NHS and Social Care Services: Parity of Esteem
Baroness Wheeler Excerpts(7 years ago)
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Baroness Wheeler
To ask Her Majesty’s Government what action they will take to ensure that their strategy for National Health Service and social care services recognises the importance of parity of esteem, including pay and professional standing, for staff across hospital, community and social care settings.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy)
My Lords, having the right number and quality of clinical and non-clinical staff is essential to realising our ambitions for the NHS, community and social care. Last week we agreed an Agenda for Change multi-year pay and contract deal, while the introduction of the national living wage has boosted pay for the social care workforce. Later this year, we will publish a 10-year integrated health and care workforce strategy informed by our recent consultations.
Baroness Wheeler (Lab)
I thank the Minister for his response. It is right today to pay tribute fully to the work and dedication of staff across the whole of health and social care. But for the future, both the NAO and our own Long-term Sustainability of the NHS Committee strongly criticised the absence of any long-term joint strategy to secure the well-trained and committed workforce that we need for a fully integrated service. The Minister told the House on 18 June that he is considering the implications of the very recent and welcome NHS staff three-year pay increase for the independent care sector. He recognised the need for the latter to be able to compete on a “level playing field”. Does he acknowledge that for the social care sector in particular that means aiming to level-up pay and professional standing between social care and the NHS, and accepting that parity of esteem is one of the key drivers to building integrated services for both patients and service users?
Health: Stroke Survivors
Baroness Wheeler Excerpts(7 years ago)
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Baroness Wheeler (Lab)
My Lords, I too congratulate the noble Lord on securing this debate and on his informative speech. This is a key opportunity to focus on rehabilitation—that is, life after stroke. Like me, he is a strong admirer and supporter of the Stroke Association on stroke research, prevention, treatment, care and support. As usual, I am grateful for its briefing in support of this debate and for the key background documentation from the Lords Library.
I have spoken on a number of occasions about the importance of renewing and updating the 10-year national stroke strategy, which ran out last year. It has taken time but the strong and determined national campaign for this has resulted in the association and others from across the healthcare system now working closely with NHS England on a national plan for stroke.
There is no doubt that, despite the huge progress in the reorganisation of acute stroke care services as a result of the 2007 strategy, post-hospital support, rehabilitation and ongoing long-term community support for stroke survivors is an area that has seen least progress. It is vital that this be a declared ambition of the new plan and given urgent priority. Can the Minister update the House of progress on the national plan and a timeframe for its development and publication?
As we have heard, stroke is the fourth-largest single cause of death in the UK and is the largest cause of long-term disability. It results in over half of all stroke survivors having some form of disability. With major strokes disability is often profound and severe and, in this context, perhaps I may digress slightly and mention haemorrhagic stroke. Some 85% of strokes are ischemic strokes. Only 15% are brain haemorrhages and there is currently no acute treatment for them, despite their being associated with the most serious strokes and the worst patient outcomes. It is a significantly underfunded area of research into prevention, treatment and rehabilitation and I make a special plea for the Minister to look at this issue.
It is relevant to consideration of whole care pathways and long-term support for stroke survivors, especially those with the severe disabilities that result from a brain haemorrhage. It is also relevant to me as my partner is hemiplegic as a result of a major haemorrhage 10 years ago. He benefited from the early days of the FAST campaign and the successful reorganisation of London stroke services, which was referred to by the noble Baroness, Lady Barker. This meant that he received the emergency and stabilising care and treatment in hospital he needed within the four-hour period. Ten years on, I am pleased to say that he has a very good quality of life, lives well and is a part of the community. I single out four key basics that have led to that outcome for him.
The first is a good, reliable package of personal care, including washing and dressing, and a domiciliary agency that, overall, provides a good service with a regular team of care workers who we both know and trust. The second is a strong and active connectivity through the local community centre, with its excellent stroke support group, and other voluntary sector support. The importance of staying in touch in keeping well cannot be overemphasised as the key to rehabilitation. The third is weekly assisted disability exercise support through a local charity, which helps maintain his limited walking ability. It is not physio but movement exercises by trained assistants. Fourthly, he has the home adaptations and the disability aids he needs, such as a profile bed and splints, plus a power wheelchair, which means that he can get out and about locally on his own. I also add to the list his amazing assistance dog, who has made such a huge contribution to his mobility, independence and confidence, and pay tribute to the charity Canine Partners for its work in training such dogs and supporting disabled people in this way.
Of course, many other elements are involved in supported care at home, such as GP and primary care support, but the current support available is under huge pressure, as noble Lords have pointed out. We know that it is medical and reactive rather than proactive and focused on rehabilitation and staying well—on wellness rather than illness, as the Committee on the Long-term Sustainability of the NHS put it.
