every morning. But many children drop sport as soon as they leave school. This is where the Department for Culture, Media and Sport, local sports clubs and local government come in. But the cuts of the last five years have made it very difficult for them to provide the facilities needed—we just need to look at the number of swimming pools that have closed.

Local authorities are ideally placed to deliver public health interventions that will improve community health outcomes. Yet within a month of being in power on their own, the Conservative Government announced an immediate £200 million cut in public health funding, putting further at risk the health service’s ability to make ends meet. This and yesterday’s further cuts to local authorities are appallingly short-sighted. How can the Government justify them?

Then there is housing. Cold, damp homes foster colds, bronchitis and many other problems. We need more decent affordable homes for families to rent as well as buy, and smaller, well-insulated homes for older people. I am one of those who is currently about to downsize to a highly insulated passive house—a home for life, I hope. Successive Governments have failed on this for decades and, as the cost of energy has risen, even people who have decent homes are finding it hard to heat them. We know that the most cost-effective way to reduce energy bills is good insulation, but much of our old housing stock is poorly insulated. The Green Deal home improvement fund provided funding for energy efficiency improvements to homes, making them greener, cheaper, warmer and of course healthier. But the Conservative Government decided to cut it. Where now will people get help to make their homes warmer and healthier?

The Department for Transport does not escape responsibility. Air pollution causes major problems for asthmatics such as myself and others. Transport policies therefore play a part. I have heard it rumoured that, alongside cutting the subsidy for solar and wind power, the Government are now planning to cut the £5,000 subsidy for electric cars. Can the Minister confirm or deny this?

If health is a whole-government issue, which I believe it is, it requires proper oversight. My answer is very slightly different from that of the noble Baroness, Lady Jay. I would like to see the Government beef up the Cabinet Committee on Health, headed by a senior Minister and involving all relevant departments at a senior level to ensure that all government policies can be scrutinised as to whether they contribute to the better health of the nation. There can be no better focus for a Government if they are truly concerned about the well-being of their people. I also believe that the Chancellor of the Exchequer should be answerable to Parliament for the health consequences of his policies.

The NHS is supported by the whole nation. It must be supported by all of government, national and local. Let us not leave it to the goalkeeper. Let us ensure that the whole team contributes to winning the cup.

Gender-based Violence: Women with HIV

Baroness Walmsley Excerpts

Wednesday 25th November 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness raises the very profound point about stigma. Where people suffer from both HIV and domestic abuse, they are extremely vulnerable and feel it very difficult to raise these issues. The Government have done a lot to try and remove the stigma and make it easier for these very vulnerable women to come forward. I am sure that the noble Baroness is aware of the sexual assault referral centres. There are now 43 of those, funded by NHS England, the police and local authorities. They are a good example of cross-government support.

[Baroness Walmsley (LD)]

My Lords, in 2012 the coalition Government set up a new research and innovation fund to collect information about violence against women in 10 African and Asian countries with the view to setting a new prevention strategy. Could the Minister tell us anything about how that strategy is progressing? Given the risk of HIV to many of these women, will that issue be covered in the strategy?

[Lord Prior of Brampton]

I think I am right that there are some 16 million women worldwide who suffer from HIV/AIDS so it is a huge problem, particularly in sub-Saharan Africa. I am not familiar with the innovation fund to which the noble Baroness referred, but I will investigate that and write to her.

NHS: Costs of Operations

Baroness Walmsley Excerpts

Monday 9th November 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, hospitals do know their costs; they know their reference costs and their HRGs. Increasingly, we will want to get patient-level costing into all our hospitals, as is already the case in some hospitals. If you know the actual cost by patient, the hospital management can have a much better discussion with hospital clinicians. Patient-level costing is important going forward in hospitals. For GPs, we have a calculated payment, as my noble friend will know: currently £75.77 per capita on the list, adjusted for various matters. A capitated figure for GPs is probably better than a much more detailed breakdown of costs.

[Baroness Walmsley (LD)]

Do the figures for hospitals discriminate between those that have to service expensive PFI contracts and those that do not? If so, and if the former are more expensive than the latter, is the department funding them appropriately to enable them to pay those costs?

[Lord Prior of Brampton]

The noble Baroness makes an important point. We have what we call a “market forces factor”, which is applied to the tariff to make adjustments for unavoidable differences in costs—for instance, providing care in London compared to providing it in a cheaper place. The way we measure the cost of capital is not entirely satisfactory, though, and if an individual trust has a very expensive PFI, that is not properly compensated for by the market forces factor. We should spend some more time looking at that issue.

Access to Palliative Care Bill [HL]

Baroness Walmsley Excerpts

Friday 23rd October 2015 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I, too, congratulate the noble Baroness, Lady Finlay of Llandaff, on introducing this Private Member’s Bill. Its admirable intention is to ensure that everyone receives the best possible care when they are at their most vulnerable, usually towards the end of life.

