Medical Innovation Bill [HL]
Baroness Wheeler Excerpts(10 years, 3 months ago)
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Lord Mackay of Clashfern (Con)
My Lords, I had not intended to take much part this morning but, my name having been mentioned, I am stimulated to respond. The Bill is about innovation. Therefore, if a doctor is attacked for some failure in respect of innovation, the ordinary rules of defence that are presently available do not seem appropriate. Our colleagues who are excellent innovators have managed to avoid the necessity for litigation as a result of their innovations. However, if by any chance any of them were challenged, how would they go about their defence?
I make this basic point in answer to my colleague the noble Lord, Lord Pannick. He quoted what I said at Second Reading. It will not surprise your Lordships if I happen to hold still to what I said then. The point is that when there is an innovation, there is not much material on which to judge whether it is reasonable or proportionate. If there were in the existing practice, it would not be an innovation. The problem is therefore that the ordinary formulations of reasonable and proportionate with which lawyers are very familiar—I am enough of a lawyer to be familiar with them—are not really appropriate. I believe that the test which my noble friend Lord Saatchi’s Bill originally had, and which is preserved among all the innovations that have taken place since, is in Clause 1(4)(a):
“Nothing in this section … permits a doctor to administer treatment for the purposes of research or for any purpose other than the best interests of the patient”.
That is a simple test which the doctor must face at the time of innovation and, so far as I am concerned, elaboration with the familiar legal phrases that are very dear to lawyers is a mistake. I therefore adhere to what I said at Second Reading.
I should perhaps say that I am not entirely without experience in this area for when I was in practice in Scotland, which is now a long time ago, I did quite a lot of work in the Medical and Dental Defence Union of Scotland area. My very first appearance as a counsel in this House was in respect of a doctor’s negligence. My experience was over quite a long period; it may not have been very good but it was certainly extensive. I very much support the Bill and hope that we need not get around to voting on it today. There is plenty of scope for discussion about these matters and a good deal of substance in many of the amendments. We should discuss them further and, if necessary, have votes on Report.
Baroness Wheeler (Lab)
My Lords, on behalf of these Benches I welcome the commencement of the Committee stage of the Bill. At Second Reading we underlined the necessity for close scrutiny by this House, and we are pleased that the opportunity has been presented to us. In that debate there was both strong support for and strong reservations about the Bill, with many questions and issues to be addressed. We have moved on since then, but despite acknowledged progress made on safeguards for staff and patients contained in the amendments from the noble Lord, Lord Saatchi, there remain crucial reservations and concerns from key parts of the medical profession and from patients’ organisations, as we continue to discuss today.
We commend the work that the noble Lord has undertaken on the Bill, and feel that the changes on patient and staff safety signify improvements to it. It is reassuring that his proposed amendments have the backing of Sir Bruce Keogh, the NHS medical director, and the Government, and that the common-law Bolam test would remain unaffected by the Bill. The noble Lord, Lord Saatchi, knows that there is strong support for the principles and the intent of what he is trying to achieve. Labour has always strongly supported efforts to put innovation at the heart of the NHS and to bring innovative treatments to patients faster.
After Second Reading, the Minister for Health, Dr Daniel Poulter, responding to a Parliamentary Question in the Commons from Labour on the progress of the Bill, acknowledged the Government’s support for the principles of the Bill but emphasised that the amendments were necessary,
“to ensure it does not: put patients at risk; deter good and responsible innovation; place an undue bureaucratic burden on the National Health Service; or expose doctors to a risk of additional liabilities”.
These four key tests are what we should keep firmly in focus today, and I hope that the noble Lord, Lord Saatchi, and the Minister will address whether they consider that the tests have been met in the revised Bill in their responses to the issues that have been raised today.
I will limit myself to speaking on just some amendments in this group. Like other noble Lords, I look forward to hearing from the noble Lord, Lord Saatchi, and the Minister on the key issues raised by the many experts in this field who have spoken today. On patient safety, as I have stressed, we welcome the efforts made by the noble Lord, Lord Saatchi, in his amendments to address widespread concerns that the overall Bill would encourage reckless rather than responsible innovation and put patients at risk. We support the new emphasis on reasonable and responsible innovation contained in amendments in the next group, as well as the reference in Amendment 10 in this group from the noble Lord, Lord Pannick, and my noble friends Lord Turnberg and Lord Winston, to the doctor needing to act in a manner that is both reasonable and proportionate. The new provisions in Amendments 8 and 9 are important because we recognise that they are designed to provide that a doctor’s departure from the existing range of accepted medical treatment for a condition is not negligent where the decision to depart is taken responsibly.