The noble Lord, Lord Lingfield, cited the Royal College of Physicians national guidance 2016 as the gold standard. It calls for stroke survivors to have,
“at least 45 minutes of each appropriate therapy … for as long as they are willing and capable of participating and showing measurable benefit”.
Hospital patients typically receive only one-third of that: the equivalent of 16 minutes a day of physio, 16 minutes a day of occupational therapy and 12 minutes a day of speech therapy. We know that, in the community, those therapies mostly have to be self-funded or obtained in the private sector.
The NHS RightCare Pathway included in the Library pack cites earlier RCP guidelines on what should be expected of NHS commissioners, which are clear and unequivocal. The guidelines stress:
“Commissioning organisations should ensure that their commissioning portfolio includes the whole stroke pathway from prevention (including neurovascular services) through acute care, early rehabilitation, secondary prevention, early supported discharge, community rehabilitation, systematic follow-up, palliative care and long-term support”.
It is vital that more CCGs and the STPs commission services that meet what is set out in the guidance. I should like the Minister to respond to that.
As all speakers have stressed, stroke is a recoverable condition. Many stroke survivors see improvements physically, communicatively and cognitively for months and years afterwards. The often-repeated adage that I heard when my partner first had a stroke—sadly, from both the public and some professionals—was that stroke improvements will not take place after two years. That is wrong. Improvements can and do happen with the right motivation, support and help along the care pathway.
I ask the Minister some questions on this issue. First, will he comment on the large regional variations in the availability and quality of community services for strokes shown in the latest national stroke audit? Secondly, will he comment on the unacceptably high waiting times for starting speech and language therapy post hospital—two months in some of the worst performing areas? Thirdly, will he comment on the 12-week waiting time for psychological support for stroke survivors across the country—up to five months in some areas, when the target is two weeks? Fourthly, will he comment on the action being taken to deal with CCGs which, despite the strong national guidance, are not commissioning ESD to provide intensive, multidisciplinary stroke-specialised rehabilitation and support for patients, carers and families? Forty per cent of patients should be eligible for this, but do not receive it. These are key questions, and I look forward to the Minister’s response.
It is small wonder that 45% of stroke survivors say that they feel abandoned when they get home from hospital, lacking in confidence, information and support. I can certainly relate to that. Fifty-one year-old Philippa Haslehurst, who had a stroke four years ago, received just two NHS sessions of physiotherapy and occupational therapy before having to pay for private treatment. She said:
“I felt like after a couple of rehabilitation sessions, the NHS had wiped its hands of me. I had made hardly any progress and I was still dealing with the debilitating after-effects of my stroke. If it wasn’t for private physio, I wouldn’t be walking now, let alone be back at work. I believe physio saved me”.
I also ask the Minister about the personalised care plans that stroke survivors are supposed to receive for their ongoing post-hospital treatment, care and support, and the findings of the recent Neurological Alliance survey that over 70% of patients are not offered one. Surely this should go hand in hand with the ESD plans for personal and domiciliary care support and generally to ensure that patients are discharged into a safe environment. Can the Minister also explain what action is being taken to ensure that all CCGs commission the six-month post-hospital review of stroke survivors’ progress and problems? Less than a third of stroke survivors receive this review and only half of all CCGs actually commission it. NHS RightCare guidance includes follow-up annual reviews, which are obviously needed if a patient’s progress is to be monitored effectively.
As the noble Baroness, Lady Barker, said, one of the key issues arising from this debate is the lack of post acute-stroke data in comparison with that for acute care. We need strong and consistent data on the provision of the different types of therapy, treatment and rehabilitation as well as on measurable patient outcomes; its lack is seriously hampering progress in this area. Can the Minister outline what work is being done and will the recommendations in the national stroke plan include ensuring that this key aspect is addressed?
This has been an excellent, thoughtful and wide-ranging debate, despite having few contributors, while we wait for the national stroke plan to be finalised and for the publication of the social care Green Paper, now promised for the autumn. I hope that the Government will recognise that prioritising effective rehabilitation for stroke survivors will achieve significant long-term savings across the health and social care system as well as being of huge benefit to stroke survivors themselves.
Cannabis-based Medicines
Baroness Wheeler Excerpts(7 years ago)
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Lord O’Shaughnessy
I am grateful to the noble Baroness for her question. Like her, I applaud the speed with which the Home Secretary and the Health Secretary have acted in this matter. It is incredibly important to think about the various stages and actions that have been taken. First, there is an urgent need for the panel which Professor Dame Sally Davies is setting to consider specific licence applications. The second part is to review whether there are therapeutic benefits of cannabis and cannabis-derived products. Then there is the evidence-gathering process, and all the relevant evidence, including the major piece of work done by the US National Academy of Sciences and the paper to be published by the WHO, will be collected as part of that. As the Home Secretary set out on Tuesday, it will make recommendations to the Advisory Council on the Misuse of Drugs subsequent to proposals for rescheduling. That will happen this autumn, if those proposals come forward.
