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.

Health: Detection Dogs

Baroness Walmsley Excerpts

Thursday 17th September 2015 Lords Chamber

[Lord Prior of Brampton]

Clearly, molecular diagnostics is a growing field and will have a hugely important role to play in diagnosing many cancers. This was certainly a recommendation of the cancer task force led by Harpal Kumar. We are not by any means saying that we should pursue dogs at the expense of molecular diagnostics, just that we should try every opportunity. There seems to be some evidence regarding the number of false positives—for example, the use of dogs to sniff urine is considerably more accurate than more conventional forms of detecting cancer. We would not therefore want to rule out the use of dogs by pursuing solely molecular diagnostics.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that many diabetes patients who would like a dog and feel that they would be helped by one but cannot get one through the NHS are paying for dogs from unlicensed trainers? However, they are of variable quality and may not be as good as properly trained dogs. Will the Minister look into this to see what can be done about it?

[Lord Prior of Brampton]

The decision on whether to supply dogs locally must be left with clinical commissioning groups.

NHS: Clinical Commissioning Groups

Baroness Walmsley Excerpts

Wednesday 16th September 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness raises a very important issue. I think that she is raising issues not about the actual formula but about the speed at which NHS England reached the target levels of the formula. She points to the discrepancy of west London, which is 31% over the formula. I can tell her that NHS England is committed by 2017-18 to bringing all those under the formula by more than 5% up to that level. It will also be encouraged to address the issue of CCGs that are above the formula.

[Baroness Walmsley (LD)]

My Lords, given that the expertise of the CCGs is also very variable, in some areas the commissioning support groups are particularly important. Is the Minister satisfied that both the expertise and the funding of the commissioning support groups is appropriate?

[Lord Prior of Brampton]

The noble Baroness is right that there is considerable variation in the performance of CCGs and, indeed, commissioning support groups. In an effort to address that variation, we are in discussions with the King’s Fund to publish in a very transparent and open way the performance of individual CCGs.

--- Later in debate ---

[Lord Prior of Brampton]

The noble Lord makes an interesting and perceptive point. I have no doubt that if we look at the commissioning landscape in five years’ time there will be a lot more integrated commissioning and that social care and healthcare will be much more joined up.

[Baroness Walmsley]

My Lords, the criteria that the Minister mentioned sound all very well, but they do not take account of existing levels of ill health in the most disadvantaged areas of the country. The criteria he quoted do not take account of the need for catch-up for those populations.

[Lord Prior of Brampton]

The report by the Public Accounts Committee raised the issue of whether deprivation was properly taken into account by the formula used by ACRA, and ACRA has agreed that in its new formulation it will look again at the adjustment it makes to the formula for deprivation.

Health: Children

Baroness Walmsley Excerpts

Thursday 10th September 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, access to health services is not just a rural issue; it relates also to deprivation, be it urban or rural. I would point out to the House the increase in the number of health visitors, which has gone up from 8,000 to nearly 12,000 over the past five years, and also to the Family Nurse Partnership scheme, which now has 16,000 places on it for younger and teenage mothers. So the Government are doing a lot to improve access. I guess they could always do more.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that in some areas fewer than half the five year-olds reach a good level of development? Given how important this is for their health, education and future employment prospects, why have the Government decided that from next year, the collection of early years foundation stage profile data is no longer to be statutory? How are the Government going to monitor how well children are developing across the piece, and how individual nursery settings are doing?

[Lord Prior of Brampton]

I am not sure that I can give that question a full answer. I am aware of the early years programme and I think that it is largely up to schools to monitor the development performance of children when they come into reception classes, which they are doing. I have seen the figures that the noble Baroness refers to—the 40% figure of children who have not reached the right development age by the time they come into reception class. It is a serious issue and I will take her words on board.

Health: Skin Cancer

Baroness Walmsley Excerpts

Wednesday 22nd July 2015 Lords Chamber

[Lord Prior of Brampton]

The NICE guidelines are due to come out at the end of July or in August. I believe that they are guidelines, not mandatory, although they should be read in the context of the report by Harpul Kumar, Achieving World-Class Cancer Outcomes. Cancer is a very high priority for this Government, and this may come out in further questions. In commissioning these services, we have to be very careful that we do not disaggregate dermatology services in hospitals; the provision of routine and complex emergency dermatology services and, of course, the training of dermatologists should be commissioned as a whole.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that consultant dermatologists often see patients who have been told by their GP that their mole was benign and did not require a biopsy? In the UK, the mortality rate is 20% compared with 12% in Australia for a similar number of cases. Given that outcomes are so closely linked to the thickness of the lesion and early diagnosis, what are the Government doing to make sure that GPs are trained to recognise the benign skin lesions and to refer the more dubious ones to consultants? I am aware that we ask a great deal of GPs, but what matters is training them to recognise these things and not wasting money and compromising patients by not referring them early enough.

[Lord Prior of Brampton]

Health Education England is aware that insufficient time is spent on dermatology issues in the training of junior doctors, and it is considering that very seriously.