We also welcome the deletion of the references in the previous Bill to the doctor’s responsible officer and appropriately qualified colleagues in respect of the staff to be consulted about the proposed treatment. These caused much confusion among both supporters and people with concerns about the Bill, and the new reference in Amendment 16 to the need to obtain the views of one or more appropriately qualified doctors in relation to the proposed treatment is clearer—although it is a critical area that will also need to be developed under guidelines, codes and/or regulations. It needs to be clear who is an appropriate qualified doctor. The new definition of a doctor being,
“appropriately qualified if he or she has appropriate expertise and experience in dealing with patients with the condition in question”,
is also an improvement to the Bill, although the question of the independence of the doctor whose opinion is being sought is a critical one.
My noble friend Lord Turnberg addressed this earlier with much force under Amendment 7. Key stakeholders have stressed that requiring the doctor to have regard to the opinions of other professionals responsible for patients’ care, together with the requirement for written consent to be sought from at least one other doctor who is independent of the responsible doctor, would be a welcome step in providing more clarity to the process.
There is an extremely worrying potential for conflict of interest here—for example, in the supporting doctor’s involvement in the development of the drug or treatment in question—and clear guidelines and rules of engagement will be essential. Sir Robert Francis QC points to the problem that arises from the choice of the appropriate qualified doctor to consult resting entirely with the doctor wanting to offer a new treatment. He or she is free to choose someone in his own partnership or laboratory, or someone with a commercial interest in promoting or selling the treatment. It is less than clear who is the final judge of whether the individual is appropriately qualified. There is also concern among a number of stakeholder groups that pharmaceutical companies could put undue pressure on doctors to try out potentially dangerous treatments, and this concern will also need to be addressed.
Concerns remain that the involvement and consent of patients to untested innovative treatments are not more explicitly in the Bill. Amendment 14 from the noble Baroness, Lady Masham, addresses this issue by specifying the need to obtain informed consent in light of the aims, processes and risks. I look forward to hearing further from the noble Lord, Lord Saatchi, on how he considers the Bill can address this, as this point has been raised by a number of noble Lords in the debate.
Baroness Masham of Ilton
My Lords, I support what the noble Lord, Lord Blencathra, has said. The use of drugs seems much more flexible in the private sector than in the National Health Service. I ask the Minister to look very closely at the funding of these drugs if they are to be accepted in the Bill.
Baroness Wheeler
My Lords, I am pleased that Amendment 28 has been grouped with the amendment of my noble friend Lord Winston and the noble Lord, Lord Pannick, as we have considerable sympathy with their attempts to define innovation. I understand that it is a probing amendment. We consider that the Bill would benefit from a clearer understanding of what we mean by innovation and indeed of some of the exclusions that would apply that were referenced in the earlier comments on Amendment 19. I am grateful to my noble friend Lord Giddens. His perspective on that was helpful. I look forward to the response on that.
Amendment 28 is also a probing amendment and underlines that medical innovation and the adoption of new treatments require the whole NHS to make both research and innovation its business. The Secretary of State, the NHS regulators and all the key NHS bodies have a clear responsibility and the authority that they need; they need to use it. We have had many debates in this House that recognise the scale and pace of innovation taking place across the NHS and the frustrating barriers that prevent innovative treatments being adopted.
The noble Lord, Lord Saatchi, considers that doctors’ fear of medical litigation or disciplinary proceedings is a key factor that,
“reinforces a culture of fear and defensive medicine in the NHS”.
Whether medical litigation evidence supports that or not, we need to keep emphasising that it is just one of a number of barriers that have to be overcome. I know that the noble Lord recognises this as the context for his Bill. As Sir Robert Francis QC puts it:
“The real obstacles to responsible innovation are not to be found in the Bolam test but in the minefield of regulation and bureaucratic inertia which doctors presumably have to surmount, not to mention the reluctance to fund innovative treatment”.
The contribution of the noble Lord, Lord Blencathra, underlines that we are far too slow in this country to introduce new treatments.
The Health Research Authority is still yet to make a real impact on speeding up the painfully slow, complex and bureaucratic process of getting innovation in care and treatment adopted in the NHS. There is huge frustration across the NHS that existing pathways and mechanisms are not being fully used, such as the single portal of entry and single application procedures for clinical trials. NHS trusts’ slow implementation of the UK life sciences strategy, Innovation, Health and Wealth, and the very low level of awareness and action that they have taken on that strategy are continuing causes for concern.
Most important too is the role of Health Education England in ensuring that innovation and research are incorporated into the education and training of key medical and other health staff. The excellent vision report from the Association of Medical Research Charities, which my noble friend Lord Turnberg takes every opportunity to raise and endorse, showed the huge challenges we face in building support among doctors and patients for participating in research that leads to innovation.
As research and innovation go hand in hand, we were keen to include reference to research and innovation in our amendment, but I hear what has been said by the noble Lord, Lord Saatchi, and the Minister on this. I note that the Medical Defence Union, while now supporting the changes the noble Lord, Lord Saatchi, has made to the Bill, also makes the point about the importance of research being included because that is where most innovation takes place. It is concerned on this issue because it feels that many doctors are likely to be uncertain about whether the Bill would apply to innovation they are contemplating. This may hold up a proposed treatment or procedure while they check the position. In most cases, the Bill will not apply. Even where innovation arises out of a research project, doctors are likely to want to ensure that information gathered in treating the patient contributes to overall research in that area, and the MDU is concerned that the wording of the Bill may prevent that. I would be grateful for comments on this point from either the noble Lord, Lord Saatchi, or the Minister.