There have been a number of reports in recent years highlighting the failings in palliative and end-of- life care. Notable themes have included: serious concerns about staff numbers and competence; poor communication between clinicians and patients, their relatives and carers; the lack of a named senior clinician accountable for end-of-life care; poor access to specialist care out of hours and at weekends; and inadequate care of patients in their own homes. In addition, we have received numerous briefings containing very disappointing statistics.

By the way, I find it very disappointing that some of these highly paid lobbyists think it is adequate to send us their briefings the evening before the debate—I often even get them on the same morning just before I come into the Chamber. It is both irritating and frustrating because they often contain really useful information that is too late to be used. Somebody is paying these people to fail to influence us.

Having got that rant over, to return to the actual statistics, there seems to be an imbalance between the percentage of the medical research budget that is spent on understanding how to improve matters for people at the end of life and the amount their deaths cost the health service. Either we need to spend more on research or spend less by giving more people what they want. As the noble Baroness, Lady Finlay, said, it does not cost more; it costs less to do it properly. Supporting families and carers to care for dying people at home—where they want to be—is far cheaper, even when a package of excellent services is provided, which I am afraid is rare. I was also concerned at the Royal College of Nursing survey, which told us that over 58% of nurses said that patients’ wishes could not be fulfilled because of a lack of time or training.

The Bill seeks to resolve many of these issues and we on these Benches support its principles and call for the wide implementation of the standards and procedures contained in it. However, we would like to discuss whether it is right to enshrine these in primary legislation rather than ensuring that they become the standard best practice everywhere. There is a danger of a legal minefield here but I am sure we will talk about that at later stages.

There is just one item missing: the Health Select Committee’s recommendation that a senior named clinician in each NHS trust is given responsibility for monitoring how end-of-life care is being delivered within their organisation. We might consider laying an amendment to that effect at the next stage of the Bill and I hope that the noble Baroness, Lady Finlay, would support that.

The Bill contains many important elements but I particularly welcome Clause 2(2)(c) and (i) and Clause 3(1)(d), which all refer to support for those who care for the patient. Clause 2(2)(c) refers to support for other health and care workers looking after the patient other than the clinicians. Clause 2(2)(i) refers to a point of contact being available at all times for those looking after patients in their own homes. Clause 3(1)(d) requires health workers to be trained in,

“ways to support families and carers”,

and to involve them in decision-making.

I particularly support those elements of the Bill because, in a Bill which focuses mainly on the medical aspects of palliative care, it would be all too easy to forget that the patient’s well-being and the peace or otherwise of their death depends very much on the ability of those around them to be confident about what they are doing. That confidence only comes from knowing that further support is there when they need it. If that support is not there, families, and even some professionals, will reluctantly agree for patients to be taken to hospital, even when they know that this would not be their preferred place to die. By the way, this would of course also take up time in A&E and/or an acute bed unnecessarily and add to the burdens on the health service when things could have been done better in a different way. Back in the day, people used to die at home—that was the norm. Perhaps we should go back to the future.

There is some very good practice and some very poor practice. I have a friend whose mother and mother-in-law had totally different experiences at the end of life. Her mother-in-law was diagnosed with terminal cancer some years ago. She was immediately given the support of a Macmillan nurse, who identified her wishes and helped the family put them in place. She wanted to die in her own home and, because everything was planned carefully ahead and they were fully supported, this was achieved. In stark contrast, her own mother and the family had a terrible experience, which I mentioned in my speech yesterday in the debate in the name of the noble Lord, Lord Farmer, in the Moses Room. The patient had multiple conditions, the course of which, although not as simple to predict as a single disease, should have been possible to plan for. However, there was no forward planning and care was reactive—slowly. Bureaucracy, inflexibility, lack of communication, slowness of services to respond, inadequate use of modern technology and complete lack of support for the family characterised their experience. It was a complete nightmare, which I would not wish on anyone else, and I am grateful to my friend for bringing these shortcomings to the attention of the House through me.

I wish the noble Baroness well with her campaign to highlight the shortcomings in our provision of these important services and look forward to further debates on the Bill in due course.

Palliative Care

Baroness Walmsley Excerpts

Thursday 22nd October 2015 Grand Committee

[Baroness Walmsley (LD)]

My Lords, in preparing for this debate, I talked to a friend who had recently been affected by the shortcomings in end-of-life care. Her mother did not have an identified terminal illness, but deteriorated slowly from multiple conditions. She had several stays in hospital and had agency carers at home. She had several assessments from social workers and occupational therapists, but no longer-term planning was done for her inevitable future decline. Care was reactive to the immediate situation only.

