Learning Disabilities: Community-Based Support
Earl Howe Excerpts(11 years, 4 months ago)
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what action they are taking in the light of the events at Winterbourne View hospital to ensure that people with learning disabilities inappropriately placed in hospital are able to move to community-based support.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government are working with health and care system partners, self-advocates, family carers and other stakeholders to improve safety, quality of care and outcomes for people with learning disabilities, including reducing significantly reliance on in-patient care, by reviewing people’s care and moving them to alternative, community-based support where appropriate.
Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the noble Earl for that. Can he confirm that the Government set a deadline of 1 June for the transfer of thousands of people with learning disabilities out of institutions such as Winterbourne View? The latest figures show that only one in 10 such residents has actually been so moved. Will the noble Earl accept responsibility for this and tell the House what the Government intend to do about it?
Earl Howe
My Lords, the Government’s mandate for NHS England in the current year includes an objective which covers Winterbourne View concordat commitments. He is right that the deadline was missed. We are not satisfied with that and we are working very hard with NHS England to set out our expectations for progress and improved rates of discharge from in-patient settings. NHS England is going to produce an action plan this August but, in the mean time, it is doing three things. It is complying with the transforming care and Winterbourne View concordat commitments, which we have tasked it to do. It will set out what progress it expects to make and by when, with milestones, and it will provide real clarity on what success looks like—an important issue if we are trying to hold it to account—and how progress will be measured.
Baroness Hollins (CB)
My Lords, is the Minister aware that in the first six months of this year, 544 new people were admitted to assessment and treatment units and only 338 were transferred? Does he agree, therefore, that prevention is as important as discharge, and that in order to achieve both of these, skilled community support and skilled specialist support in the community are urgently needed and need to be funded?
Earl Howe
I do agree with the noble Baroness. For people who, with the right support, could and should be living in community-based settings, there is a variety of reasons why sometimes that does not happen. The lack of appropriate housing can be a barrier. For others, we know that clinical decisions are preventing discharge. NHS England is looking very carefully at how to strengthen second opinion to support people in in-patient settings to challenge the reasons for their placement as and when they need to. We are looking at making some capital funding available to support the transfer of people from in-patient care to community-based support.
Baroness Tyler of Enfield (LD)
My Lords, given the figures we have just heard about the number of people with learning disabilities being admitted to costly assessment and treatment units rather than leaving them, will my noble friend the Minister say what action the Government are taking to ensure that local commissioners—in both local government and the NHS—have the necessary skills and competence to deliver the high-quality local services that are needed to allow as many people as possible to return to their communities?
Earl Howe
My noble friend is absolutely right to focus on the role of commissioners. The Winterbourne View joint improvement programme has already stepped up its activity in working with local areas, including identifying 35 areas for in-depth review. NHS England is engaging with commissioners to reinforce the importance of ensuring appropriate services for people with learning disabilities close to their homes and families. That includes looking at how funding streams can be shared with local authorities so that there is no procedural blockage in the way that money moves across the system.
Lord Wigley (PC)
My Lords, on that very point of funding, how will the Government ensure that funding in fact follows the individual and does not, as so often currently occurs, remain locked into the funding of the wrong kind of provision? In asking this, I draw attention to my registered interest as vice-president of Mencap.
Earl Howe
Lessons are being learnt almost by the day by the NHS and local government on how to pool funding and share responsibility in areas of this kind. Admittedly, most of the effort at the moment is on the vulnerable elderly but the lessons apply equally to those with learning disabilities and to ensuring that we do not have any artificial walls forming between the NHS and local government as regards the flow of money. I can tell the noble Lord that this is a major area of focus for both NHS England and the Local Government Association at the moment.
Baroness Warwick of Undercliffe (Lab)
My Lords, given the recent resignation of the director of the joint improvement programme, which was tasked with delivering the Winterbourne View action plan only 18 months ago, will the Minister let us know what the future of the programme holds and how it will work with the new group, also tasked in a similar way, led by Sir Stephen Bubb?