Our amendment seeks to place the Bill in the context of the duty of the Secretary of State and the key bodies of the NHS to support responsible innovation in medical treatment and makes it clear that that is the overall purpose of the Bill. I would welcome a response from the noble Lord, Lord Saatchi, on whether, despite his desire to keep the Bill short, he considers that a clear definition of the core concept of innovation, as the noble Lord, Lord Pannick, said, could be incorporated into the Bill as a reference to its overarching purpose. I would also appreciate the Minister’s comments on this.
Baroness O'Neill of Bengarve
My Lords, before the noble Earl responds, I would like to know whether other noble Lords think that this attempted definition of “innovation” does not perhaps inadvertently classify some entirely traditional medical treatments as innovations simply because they have been around for much longer than randomised clinical trials with equivalent clinical validation, and there will be no published evidence of their risks and benefits in peer-reviewed medical journals. I have in mind such homely treatments as prescribing the drinking of a lot of water, taking the waters or dietary advice. Many such things seem to be medical treatments but have probably not been documented in the journals.
Lord Kirkwood of Kirkhope
Perhaps I may expand on the point I made on the first group of amendments. I am grateful for the comment from the Minister, which I understood as far as it went. I agree with what the noble Lord, Lord Turnberg, has just said. This changes how the regulator approaches a complaint, as far as I can see. It would not change the way that the regulator decides whether there is a case to answer but it seems that this clause—which I think I welcome—gives the doctor an option of which defence he uses against the allegations in front of him.
As I know from previous experience, the General Medical Council has very clear, long-established systems for determining how complaints are lodged and how fitness-to-practise procedures are put in hand. It is very carefully controlled. Do I understand that the proposed new clause in Amendment 29 would merely—if I can put it that way—give the doctor against whom the complaint was alleged the choice of one of these channels of defence in relation to any complaint made against him by the regulator? I am still not clear as to whether I understand this properly. I think I am in favour of this amendment but I am not too sure. If anybody can help me understand it better, I will be really pleased.
Baroness Wheeler
My Lords, we have had a very authoritative and detailed contribution on the issues raised by Amendment 29 from the noble Lord, Lord Saatchi. Opinion among noble Lords and indeed the stakeholder medical and patients’ organisations is still divided on: first, whether a change to the law is required or whether the existing law and professional ethics arrangements will allow responsible innovation; and secondly, whether the potential two options/processes—or three as my noble friend now makes it clear will be available if the Bill becomes law—will improve and speed up the administering of innovative treatments or will cause considerable confusion among doctors about which system they should use, lead to more bureaucracy and deter them from embarking on the course?
As we said earlier, we welcome the attempts of the noble Lord, Lord Saatchi, to ensure that with this amendment the Bill does not affect the common-law Bolam test. On the overall Bill he has led a powerful campaign and is reported to have won the support of patients responding to the consultation and the publicity from Cancer Research UK, Marie Curie Cancer Care and other patient organisations. I was pleased that the noble Baroness, Lady Masham, raised a number of questions from Marie Curie about palliative care and the use of drugs arising from issues in the Bill, and I was grateful for the Minister’s very helpful response.
The General Medical Council has now given its support to the amended Bill and the Medical Defence Union has said that the amendments cover the main objections to the previous Bill. However, we have to acknowledge that some key stakeholders maintain that the Bill is not necessary because the existing law already ensures protection for doctors to innovate, and the current law and ethical guidance from the General Medical Council are clear. The Royal College of Surgeons still has strong reservations about the Bill, particularly about it applying to surgery, as we have heard. The Medical Protection Society still believes that it confuses rather than clarifies the law. The Association of Personal Injury Lawyers says that the amendments make a confusing Bill even vaguer. The BMA still strongly questions the necessity and desirability of clarifying or changing the law. Action Against Medical Accidents, one of the leading patient organisations, still says that the Bill is fraught with unintended and dangerous consequences and will create a more bureaucratic system. Sir Robert Francis QC, while considering that the amendments have produced an improvement in safeguards over what was originally proposed, has said that serious problems remain. In particular, he is concerned, as my noble friend Lord Turnberg pointed out earlier, that the Bolam amendment, while restoring a level of safeguard, also has the disadvantage of restating Bolam in different language, leading to a real risk of confusion. His question is: why not just stick to Bolam? I would be grateful for the noble Lord’s comments on that.
Will the noble Lord, Lord Saatchi, and the Minister tell the Committee whether they consider that the amended Bill now meets Dr Dan Poulter’s key test that I referred to earlier; namely, of not placing an undue bureaucratic burden on the NHS or not exposing doctors to a risk of additional liabilities?