In her final few weeks she deteriorated rapidly and her carers struggled without additional equipment, but it took several days to get further assessments. By the time the occupational therapist arrived to assess the suitability of her room for a bed with a hoist, which would have allowed the carers to handle her, the family were at crisis point. My friend, at her wits’ end, tried to get the bed, but it was a Friday morning and she was told that no equipment could be delivered before Monday. By the evening, her mother became unconscious in her chair. The out-of-hours service suggested an ambulance to take her to A&E. The family declined. They were then on their own. My friend’s mother died during the night, but had she survived into the weekend it would have been almost impossible to care for her properly at home.

My friend’s reflections from this episode are as follows. In contrast to the planning following a terminal cancer diagnosis, from which we need to learn, there is a lack of co-ordination and forward planning for the care of elderly people with multiple conditions. Home assessments are time consuming. Using modern technology such as iPads and Skype and a simple assessment sheet, any sensible person could have assessed the room and had direct contact with professionals for instant advice, rather than waiting for a home visit. Essential equipment should be available in much fewer than four days. You can now order almost anything from Amazon online and have delivery the same day.

There needs to be greater support for those caring for the dying person, especially in the evening, the night or at weekends. No professional or other care support was offered to my friend in the final few hours of her mother’s life, so it is not surprising that many people do not feel competent to care at home, even though they do not want their loved ones to die in hospital. If someone cannot be cared for at home, transfer should be directly into a hospice, rather than admission through A&E to a bed on a busy acute ward.

In the July 2014 report Choice in End of Life Care it was recommended that each person approaching the end of life should have a fully interoperable electronic health record to help to ensure their preferences are recorded and shared with everyone involved in their care, and that people should be able to access and add to their own records. Will the Minister say what progress is being made towards having this in place by 2020?

Health: Post-polio Syndrome

Baroness Walmsley Excerpts

Tuesday 20th October 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Lord is much better informed about this than I am, and of course I agree with him 110%. However, there are other aspects to treating this pernicious illness; clearly pain relief is important. It raises the issue that GP practices having a multidisciplinary team—physios and people who are experts in mobility, orthotics, pain relief and exercise—is very important.

[Baroness Walmsley (LD)]

My Lords, people with post-polio syndrome often require the care of a wide range of different specialists, which makes the linking up of their care and treatment particularly crucial. What are the Government doing to ensure that these can be linked up? Could the Minister say whether any of the vanguard sites are working on partnerships that will enable this to happen?

[Lord Prior of Brampton]

NHS England’s approach to most people who are suffering from long-term conditions is best summed up through its House of Care programme, which is very much based around the individual and their carers and so is personalised. Of course, personal health budgets can have a big role to play for people with long-term, complex, chronic conditions.

Primary Care: Targets

Baroness Walmsley Excerpts

Tuesday 13th October 2015 Lords Chamber

Asked by

[Baroness Walmsley]

To ask Her Majesty’s Government whether they will encourage general practitioners’ practices to employ nurse prescribers, nurse practitioners and pharmacists in order to achieve their seven day target for primary care.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, broadening the skill mix within general practice is an important part of improving access for patients. General practices are including nurse prescribers, nurse practitioners and clinical pharmacists in their multi-disciplinary teams and experience suggests that this results in significant benefits for patients. Earlier this year, NHS England launched a £15 million scheme to fund, recruit and employ clinical pharmacists in GP surgeries.

[Baroness Walmsley (LD)]

I thank the Minister for that reply, but is he aware that the GP shortage is made worse by the fact that a declining number of young doctors want to go into GP practice for various reasons, including pay, working hours and the volume of consultations? At the same time, we have a surplus of excellent young pharmacy graduates looking for jobs who would be very happy to go into clinical general practice. Is it not time for a new initiative to bring these two things together and ensure that doctors get the assistance of all these excellent young graduates?

[Lord Prior of Brampton]

The noble Baroness makes a very good point. There is plenty of evidence to suggest that where general practices employ clinical pharmacists, it relieves GPs of a considerable burden. Interestingly, the NHS Alliance produced a report last week called Making Time In General Practice. It identified that up to one in six patients seen by GPs could in fact be seen by someone from a broader skill mix within general practice, so what the noble Baroness says makes a lot of sense.

NHS: Mental Health Patient Assessment Needs

Baroness Walmsley Excerpts

Monday 12th October 2015 Lords Chamber

[Lord Prior of Brampton]

It is obviously not possible for me to comment on an individual case but it sounds like a very tragic and a very difficult case. Of course, someone in that kind of position ought to have access to normal NHS facilities and care, and I am at a loss to know why my noble friend’s grandson has not been able to get proper access. The fact that a general anaesthetic is required, and has been said to be required by a clinician, should not make it any more difficult to access that kind of care. I am very happy to look at this as an individual case and, if it is not just an individual case but an example of a broader problem, I shall be very happy to meet my noble friend outside the Chamber to pursue the matter with her.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that NHS staff are a very resourceful group of people and that in the past many of them have found ways of helping patients through these scans and so on when they have found them very difficult? What are the Government doing to ensure that these creative responses to patients’ individual needs can be shared with other members of NHS staff? Will the Government consider some kind of restricted-access online resource centre, through which NHS staff can share their good ideas and what they have found to work?