Earl Howe
My Lords, I have every confidence that the programme will continue as we had hoped it would, and indeed with a renewed momentum. The noble Baroness is right that NHS England has asked Sir Stephen Bubb, the chief executive of the charity leaders’ network ACEVO, to head a new group of experts and advisers to develop a national guide on how we provide health and care for those with learning disabilities. We have every confidence that Sir Stephen, with his immense experience in these areas, will be able to bring everybody together to a good result.
Lord Laming (CB)
My Lords, will the Minister assure the House that the only criteria that will be used in making these arrangements is the way to improve the quality of life of the user of the services rather than any bureaucratic processes set by NHS England?
Earl Howe
The fundamental principle that must underpin and inform all decisions in this area is about ensuring that we respect people with learning disabilities as individuals who have the same rights as everyone else, including the opportunities to make informed choices about where and with whom they live. The noble Lord is absolutely right.
Health: Midwives
Earl Howe Excerpts(11 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we are committed to improving maternity care and have charged Health Education England with ensuring that staff with the right skills are being trained and developed to meet future needs. Between May 2010 and March 2014, the numbers of full-time equivalent midwives increased by more than 1,700 and over 6,000 are in training. Health and social care is a devolved matter and the responsibility of individual devolved Administrations.
Lord Harrison (Lab)
My Lords, what are the Government actively doing to retain experienced, longer-serving midwives at a time of recruitment shortages? Why is it that, according to the National Federation of Women’s Institutes, only one in eight mothers giving birth is helped by a midwife known to her?
Earl Howe
My Lords, we attach great importance to choice in maternity care and, in particular, to each mother having a named midwife throughout the care pathway. That is what we are aiming at and what NHS England and Health Education England are charged with delivering. As regards the age profile of midwives, my advice is that there is not a particular age bulge, although we are keen to ensure that we do not lose qualified midwives who, clearly, we can ill afford to lose. However, we have made a commitment to ensure that the number of midwives in training is matched to the birth rate and, so far at least, we have been successful in that.
Baroness Manzoor (LD)
My Lords, continuity in care is very important, particularly when you consider that one in 10 women suffers from postnatal depression, and that number increases to four in 10 for teenage mothers. Can my noble friend reassure the House that, first, there is good identification of health needs for mothers during the prenatal stage; and, secondly, that there is one-to-one care during labour and postnatal so that these women are helped and supported?
Earl Howe
My noble friend makes two important points. As I said, we attach great importance to each mother being able to have throughout the care pathway a named midwife. Improving diagnosis and services for women with pregnancy-related mental health problems is one of our objectives for maternity care. The mandate from the Government to NHS England includes an objective for NHS England to work with partner organisations to reduce the incidence and impact of postnatal depression through earlier diagnosis and better intervention and support. We are clear that midwives have a key role to play in that.
Baroness Pitkeathley (Lab)
My Lords, what have we done to address demographic inequalities in the experience of childbirth, particularly for black and minority ethnic women, who often express a great lack of satisfaction with the treatment they receive during labour?
Earl Howe
My Lords, helping commissioners to reduce unwarranted variation in service delivery is one of the key roles of maternity and children strategic clinical networks, which are being established and supported by NHS England. We know from experience that these networks have a tremendously beneficial effect in ironing out inequalities in access.
Baroness Cumberlege (Con)
My Lords, will my noble friend rejoice with me that independent midwives now have professional indemnity? Does he agree that they make a very valuable contribution to maternity services, especially for vulnerable women?
Earl Howe
My Lords, we naturally applaud the professionalism of independent midwives. I agree with my noble friend that it is a positive step forward that all healthcare professionals in this country have professional indemnity insurance. We must think of the patient always and, should something go wrong, it is right that every patient is protected by indemnity or insurance.
Lord Christopher (Lab)
My Lords, is the Minister content that the measure of training, related only to the birth rate, is adequate? Should we not build in wastage?
Lord Christopher
Is a measure of the numbers training which is related only to the birth rate adequate, unless you also build in the wastage rate?