I welcome the response of the noble Lord, Lord Saatchi, on the question of convening a round table, which I think will be a very helpful way of going forward. Obviously, it will never be possible to satisfy everybody’s concerns but, if the Bill is to be further supported, what steps will be taken by the Government to engage with stakeholder concerns?
Earl Howe
My Lords, the Government support these two amendments, which ensure that the Bolam test will remain unaffected by the Bill. In practice, this will mean that it is for the innovating doctor to decide whether to take the steps set out under the Bill or to rely on the existing Bolam test. In other words, there would be no requirement for doctors to follow the Bill when innovating.
The amendments clarify that, separate to the existing Bolam test which is applied by the courts, the Bill provides doctors with an alternative option for showing that they are acting or have acted responsibly. Furthermore, subsection (2)(b) of the proposed new clause provides that doctors are not negligent, and thus will not be judged adversely if their actions are later challenged, merely because they have not followed the Bill.
My noble friend Lord Kirkwood asked how the proposed new clause affects how a regulator approaches a complaint or fitness-to-practise procedures. This Bill addresses clinical negligence law and how the courts will assess these cases, not how the regulators will process fitness-to-practise cases.
The noble Baroness, Lady Wheeler, asked whether the Bill was necessary. The Department of Health’s consultation on the Bill revealed that some doctors find the threat of litigation to be a block to innovation, although this view was not universally held. The Bill is aimed at reassuring those doctors who feel unable to innovate due to concerns about litigation. There will also be many doctors who are not afraid to innovate and for whom litigation is not a material concern. Those doctors can continue to act as they have done previously and rely on the existing law of clinical negligence, or, as I have explained, they may choose to take advantage of the Bill instead.
I hope that noble Lords will accept these two amendments, which give flexibility and choice to doctors who want to innovate.
Children: Obesity
Baroness Wheeler Excerpts(10 years, 3 months ago)
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Earl Howe
My Lords, our current emphasis is on overall calorie reduction, of which sugar forms an important part. The scope for reformulation to reduce sugar levels varies widely depending on the food that one considers and a reduction of sugar levels does not always mean that the overall calorie content is reduced. The issue is not black and white. An example of that is when sugar is replaced by starch or other ingredients. Nevertheless, we are discussing with the food manufacturing industry ways in which it can reformulate its food and the Scientific Advisory Committee on Nutrition is finalising its review on carbohydrates, looking at sugar as a particular component of that.
Baroness Wheeler (Lab)
My Lords, given the difficulty of ensuring effective cross-department co-ordination on childhood obesity, what is the Government’s response to a call by the Royal College of General Practitioners to set up a COBRA-style task force? Would that not be a key way of ensuring a joined-up approach that extended beyond the Department of Health?
Earl Howe
My Lords, as I mentioned earlier, we have set up the Obesity Review Group, which contains a multiplicity of experts to co-ordinate the efforts being conducted not only in government but also in local government and on the part of business and the wider private sector. While I buy into the central point made by the noble Baroness that this needs an overarching scrutiny, we believe that we have that already.
Health: Stroke
Baroness Wheeler Excerpts(10 years, 6 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what action they are taking to support children and young people who have had a stroke.
Baroness Wheeler (Lab)
My Lords, most of us, even if we have had first-hand experience of a family member or friend who has had a stroke, think of it as associated with older people. Indeed, when my partner, who was then 62 years old, had a major stroke nearly seven years ago, I was a bit surprised to see two patients on the stroke ward and in the physio room in their 20s and mid-30s who had had major strokes, suffering from effects just as debilitating as for an older person but, of course, with even longer-term impact.
However, later, as a member of the All-Party Parliamentary Group on Stroke, I met the amazing Eliza Cooke, a 16 year-old ambassador for the Stroke Association, who has played a very important role in developing its key campaign to build awareness of child stroke, which has inspired the debate today. Eliza, who is here today, had a mild stroke aged 10 when she was on holiday in France, where an MRI brain scan, had it been available, could possibly have prevented the major stroke she suffered 10 days later on arriving back home. She had the classic symptoms of right-hand brain stroke but, here in Britain, she did not have the MRI scan straight away, because the health professionals she came into contact with were just not sufficiently aware that children have strokes.
By the time Eliza was referred to Great Ormond Street Hospital, 24 hours later, it was too late for surgery. She was completely paralysed down her left side and her brain was seriously injured. Eliza was an in-patient at the London Hospital for four months and had good physiotherapy, there relearning to walk, but she never regained the functioning of her left hand and has a weak left arm and leg, causing her to limp. School and study have been challenging because her memory was also affected, as was her ability to process things visually. However, she is an inspirational and determined girl and, and out of all that, is now doing her AS-levels—and, moreover, wants to study politics at university.
Eliza still has physio and occupational therapy, which she needs to ensure that she retains the movement that she has, but, like other young adults with disabilities, the key question and uncertainty for her is always: will the therapy continue when I am 18?