If I may just take the time to say this, the noble Baroness raises a third issue, which is long-term horizon scanning for Schedule 1 drugs for which a therapeutic benefit has not yet been demonstrated but which may be demonstrated in future. We clearly need to set up a device to do that, and the MHRA may be the right vehicle. That is something we are considering.
Baroness Wheeler (Lab)
My Lords, can the Minister update the House on the number of cases the expert panel is expected to consider? Assuming they are current cases, can we be reassured that they will be dealt with in a way that avoids the awful situation faced by Alfie Dingley and his parents and ensures they have the best possible medical treatment?
Lord O’Shaughnessy
I completely agree with the noble Baroness about the need for speediness. Frankly, at this point we do not know the number of cases. The Home Secretary said on Tuesday that the service will be up and running and receiving applications within a week of his Statement—so from next Tuesday onwards, with a panel constituted rapidly so that it can start considering them.
Gosport Independent Panel: Publication of Report
Baroness Wheeler Excerpts(7 years ago)
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Baroness Wheeler (Lab)
My Lords, I thank the noble Lord for reading out the Statement. I was able to hear only a little of the media coverage in anticipation of the report this morning, but I heard one of the relatives speaking about what she had been through over the past 20 years. It was heartrending. Our thoughts, sympathies and condolences go out to the families of those 450 patients whose lives were shortened and who have campaigned for so many years to find out what happened.
We also pay tribute to the relatives for their determination, tenacity and persistence, and to the parliamentarians and others who have played their part in helping to get the panel established or supporting the relatives who have lost loved ones. I include in this the organisation, Action against Medical Accidents, which helped the families to get inquests and to press for a full inquiry, as it has done on so many of these very difficult, awful occasions.
I finally place on record our thanks to all who served on the inquiry panel and offer particular thanks for the extraordinary dedication and calm, compassionate, relentless and determined leadership yet again of the former Bishop of Liverpool, James Jones, in uncovering injustice and revealing the truth about a shameful episode in our nation’s recent history. In its own words, the panel finally,
“listened and heard the families’ concerns”.
The four key conclusions of the panel were that there was disregard for human life and a culture of shortening lives of a large number of patients; that there was an institutional regime of prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated or justified; that relatives were constantly let down by those in authority in the hospital when they complained; and that senior management, Hampshire Constabulary, local politicians, the coroners system, the Crown Prosecution Service, the GMC and NMC all failed to act in ways that would have better protected patients and relatives.
As the panel comments, patients’ and relatives’ interests were,
“subordinated to the reputation of the hospital and the professions involved … a large number of patients and their relatives understood that their admission to the hospital was for either rehabilitation or respite … they were, in effect, put on a terminal care pathway”.
The report is a substantial, 400-page document published only this morning and it will take some time for us all fully to absorb each detail. I welcome the Government’s commitment to coming back to the House with a full response as quickly as possible. I also welcome the setting up of a hotline and making available counselling provision to those affected and who have lost loved ones, as well as the Secretary of State’s commitment to meeting the families, with Bishop James continuing to act as a link.
Perhaps I may raise five key issues at this stage. First, can any further action be taken in respect of the 200 additional patients whose clinical notes or medical records were missing and who the panel considered to have been affected in a way similar to that of the 450 patients given opiates without appropriate clinical direction or as a result of the prescribing and administering opioids that became the norm at the hospital?
Secondly, on GMC and NMC failures in this matter, does the Minister accept that this underlines the urgent need for legislation to streamline their professional regulatory procedures and responses? In this instance, despite GMC disciplinary action against the doctor involved resulting in her being found guilty of serious professional misconduct, it did not have the authority to overturn the decision of its disciplinary panel not to strike the doctor off the register. I understand that a White Paper on regulatory matters issued by the GMC this week emphasises that, as matters stand, the GMC is operating under a legislative framework that is 35 years old and simply not fit for purpose. A Bill has been sought by this and the other professional bodies and promised by the Government, but we still have had no sight of it. Is it not now vital that such legislation is forthcoming?
Thirdly, on the key question of patient safety, in light of this inquiry, what changes have been made, or will be made, to the oversight of how medicines, particularly opiates, are dispensed in our hospitals? Is the Minister satisfied that oversight of medicines in the NHS is now tight enough to prevent incidents like this happening again? What are the wider lessons for patient safety and the need to build the safety culture in the NHS, and is additional legislation required to keep patients safe? Do the Government now regret the abolition of the patient safety agency? Do they consider that a new independent body is urgently required to pick up and take forward the PSA remit, and will the Minister promise to review this issue? Is there a need for the scope of the draft patient safety investigations Bill to be widened to reflect the learning from these tragic events?