[Lord Prior of Brampton]

My Lords, I think spreading best practice is a perennial problem in the NHS. The noble Baroness gave an example of that but I could give many, many others: we are not good in the NHS at spreading best practice. I hope that the newly reformed combination of the TDA and Monitor into NHS Improvement will be a very useful repository of good practice, in the same way as the IHI is in the USA.

NHS: Financial Performance

Baroness Walmsley Excerpts

Monday 12th October 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, I thank the noble Lord for those helpful comments. His first question was: what is the updated estimate for the full year? There is a general figure out there that the King’s Fund, the Health Foundation and others have come up with—£2.1 billion—as the underlying provider deficit for the year. That figure is largely based on the first quarter’s results because you cannot annualise the first quarter’s results; the first quarter is often much worse than the subsequent three quarters. We believe we can manage that £2.1 billion down quite significantly; interestingly, last year the underlying provider deficit was £1.2 billion. We have other ways of managing that deficit through the surpluses that may arise on the commissioning side and other sources of revenue.

The noble Lord talked about agency staff. I recognise some of what he says but there is no doubt that in the aftermath of the tragedy at Mid Staffordshire, the strengthening of the CQC when I was there has led to greater pressure to increase staffing numbers. I heard the noble Lord say, I think when he was chairman of the Heart of England trust, that if you are going to get shot it is better to get shot for not hitting your financial budgets than for not having enough staff on the wards. There has been a much greater emphasis on higher levels of staffing and that has put pressure on agency staffing. There are actually 8,000 more nurses and 9,000 more doctors in the NHS since 2010.

The noble Lord mentioned the cost of consultants. I recognise the strength of what he says—that it is a bit rich for us to complain about the cost of consultants when, through our arm’s-length bodies, we have been responsible for recruiting them. We expect much of the improvement methodology that has been provided by independent consultants to be provided by NHS Improvement; for example, the fact that we have now taken on Virginia Mason to help us spread best practice in running hospitals in the NHS is a model for things to come. I also hope that chains of hospitals will emerge and develop some of the best practice from hospitals such as Salford Royal, Frimley Park, the Royal Free and others, so that we can spread best practice without relying so heavily on external consultants.

Unfortunately, I have not read the article by Tom Hughes-Hallett. I would say to Tom, who I know, that he might spend more time focusing on his own hospital, which got a “requires improvement” notice from the CQC, than on spreading his views to all and sundry, although I recognise the strength of some of them. Sorry, I am running past my time. I had not realised that time was of the essence.

[Baroness Walmsley (LD)]

My Lords, quite clearly there is a crisis of funding in the NHS on an enormous scale and nothing I have heard from the Government indicates that the problem is going to be solved by any single party. This should be of cross-party concern. During the election, my right honourable friend Norman Lamb asked the Secretary of State for Health if he would co-operate with a cross-party commission to look at a cross-party solution to a new settlement for the NHS. He agreed, as did the Labour spokesman, yet five months later nothing has happened. Can the Minister tell me when it will?

In Scotland health and social care have been integrated and are already showing successes because of that. When will that happen in England? The situation in Scotland illustrates the fact that the challenges to the NHS are never going to be solved by the NHS alone. This is a whole-government issue. When will the Government beef up the Cabinet committee on health so that every department can be held to account for whether its policies contribute to the greater health of the nation or not? Until that is done, the NHS alone cannot be expected to solve the looming problems.

[Lord Prior of Brampton]

My Lords, it is worth reminding your Lordships that there was considerable consensus around the five-year forward view. I think that the noble Baroness’s party wholly signed up to it and, along with the Conservative Party, to committing £8 billion of extra money to the NHS over the lifetime of this Parliament. We stand by that. The NHS, in its turn, agreed to find £22 billion-worth of efficiency savings, which I think the noble Baroness accepted when she was part of the coalition Government. That is still the situation so I do not think that we need a new settlement. There is a settlement: it is called the five-year forward view and we are fully committed to it.

The noble Baroness raised the issue of integration. I agree 100% with her and it is an essential part of the five-year forward view—the vanguards are based on it. I remind noble Lords that the spending in the UK per capita on health is $3,200. In France it is $4,100 and in Germany it is $4,800. The NHS does a remarkable job in delivering world-class healthcare, which is rated by the Commonwealth commission and other independent agencies as among the best in the world, with considerably fewer resources than any other developed system in the world.