That children have strokes is the key message from the Stroke Association’s campaign. Awareness and recognition of the possible symptoms among health professionals and the public are vital so that, as with adult stroke, care and treatment can be fast and commence as soon as diagnosis is made. Children with suspected stroke should be seen by a consultant paediatric neurologist, paediatrician or neurosurgeon and have fast access to an MRI brain scan to determine whether it is a stroke and, if so, what type of stroke it is. Late diagnosis is a major problem with childhood stroke, and failure to get the right treatment can have a devastating impact on children and their families for the rest of their lives.
Childhood stroke is, thankfully, relatively rare. It has been estimated that about 400 children and young people in the UK have a stroke each year, and stroke is one of the top 10 causes of death in childhood. Indeed, reliable top estimates suggest that as many as 1,500 children a year could be affected by stroke.
The long-term outcomes of paediatric stroke are difficult to predict. More than half of children will be left with significant long-term disabilities after stroke—some well known, such as one-sided paralysis or weakness, or problems with speech and communication, but others less known, such as difficulties of perception and awareness and psychological and emotional changes.
The causes of childhood stroke are different from those in adults, more varied and often unknown, which is why early diagnosis can be so difficult. Those strokes occur as a result of a very diverse range of conditions—most commonly, congenital heart disease and sickle cell disease. Other underlying causes are infectious diseases, moyamoya syndrome, vasculitis and blood disorders. Childhood infections such as chicken pox, encephalitis and sepsis can also be linked to stroke in children and young people. Fear of the stroke recurring is a major concern for children and families. Ischaemic stroke, caused by a clot, recurs in between 6% and 20% of all children and in more than 60% of children with sickle cell disease.
Since tabling this debate, I have met a number of parents with their children who have suffered a stroke—Eliza and her mum, Liz, and Renee and her son Ollie, who had two strokes aged 13 and 14, are here today—all involved in the raising awareness campaign. I also want to mention eight year-old Caitlin McLaughlin, who had a stroke before she was born and now has a number of different conditions, including cerebral palsy, epilepsy and severe visual impairment. Caitlin’s 13 year- old big sister Cheyenne won the carer’s award at the Stroke Association’s recent Life after Stroke awards, for her commitment and dedication to helping to care for her sister and providing her with personal, physical and emotional support.
Sarah Scott was the deserving winner of the volunteering award. Now 23, she had a stroke while in the sixth-form class at school, at the age of 18. It resulted in right-side paralysis, from which she gradually recovered, but she was left with severe aphasia, affecting her speech, reading and writing skills. As we know, aphasia causes social isolation, particularly for someone of Sarah’s age, but she has benefited greatly from NHS speech therapy, which helped prepare her for working part-time in a local school. She has also set up a support group for young adults in her home city, and organises all their activities and outings as well as visiting other stroke survivors to provide support.
These are the inspirational stories on which I wanted to focus today, to reinforce the need for concerted action on child stroke to match the huge improvements we have seen in adult stroke care and support over the past decade. Three things need to happen. The lack of awareness of childhood stroke, its symptoms and impact—which contributes to the problem of late diagnosis—needs to be addressed; there needs to be more research into its causes, treatment and longer-term effects; and there needs to be a particular focus on improving specialist rehabilitation and longer-term services, as well as the provision of information and support for survivors and their families.
The Stroke Association and other excellent charities in this field, such as Different Strokes, Sickle Cell and Young Stroke Survivors and HemiHelp, have done tremendous work campaigning for action to raise awareness and to support parents and families. Different Strokes, for example, worked closely with the producers of the TV programme “Waterloo Road” on its recent storyline about a 14 year-old boy who had a stroke at school. When Sarah Scott had her stroke in the classroom at school, her classmates recognised the signs from the national Act FAST television adverts about strokes in adults, so an ambulance was called urgently.
Action to raise awareness needs to be taken nationally by the Government as part of an integrated strategy for childhood stroke. Does the Minister agree that plans should be put in place to build on the successful Act FAST campaign on adult stroke to raise public and professional awareness? The action of Sarah’s classmates showed how the campaign could have a very positive impact on young people. Does the Minister agree that a national strategy for childhood stroke needs to be urgently developed and fully integrated into the national cardiovascular disease outcomes strategy, which currently does not address this area? What action will the Government take to rectify this?
On awareness among health professionals, the parents I have talked to say they are often taken aback by the fact that so many doctors have not heard of childhood stroke, let alone nurses and paramedics. A recent study by Bristol University of children in the UK with ischaemic stroke found significant delays in the time from symptom onset to diagnosis, finding that diagnosis took longer than 24 hours in 51% of cases. Better implementation of national and international guidelines around the diagnosis, treatment and long-term management of childhood stroke is crucial here. What action are the Government taking to address this? What support will they give to the Royal College of Physicians, the Royal College of Paediatrics and Child Health and stroke organisations to develop new guidelines to replace the RCP’s 2004 document, which is now 10 years old? Does the Minister agree that bringing together the latest research and the views of children, families and health professionals in this way to develop new guidelines would be a major step forward in helping to address the cases of late diagnosis and misdiagnosis?