Fourthly, there is the issue of how a proper inquiry in such appalling situations is actually started when there are ongoing police investigations and coroners’ inquests to be held. Delay is built into the system from the outset. It is a key issue that we need to find a way through.
Finally, we have all welcomed the learning from deaths programme set up to build organisational learning on the sorts of failures that we are discussing today. How will the programme assist in helping learn the lessons in this report?
We will rightly acknowledge 70 years of the NHS and the great efforts of our NHS workers every day. On this occasion, however, the system has let so many down and we must all ask why.
Baroness Jolly (LD)
My Lords, I shall crave the indulgence of the House for a moment while I read out the first two points in the summary and conclusions of the report:
“In waiting patiently for the Panel’s Report, the families of those who died at Gosport War Memorial Hospital … will be asking: ‘Have you listened and heard our concerns, and has the validity of those concerns been demonstrated?’ … It is over 27 years since nurses at the hospital first voiced their concerns. It is at least 20 years since the families sought answers through proper investigation. In that time, the families have pleaded that ‘the truth must now come out’. They have witnessed from the outside many investigative processes. Some they have come to regard as ‘farce’ or ‘cover-up’. Sometimes they have discovered that experts who had found reason for concern had been ignored or disparaged. Sometimes long-awaited reports were not published”.
I commend my right honourable friend Norman Lamb for having a quiet word with the Secretary of State to ensure that this was moved forward.
This report makes for shocking reading. It hangs on a confusion of responsibilities between two organisations, the NHS and the police force, and there is a multitude of questions to be answered. I shall put only two questions to the Minister and hinge them on two points in the report. The first is paragraph 12.62. Health bodies felt prevented from taking action because police investigations were under way. The report points out:
“All concerned assumed not only that the police investigations took priority, but that they prevented any other investigations from proceeding”.
There is clearly a need to clarify lines of responsibility between the police and the NHS regulatory bodies when there are allegations of wrongdoing and systematic failings of this kind so that organisations simply do not pass the buck. Can the Minister assure me that this work will start?
Secondly, how will the Government take forward the call for action in paragraph 12.60? I welcome the Minister’s commitment to an independent inquiry in future in such circumstances to be carried out by the police force, but the report states that,
“the evidence … suggests that, faced with concerns amounting to allegations of unlawful killing in a hospital setting, there are clear difficulties for police investigation. It is not clear to the Panel how the police can best take forward such investigations, and how they are to know whose advice to seek from within the health service without compromising their enquiries. This is … significant if the problem concerns the practice on a ward where more than one member of a clinical team is involved. It is a need that calls for action across different authorities, rather than a matter for the police service in isolation”.
We cannot guarantee that something similar to this could not happen elsewhere—please God that it does not—but what action will be taken to ensure that there is not such a muddle and confusion in a resolution? What processes are either in place or being put in place within NHS settings and with police forces to make sure that this does not happen again?
Branded Health Service Medicines (Costs) Regulations 2018
Baroness Wheeler Excerpts(7 years ago)
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Baroness Jolly (LD)
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this slightly interesting regret Motion.
It is clear that the issue at stake is the appropriate treatment of hypothyroidism. We have to trust clinicians to prescribe based on what they consider is best for their patients, as the noble Lord, Lord Turnberg, said. I have done an awful lot of reading about this over the last few days, and, although it depends on which article you read, it seems that a significant number of women have this condition: one figure I was given was 10%. In fact, for the last 25 years I have been diagnosed as hypothyroid. I take T4— levothyroxine—which is cheap as chips and costs the NHS about £1.30 every month. But of course, not everybody responds to that, and the alternative is the very much more expensive T3. Some 10% to 20% of patients diagnosed with hypothyroidism come into this category. It is therefore important that the patient receives the right drug. We have heard completely unacceptable tales of patients, as a result of decisions made by clinical commissioning groups, surfing the internet to see what they can get. I did exactly the same last night—having a look to see what I could get—and, again, the T3 was ridiculously expensive, whereas T4 was hardly worth buying online as you could get it very much more cheaply.
What is to be done about this? I was going to explain what it is like when you develop hypothyroidism, before you are diagnosed, and so I thank the noble Lord, Lord Borwick, because his description was lovely: “pathetic, befuddled and exhausted”. I went to see a doctor because my brain was in a fog. I explained it to him and he said, “What do you expect? You work full time and you have two toddlers”. So I was sent away. Curiously enough, at a family event—a lot of my family are doctors or nurses—my mother-in-law asked me, “How long have you had a thyroid problem?” and I said, “I didn’t know I had a thyroid problem”. I went to see my GP, who said, “No, you haven’t got a thyroid problem at all. Who said you had one? Gosh—what does a paediatrician know about it?” Eventually, I had to leave my practice and go to another one to get a diagnosis. I am sure that that is not normal, but it was quite an interesting experience for me. Since then, I have been as fit as a flea. The medication works like a magic charm; very quickly you feel normal and well again. So I cannot overstate to Members of your Lordships’ House how important that prescription was.