It is all-important for teachers and other schools staff to be aware of stroke symptoms and the need for rapid response, especially for children with sickle cell anaemia. They need to be part of a multiagency team which is involved in the return to school reintegration plan, and in the development of special needs education statements to allow the child to participate in school as fully as possible. Regarding research, there is widespread recognition that the best medical and rehabilitative treatment options in childhood stroke are significantly under-researched. I know other noble Lords will be addressing this, particularly the noble Lord, Lord Patel, whose experience and insights on the key issues and what needs to be done will be invaluable.
Finally, I turn to rehabilitation. Many parents of children who have had a stroke say they have to fight for their child to receive the care and treatment they should be getting. This is particularly the case for the frequency and intensity of contact with therapists, and delays in access to physio and occupational therapy. Of course, there are hospitals which do brilliant work in this area, such as the multidisciplinary child stroke services at the Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, and Great Ormond Street Hospital.
I recently sat in on a session at the Evelina with a three year-old girl who had suffered a stroke when she was nine months old, and her parents. The session was led by Dr Anne Gordon, the consultant paediatric occupational therapist, who is also here today. As a carer of a stroke survivor I do not need convincing about the importance and necessity of physio and occupational therapy, but watching specialist child stroke therapy in action underlines this.
The little girl had left-side paralysis and, although she could walk, she just was not aware of her left arm. Why should she be when she had never used it? So Dr Gordon was working and playing with her and the parents, encouraging her to move her shoulder and learn to see the arm as a tool that she might use to tuck things under or generally to assist her. It was a process of joint working with the child, the therapist and the parents, and fully involving the parents so that they could continue the physio exercises with her at home. Childhood stroke impacts the whole family including parents, siblings and grandparents. Health, social and education services need to work together to provide the multidisciplinary assessments and support that the child and their family need.
Finally, the Evelina has a dedicated childhood stroke co-ordinator, who provides direct support and information to children and their families while in hospital, during the transition from hospital to home and over the longer term, by helping the child receiving rehabilitation or with starting or returning to school. The co-ordinator works closely with health professionals and uses the parent carer networks to help them reach out and support each other. Sadly that is a one-off, made possible by three-year funding from a Stroke Association corporate sponsor. How does the Minister consider that such services can be sustained and made more widely available to childhood stroke survivors and their families?
There is so much to say, and I have run out of time, but I am confident that the noble Lords who are due to speak will flesh out and expand on the many issues I have raised. I thank them all for coming to speak in this important debate today.
NHS: District Nurses
Baroness Wheeler Excerpts(10 years, 7 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what action they are taking to ensure that the National Health Service has sufficient district nurses.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Department of Health is working with Health Education England, NHS England and the Queen’s Nursing Institute to raise the profile of district and community nursing and to attract more nurses to choose this as a career path. That work includes a workforce project led by the Community Nursing Strategy Programme to ensure an adequate supply of highly skilled district nurses to support patients in community settings, provide quality care and improve patient outcomes.
Baroness Wheeler (Lab)
I thank the Minister for his response. Does he not agree that the failure to address the chronic shortage of district nurses makes the RCN’s call to action even more urgent? The college has found that district nurses are so stretched that they can spend only 37% of their time actually dealing with patients in the community, which is deeply worrying. How does this help people with long-term conditions who depend on specialist nursing care to stay out of hospital? When is a comprehensive strategy that addresses the urgent action which needs to be taken on this matter going to be published?
Earl Howe
My Lords, we recognise the need for urgent action, and that it is required across the piece. We need to train more district nurses, and therefore training places have gone up both last year and this year. We also need to equip district nurses with technology. To that end, the nursing technology fund will address the issue that the noble Baroness referred to initially, which is the time that nurses have to spend with their patients. Technology can make time management much more efficient, and it is also good for the patient, who feels more in touch. NHS England and Health Education England have set up a workforce project which, as I said in my initial Answer, is designed to address not only workforce numbers but also the attractiveness of district nursing to trainees.
Health: Multiple Sclerosis
Baroness Wheeler Excerpts(10 years, 7 months ago)
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Earl Howe
My noble friend will know that NICE looks at the clinical effectiveness of a drug alongside its cost effectiveness. The cost-effectiveness equation will naturally include consideration of unpleasant side-effects. The advice that it issues will reflect the evidence that it has from clinicians on that matter. It will then be for clinicians to decide whether the risk-benefit ratio is appropriate for particular patients.
Baroness Wheeler (Lab)
My Lords, when considering the Care Act we were very concerned to ensure that care and support plans for social care users included contingency planning for people who have fluctuating conditions such as MS and rheumatoid arthritis, where support needs can vary from week to week and day to day. What mechanisms are being put in place to ensure the provision of the flexible and comprehensive care plans that are needed?