I emphasise to the Minister what other noble Lords have said today. We must use the purchasing power of the NHS to drive down the costs of T3 in order to make the argument go away. That might be done by effective negotiation, as the noble Lord, Lord Lucas, said, or in another way, but it is completely scandalous that patients have to buy their own drugs online, and CCGs should therefore review or rework their guidelines as a matter of urgency. Drug companies must not hold the NHS to ransom over the cost of medication that will make patients feel absolutely well again.
On the issue of the costs of medication, one of the non-medical side-effects of having a diagnosis of hypothyroidism was that any other drug I had became free. It is on a list of conditions which, if you have them, mean that any other medication you need becomes free. At that time I was in my early 30s and working. It was very nice to have free prescriptions; I tried to pay for them but they would not let me. However, it means that for the NHS, an awful lot of money is spent inappropriately. Can the Minister give an indication of whether the department has any indication of how much this costs the NHS? I am happy for the NHS to pay for my levothyroxine, but it should not have paid for all other medication I was in receipt of—although, now that I am old, it comes free anyway. How sustainable is this in the current climate, and when was the principle last reviewed?
My takeaway issue for all this is that, whatever happens, we should ensure that the cost of T3 is driven down. However, I would also like the Minister to take this other issue away and—not as a matter of huge urgency—come back to me with some answers.
Baroness Wheeler (Lab)
My Lords, I thank my noble friend for tabling this Motion and for his excellent speech setting out the concerns we all share about NHS patients getting access to the drugs they need and how a number of CCGs are in effect placing a ban on expensive branded medicines—in this case ignoring NHS England’s advice concerning T3 in the treatment of hypothyroidism. I look forward to the Minister’s response to the key questions put forward by noble Lords on this issue.
The Motion has the full support from these Benches. I also commend the work of the British Thyroid Association and Thyroid UK in highlighting this issue, and the very helpful information on their websites, as well as the expert explanation from my noble friend Lord Turnberg on hypothyroidism. The websites include case studies of patient voices which clearly show the impact and suffering of patients who are either denied T3 or who are taken off it because of a decision made by their CCG. It is especially upsetting when patients who have successfully taken the drug for a number of years suddenly have to go back on to a drug, mainly T4, which they already know does not provide them with the treatment they need or will make them ill again. The case studies refer to both the T4 drug and the natural desiccated thyroid—NDT—drug, which I understand is the treatment given before T4 came on to the market but which is not now available in the NHS as it has to go through the Food and Drug Administration process, and it is not known when the branded NDT products will be licensed.
My noble friend and other speakers described their concerns over current CCG decisions that go against NICE guidelines and the advice of NHS England, and the increasing rationing of key services, so I will not repeat them and will await the Minister’s response. The NHS England recommendation and guidance on T3 needs to be clear and unambiguous. I hope that the Minister will acknowledge the confusion and concerns, and will ensure that NHS England informs CCGs that they must both comply with their guidance and amend it to end the scope for CCG misinterpretation. I hope that he will also acknowledge that access to T3 on the NHS is a matter of urgency for many patients and that he will give serious consideration to the call from Thyroid UK and ITT for the procurement of T3 from outside the UK for NHS prescriptions until its UK cost comes down.
On the regulations, I note paragraph 4.7 of the Explanatory Memorandum, which deals with provisions of the Health Service Medical Supplies (Costs) Act 2017 that have been included. This includes the promise of the annual review of the operation and objectives of the statutory scheme which is to be published and put before Parliament. Can the Minister tell the House what the current thinking is in terms of the review process and timing, and say when he would expect the first review to be completed?
The impact assessment also states that the implementation of these regulations will generate a saving of £33 million to the NHS between April 2018 and March 2019. The Department of Health and Social Care says that this will enable the provision of additional treatments and services estimated to provide NHS patients with an additional 2,213 quality-adjusted life years, valued at £133 million. Can the Minister explain to the House exactly how the Government have calculated the savings, and can he give more details of how this money is to be spent in the NHS?
The Explanatory Memorandum also says that the regulations set out other instances when the Secretary of State can give a direction specifying the maximum price of drugs—for example, when there are supply issues with respect to a particular branded health service medicine and the Secretary of State is satisfied that a new temporary minimum price needs to be provided to help resolve the supply issue. Can the Minister explain to the House how the Secretary of State is to decide on the temporary minimum price?