Health: Rheumatoid Arthritis
Baroness Wheeler Excerpts(10 years, 8 months ago)
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Earl Howe
I am grateful to my noble friend. Expenditure on musculoskeletal disease research by the National Institute for Health Research has increased from £15.5 million in 2009-10 to £23.1 million in 2012-13. The NIHR is investing over £21 million over five years in three biomedical research units in musculoskeletal disease. They are all carrying out vital research on rheumatoid arthritis. The NIHR is currently investing £2 million in a programme of research on treatment intensities and targets in rheumatoid arthritis therapy.
Baroness Wheeler (Lab)
My Lords, can the Minister tell the House what impact the very worrying reported shortage in take-up of family doctor training places is likely to have on the ability of GPs to support patients with potential rheumatoid arthritis symptoms? A recent survey by Pulse found that only 7% of the funding for medical schools goes into teaching general practice. Does this not augur badly for the future of primary care?
Earl Howe
My Lords, we of course recognise the very hard work that GPs do. Despite a decrease in headcount, there has in fact been a 1.2% increase in full-time GPs since 2012 and the number of practice nurses and practice staff has also grown. However, we also recognise that the workforce needs to grow to meet rising demand. That is why our mandate to Health Education England requires it to ensure that 50% of trainee doctors enter GP training programmes by 2016. Generally, we will work with NHS England to consider how to improve recruitment, retention and return to practice in primary and community care.
NHS: Clinical Commissioning Groups
Baroness Wheeler Excerpts(10 years, 8 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government how they will ensure Clinical Commissioning Groups’ strategies and implementation plans support carers and take account of their needs and aspirations.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, NHS England assures clinical commissioning groups’ plans to support and challenge them to meet the needs of their populations. This includes considering supporting carers, who are a hugely valuable asset for local communities. NHS England has published a commitment to a carers action plan. It will review the delivery of these commitments through feedback from carers and carers’ organisations and through progress towards the relevant outcomes indicators and mandate objectives.
Baroness Wheeler (Lab)
I thank the Minister for his response. At the start of national Carers Week, it is right for the whole House to pay tribute to our 1.5 million carers and the vital support that they provide in caring for their partners, friends or a family member. What is the Minister’s response to a recent Carers UK survey, which found that while GPs have implemented systems to identify those undertaking carers’ responsibilities, few are actually doing anything differently to accommodate them—for example, giving regular health checks or changing appointment systems to support getting somebody to the surgery who is in a wheelchair or caring for somebody with dementia? Does the Minister agree that the appointment of carers leads under CCG implementation plans is a key step in bringing about the major push that is needed to get GPs to up their game? How will the Government ensure that that happens?
Earl Howe
My Lords, I fully endorse the comments of the noble Baroness about the importance of carers. They play a crucial role as partners in care for the well-being of those they look after. I saw that report and of course it is important that GPs are aware of their role in supporting carers. We set out our vision for this in a document we published, Transforming Primary Care. That recognises the importance of involving and supporting carers. It sets out an expectation for GPs to identify carers as a matter of course. As I said in my original Answer, CCG plans will be assured by NHS England, including the important element of carers’ support and recognition.
Care: Older People
Baroness Wheeler Excerpts(10 years, 9 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what response they intend to make to the findings of the Age UK report Care in Crisis on the impact of cuts to care for older people.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, social care is a priority for this Government, which is why we have allocated an extra £1.1 billion to councils this year to protect services. We are building on this by creating a £3.8 billion fund next year to join up NHS and social care services. Both health and social care need to work differently to respond to the needs of our ageing population, focusing on keeping people well and living independently for as long as possible.
Baroness Wheeler (Lab)
I thank the Minister for his response. Age UK’s report found that social care cuts between 2010 and 2013 have resulted in 168,000 older people no longer receiving help with essential tasks such as eating, washing and getting dressed. The Nuffield Trust recently put the figure over four years at 250,000 people who have lost state funding support. In the light of today’s developments, can the Minister please comment on what is now happening to the Better Care Fund and when does he expect to update the House fully on why the launch of the fund has been delayed? The Minister knows that the fund basically uses resources already committed to shoring up the existing reduced level of services and that there is no new money in it. We now learn that the Cabinet Office says that the fund lacks financial credibility, in particular as to how on earth local hospitals are to save money to move care into the community in the current climate of substantial cuts. How does the Minister think progress can be made on the transfer to community care amidst the chaos and confusion into which this policy has now fallen?