Finally, in respect of the provisions in the regulations for manufacturers and suppliers to pay 7.8% of their net sales income to the Government, the impact assessment provides for those in the PPRS with annual NHS sales above £5 million to make percentage payments based on the difference between allowed percentage and actual percentage growth in NHS expenditure on branded medicines. Can the Minister provide more clarity on how this 7.8% figure has been reached?
Carers: Back Pay Liability
Baroness Wheeler Excerpts(7 years, 1 month ago)
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Lord O'Shaughnessy
I thank my noble friend for raising the issue, which we are looking into. The point here is that the change in policy has come about because of decisions made by employment tribunals and a clarification of the law, and the job of government is therefore to help providers to comply with the law. That is how the scheme has come about, and why extra support is being looked into. We are working closely with providers to try to understand the scale of the liability and how it affects organisations differently—we think that up to two-thirds are affected. We will also make sure that any intervention that might follow—I stress “might”—is proportionate, fair and legal.
Baroness Wheeler (Lab)
My Lords, Jeremy Hunt told MPs last week that a lot of work was going on in government on this issue to,
“understand the fragility of the current market situation”.—[Official Report, Commons, 8/5/18; col. 520.]
However, we already know that the viability of nearly 70% of the disability care sector is threatened by the sleep-in pay crisis, as last week’s survey by disability charities shows. Homes will have to be sold or more local authority contracts handed back. Is this not enough evidence of the desperate state the care sector is in and why the extra funding is needed from the Government to ensure that already low-paid staff are treated fairly and receive the money they are owed?
Lord O'Shaughnessy
The noble Baroness makes an important point about the attention my right honourable friend the Secretary of State is giving this. We are taking this issue seriously, and she is quite right about the number of organisations that are affected. As I said, a scheme already exists which allows providers to defer any payments, and we are investigating whether any further interventions are necessary during that period when they can defer them.
The Long-term Sustainability of the NHS and Adult Social Care
Baroness Wheeler Excerpts(7 years, 2 months ago)
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Baroness Wheeler (Lab)
My Lords, I, too, congratulate the noble Lord and his committee on this excellent report. The debates on the long-term future of the NHS and social care at this time, as we approach the 70th anniversary of the NHS, are invaluable, particularly as recognition of the need for long-term funding solutions is under the spotlight more than ever before. We also have the very welcome recent evidence from last year’s social attitudes survey that shows that the majority of voters now back a tax rise to fund the NHS. The Government’s response to the committee’s report, a year after its publication, has been described as anodyne, pedestrian and underwhelming—and those are the kind descriptions. In truth, it contained very little that could not have been said three months after the report was published. The Minister has been very apologetic on many occasions about the delay, so perhaps we might be rewarded today with an actual explanation as to why it took so long to say so little.
Noble Lords have spoken on the key funding, structural and workforce issues arising from the report. I want to speak about these in the context of the future of stroke services. I know that the noble Lord, Lord Patel, will welcome this, as it is an issue close to his heart, and I commend the key role that he has played in this House in support of improved stroke care.
Stroke is the fourth-largest single cause of death in the UK. It occurs approximately 152,000 times a year in the UK, there are over 1.2 million stroke survivors, and it is the largest cause of disability. Over half of all stroke survivors have some form of disability. Every year, 80,000 people in England are admitted to hospital after having had a stroke. Stroke costs the health and social care system over £8 billion a year, but research by the Stroke Association shows that when informal care and lost productivity are factored in, this spirals to £26 billion. Without action, this is expected to at least double or triple by 2035. Indeed, the quality of stroke prevention and care in England is a strong barometer of how our health and care system is working, as it is both a medical emergency and a long-term condition. As the committee’s report underlines, reorganising and centralising stroke services reduces disability and can save lives.
The 10-year National Stroke Strategy, brought in by the Labour Government in 2007, has led to major improvements in stroke prevention, treatment and outcomes. But progress has stalled as a result of funding cuts, CCGs not giving stroke reconfiguration the priority or support it needs, which results in huge variations in services across areas, and little attention being given to the whole stroke care pathway—and because of the Government’s mistaken refusal to update the strategy forward into 2018 and beyond. However, the news that NHS England, along with the Stroke Association and others from across the health and social care system, are now working in partnership to develop a new national plan for stroke in England, is welcome. It is essential that this plan is prioritised and effectively implemented to provide the leadership and direction needed to achieve better treatment, care and outcomes for those affected by stroke. Can the Minister update the House on progress on the national plan and on the timeframe for its development and publication?
While reconfiguration of services is planned or under way in many areas across the UK, progress is slow and patchy, with huge challenges in persuading local commissioners to prioritise these services, and persuading communities and patients that reorganisation works. In reality, much of the change is still small scale and limited in scope, such as shutting one unit and diverting ambulances to hospitals with better stroke facilities and staffing. Although 32 STPs have used the opportunity to review acute stroke services, most of these reviews have yet to be actioned and only four consider the whole stroke pathway. The committee’s report makes it clear that the jury is still out on the current effectiveness of STPs, and this is certainly true of their likely impact on stroke reconfiguration and services. As both ADASS and the Local Government Association have pointed out, STPs’ main focus is on NHS transformation, not on social care. The LGA sums it up, saying that,
“there has been little meaningful consideration of adult social care as a vital component of a resilient and sustainable health and care system”.
Can the Minister say how this is being addressed as STPs are taken forward?
Sadly, for stroke survivors the care pathway is the area that has seen least progress in recent times. For comprehensive post-acute stroke care, such a pathway means early supported discharge, long-term neurological rehabilitation, vocational rehabilitation, exercise programmes, vascular risk reduction advice and support, and long-term follow-up and intervention for patients whose functional ability deteriorates. Nearly half of all stroke survivors who responded to the Stroke Association’s recent survey say they felt “abandoned” after leaving hospital and lack confidence and information about how to navigate the post-acute pathway; two-thirds did not receive the vital six-month review of their care needs. Forty per cent of stroke patients are eligible for early supported discharge, which reduces the length of hospital stays and provides intensive multidisciplinary stroke-specific rehabilitation at home. But two out of 10 hospitals in England, Wales and Northern Ireland do not offer ESD, and it is not being commissioned by many CCGs despite national guidance. There are long waiting times in most areas for key post-stroke psychological and emotional support; on speech and communication, the average wait to start speech and language therapy is 22 days, varying from 8.5 days to two months between the best and worst-performing areas. These are precious lost days that can have a lifetime impact on the ability to communicate after a stroke.
On carer and family support, shockingly, one in three areas in England, Wales and Northern Ireland does not provide support for carers and families of stroke survivors. As a carer of my partner who is a stroke survivor of 10 years, I cannot stress enough how important being part of the local stroke community is to the well-being of stroke survivors, particularly those with severe disabilities.
In my area, we are lucky to have a stroke group just down the road, run and funded by the Stroke Association. We also have an amazing local charity called TALK, which provides support with speech, memory and communication difficulties. It is run by volunteers but against increasing odds. It was recently given one month’s notice by the CCG that its small grant is to be stopped this month. When we talk about NHS and social care sustainability, surely these are exactly the sorts of services where local authorities need increased national funding so that they are able to provide support.
Many of your Lordships know that I always have lots to say about stroke but in the time left I shall make just a couple of points. I really welcome the committee’s frank assessment and criticism of the current absence of coherent health and social care workforce planning. I hope that the Minister will today acknowledge this, look at the problems that are occurring and commit to a long-term workforce plan covering both health and social care. There are lots of examples of staff shortages in stroke services which I do not have time to go into. Again, I support what noble Lords have said about the need for increased social care funding.
Thirdly, straying a bit from the committee’s report, the excellent “Children get dementia too” adverts on the Tube have prompted me to remind the House that children get strokes too, because the debates in this House have led to some progress being made. Childhood strokes affect around five out of every 100,000 children a year in the UK. People do not think that children have strokes, but they do, as the families of children who have had major strokes in the womb before birth or later in their teenage years know all too well. Awareness raising, more support for carers and families caring for children who have had a stroke, and much more research into childhood stroke, are needed.
Finally, I join other noble Lords in giving wholehearted support to the committee’s recommendations on prevention and public health, and the need to move from an “illness” to a “wellness” service. For stroke, this is very important, and there is a need for better screening and diagnosis of atrial fibrillation.
In summary, stroke embodies the challenges of planning for population health and delivering integrated, accountable care, and it requires the joined-up health, social and voluntary sector support called for throughout the committee’s report. I look forward to the Minister’s response.
Domiciliary Home Care Support
Baroness Wheeler Excerpts(7 years, 2 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what action they are taking to ensure the provision of domiciliary home care support, in the light of the decision by Allied Healthcare to file for a company voluntary arrangement.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)
My Lords, the law is clear that, if services may be disrupted due to business failure, the Care Quality Commission will notify local authorities so that they can put appropriate contingency plans in place. In respect of Allied Healthcare, no such notification has been made to date. The public should be reassured that the Care Quality Commission has been monitoring closely the situation at Allied Healthcare and will continue to do so.
Baroness Wheeler (Lab)
My Lords, Allied Healthcare is the latest hedge-fund-owned care provider to have to take drastic action to keep up the huge burden of paying off loans to its creditors. The precarious finances of many domiciliary care companies has already led to large-scale provider closures and to companies handing back contracts in almost half of councils, and we know that residential care is in a similar position. The CVA means that Allied Healthcare has four weeks to come to an arrangement with its creditors. Its closure would have serious consequences for continuity of care and the safety of its 13,500 clients, including many vulnerable older people and people with learning difficulties, and for its 8,700 staff. With local authorities unable to pay fees that cover the actual cost of care or meet the implementation costs of the national minimum wage, let alone address the potential £400 million of deserved back-pay costs for staff sleep-in payments, what reassurances can the Minister give that councils will be able to discharge their statutory duty to deliver care if Allied Healthcare collapses? Does he really think that this is the way to fund the care that people in need of support in their homes deserve?