Earl Howe
My Lords, I can assure the noble Baroness that there is no chaos and confusion. As regards reduced numbers, which was where the noble Baroness started, the transformation in the service model that we are promoting focuses above all on prevention and is designed to enable people to live independently for longer, as I said earlier, so as to reduce the number of people who are dependent on formal care. Councils have told us that lower social care user numbers are partly due to the success of their core prevention work, but also due to increased use of re-ablement services for people who leave hospital to help them get back on their feet. As regards the Better Care Fund, there has been no delay there. We wanted to set aside enough time to make sure that all areas of the country have developed comprehensive plans for joined-up care. The better care plans start from April next year, as the noble Baroness is aware, and we have asked for early versions to be completed a year in advance so that we can review them, check their level of ambition and test how they will be delivered. That is what is happening now and we are broadly on track with the programme.
Care Bill [HL]
Baroness Wheeler Excerpts(10 years, 9 months ago)
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Baroness Wheeler (Lab)
My Lords, I thank the Minister for his full and thorough explanation of the Government’s changes to the Bill since it left this House. We will deal with each issue as it comes up. I will deal with Amendments 1 to 10, 44 and 46 to 51 on the Better Care Fund, and Amendments 12 to 39 on the care and support appeals process.
In light of today’s revelations about the Government’s problems with the aims and operations of the Better Care Fund, perhaps I might ask a couple more questions that follow on from the earlier exchange with the Minister on this matter. The Government’s technical amendments—Amendments 1 to 10, 44 and 46 to 51 —on the fund and achieving integration of care and support between the NHS and local authorities are straightforward. Of course, whether the fund can ever achieve what it set out to achieve looks like a very different matter.
The Cabinet Office review has found that the £3.8 billion fund lacks financial credibility. The Nuffield Trust says that it is based on “flawed logic”. The King’s Fund says that the aim stressed by the Minister earlier to get spending plans in place for the fund in time for the 2015-16 Budget is “completely unrealistic”. Its chief executive, Chris Ham, points out in today’s Guardian what many of us have been stressing all along, despite supporting the principle of and need for the fund; namely, that hospital budgets can be reduced only if much more care is already being provided in the community by GPs, community nurses and staff who are supporting patients in their homes. He says that just cutting NHS hospital budgets now would place,
“additional stress on an NHS already struggling to balance the books and maintain acceptable standards of patient care”.
Surely that is the point. Taken with the huge underfunding of local authority social care highlighted by the Age UK report Care in Crisis that was referred to earlier, this is the underlying problem that has still to be addressed. The fund does nothing to address the huge social care funding gap that has led to the cuts in social care support that Age UK’s report has highlighted, particularly the ending of help with essential tasks for older people, such as eating, washing and getting dressed. Those are the very services that help them remain independent and living in their own homes with a good quality of life.
The Minister says the fund has not been suspended, but there are clearly problems. Can the Minister give us any further details about the Cabinet Office review findings, and in particular the concern about the lack of detail about how the savings will be achieved? What is the timescale for the further review referred to by several newspapers and the specialist press today? Can the Minister explain how progress is to be made in enabling older people to remain active and independent at home or in the community when there is just not the funding or support available to help them?
Finally, on the technical amendments to the care and support appeals process, we welcome the Government’s announcement accepting the two recommendations from the Delegated Powers Committee and fully support these government amendments.
Baroness Brinton (LD)
My Lords, I have just one issue to raise, on Amendment 32 and the Government’s amendments in light of the Delegated Powers Committee report. I speak on behalf of a number of people who are grateful that the Government have been able to respond very quickly to this. It is much more sensible for this to be an affirmative instrument rather than a negative one.
Lord Rix (CB)
My Lords, on behalf of learning disabled people and other vulnerable people I should like to thank the Government for making this amendment, which certainly ensures that their care will be greatly attended to in the future.
Baroness Wheeler
My Lords, briefly, I also support the Government’s amendment on this long-running but vital issue. As the House knows, we strongly supported the need for the amendment. We, too, warmly congratulate the noble Lord, Lord Low, on his dogged determination and efforts to achieve this outcome. We also thank noble Lords from across the House who have helped to bring this about. On these Benches, we recognise that this was very much unfinished business from the Labour Government. We congratulate the Minister on the hard work he has put into finding a way forward and to getting cross-government departmental agreement, which has been important. We recognise that the amendment is a very significant step. I was going to ask for clarification on a couple of issues, but they have been raised in the debate so I shall leave it there.
Health: Liver Disease
Baroness Wheeler Excerpts(10 years, 9 months ago)
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Baroness Wheeler
My Lords, I, too, pay tribute to Elena Baltacha, who was a truly remarkable and very brave woman. One in five people in the UK is at serious risk of liver damage, but a recent government response shows that the Secretary of State has not met any external organisations to discuss liver disease since May 2010, and current Ministers have not met representatives of people living with liver disease since September 2012. Can the Minister commit urgently to remedying this situation, particularly as it is in such stark contrast to the 130-plus meetings the Government have had with the drinks industry?
Earl Howe
My Lords, liver disease is very much in the sights of my honourable friend the Minister for Public Health, as is evidenced by the document we published last week, Living Well for Longer, in which there is a whole section on alcohol and liver disease, and by what NHS England and Public Health England are doing to tackle them.