Lord O'Shaughnessy
I thank the noble Baroness for the opportunity to provide that reassurance for people using and benefiting from the care provided by Allied Healthcare. I want to reassure them that the Care Act 2014, passed by the coalition Government, gives local authorities responsibility for continuity of care if a business were to fail. Of course, we are not in that position with Allied Healthcare, because it still has to go through the CVA process. I can reassure people that the LGA has said that councils have “robust”—its word—plans in place to ensure continuity of care if that is required. I put that on record for those who may be worried about it.
We know that extra funding is needed in the sector. Over three years, through a number of means including extra money through the precept and direct funding to local authorities, the Government have increased by about £9 billion the funding available for social care, which we know is required. I also point out that, if you look at domiciliary care provider numbers, you will see that there are 50% more than there were eight years ago. We know that markets have entrants and that providers are exiting, but we have more providers in the market and more packages being delivered than ever before. Ultimately, the backstop is that local authorities have that responsibility to provide continuity of care.
Health: Online Services
Baroness Wheeler Excerpts(7 years, 2 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what action they are taking in response to the Care Quality Commission’s report, The state of care in independent online primary health services, published on 23 March.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)
My Lords, the online provision of primary care is a development with the potential to improve patient outcomes. However, it is important that these services are regulated and inspected properly. The CQC will continue to hold online providers to account while sharing good practice. Following its report, we are considering what further action is needed to ensure that the right balance is struck between the provision of safe, effective care and encouraging further innovation.
Baroness Wheeler (Lab)
I thank the Minister for his response. We are strongly in favour of technologies and innovations that help to provide the widest possible access to primary health services, particularly when getting a timely GP appointment is so difficult for thousands of patients. The CQC inspection role is crucial but there is no disguising the serious issues to be addressed and resolved. These include checking patients’ identity, sharing information with the NHS GP and the safe prescribing of medicines. Some 43% of companies are failing to meet regulations for keeping patients safe and there are particular concerns about inappropriate prescribing of antibiotics and medicines and about managing long-term conditions. How will the Government ensure that the lessons from the first phase of the CQC inspection are learned, and will they pledge to take swift action on the problems now before the service is further rolled out?
Lord O'Shaughnessy
I thank the noble Baroness for raising this important issue. She is right that the CQC report identified some serious issues among this group of online providers, which of course operate in the independent sector. She mentioned safety and safeguarding, and I would add to that. It is worth saying that there were some positive responses, in terms of 97% of the providers being caring and 90% of them responsive, so some strengths were identified as well as weaknesses. Obviously the CQC retains the ability to take regulatory action. As it sets out in the report, it has done so to ensure that standards improve, and in general they improve from one inspection to the next. However, this is of course the independent sector. We are looking at the lessons for the provision of NHS services. The biggest one of those that comes out of the report is around data sharing: to ensure a clear flow of data between an online provider and a GP, if they are different, so that any problems can be spotted early on. That is particularly important for safety.
HPV Vaccinations
Baroness Wheeler Excerpts(7 years, 3 months ago)
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Lord O'Shaughnessy
My noble friend makes an important point, that vaccinations against the HPV virus brings wider health benefits beyond defending against cervical cancers. It is important to state that it is not my judgment that matters here but that of our expert group, and in its interim advice it did not recommend an extension of the HPV programme to boys as being cost effective, not least because of the high levels of immunity and uptake among girls, with the indirect benefit that that has. But that was its interim advice; the final advice is being considered at the moment, and I can tell the House that that advice and the underlying assumptions on cost benefit will be published when the decision is made.
Baroness Wheeler (Lab)
My Lords, last year’s interim statement referred to by the Minister mentions referring the issue of equality of access to the HPV vaccine to the Department of Health for consideration. Has that referral been made? Given that the clinical benefits of gender neutrality have been so widely advocated by top medics over a very long period, is the department treating this with urgency? When is a response expected, and has any legal advice been taken on whether the current situation of only directly protecting girls and gay men constitutes discrimination by gender or sexual orientation?
Lord O'Shaughnessy
The noble Baroness is quite right that equality is an issue, and an equality analysis will take place. That can be completed only once we have the final advice from the joint committee. I can also promise her that we will publish that analysis, so that will be able to be scrutinised. As for legal advice, it is subject to threats of judicial review at the moment, so I cannot go any further than that, but I can promise that equality considerations are very high on the list of the issues that we are dealing with.