Earl Howe
The noble Lord makes a good point about building in a wastage rate. Since 2010, the number of midwives has increased by 5.75% and the number of births has decreased by 3.3%. This is why I indicated in my earlier answer that we were, in that sense, ahead of the curve. There is a great deal of work going on to ensure that there is no attrition or wastage during the training period, as this is a waste of the person’s skills and taxpayers’ money.
Baroness Tonge (Ind LD)
My Lords, what progress has been made in implementing the top 10 recommendations in the Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom, especially those relating to the 19 women who died from pre-eclampsia between 2006 and 2008, which are the latest figures we have? Can the Minister also tell us when we will get a more up-to-date report on maternal deaths?
Earl Howe
My Lords, I do not have information on the confidential enquiry in my brief but, according to international statistics, the NHS remains one of the safest places in the world to give birth. The latest independent CQC survey found that maternity care in England has improved, with women reporting a high level of trust and confidence in the staff caring for them. I shall gladly let my noble friend know the latest that my department has on the issues she has raised.
Lord Hunt of Kings Heath (Lab)
My Lords, did the noble Earl see the report in the Times this morning that the Nottingham University Hospitals NHS Trust maternity unit closed 97 times in a period of 12 months due to pressure? Freedom of information requests have shown that some 62 maternity units were forced to close because of pressures in 2013. Is that not a firm indication of a shortage of midwives? Does it not show that the Government are less than active in seeking to put this right?
Earl Howe
It is up to commissioners to ensure that facilities are available to meet the needs of women who are due to give birth. There may be limited occasions when a maternity unit cannot safely accept more women into their care. That is why we have seen some temporary closures of units. Any decision to redirect women is made by a clinician as part of a carefully managed process. It is not something that suddenly happens. However, commissioners need to be alert to the risks for provider facilities that a bulge in births can create.
NHS: Ambulance Response Times
Earl Howe Excerpts(11 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the NHS is responding to the majority of emergency calls in less than eight minutes, despite the number of these calls having increased by almost 14% from 2011-12 to 2013-14. The NHS has been supported to ensure that urgent and emergency care services are sustainable all year round and are ready for the pressures that winter can bring. Some £18 million will be allocated directly to ambulance service commissioners with a further £10 million to ensure sustained high performance.
Lord Kennedy of Southwark (Lab)
My Lords, FOI disclosures indicate that, since 2010, seven out of 10 of England’s ambulance trusts have increased their spending on commercial and voluntary ambulances. In London, spending has grown from £829,000 in 2010 to £9.2 million in 2013. Does the noble Earl share the concern of the president of the College of Emergency Medicine, Dr Clifford Mann, who has said that this is an issue which is causing deep concern and is,
“incredibly wasteful and potentially dangerous”?
Earl Howe
My Lords, patients have the right to a high-quality urgent and emergency care service whenever they call upon it, and we expect ambulance trusts to provide that. We are aware that independent or voluntary ambulance services may be used to support NHS ambulance services because they can help manage peaks in demand. Individual NHS ambulance services have got to ensure that 999 calls are attended by staff who are properly trained and adequately equipped. Indeed, since 2011 the providers of independent ambulance services have had to register with the Care Quality Commission, which monitors, inspects and regulates all services.
Baroness Gardner of Parkes (Con)
My Lords, is it not a shame that London has only one air ambulance, which is run by a charity, when Sydney and Paris have six and four respectively? Does the Minister not think that it would be to the advantage of patients to have more air ambulances operating in London, because at least they can deal with any major traffic problems?
Earl Howe
My Lords, we owe a great deal to the air ambulance services across the country, all of which, I think I am right in saying, are organised as charities. However, it is the case that in every instance the NHS pays for the clinical staff on those ambulances while the charity pays for the helicopter and the pilot. That is the balance we have struck and successive Governments have taken the view that it is the most cost-effective model for the NHS. However, that is not to downplay the very important role that ambulances perform in our society.
Baroness Hussein-Ece (LD)
My Lords, will the Minister give an assurance that, when ambulances are called out for patients who are having prolonged epileptic seizures, there will be qualified paramedics in attendance and that we shall not go back to the situation we had of several tragic cases where paramedics were not in attendance and patients with prolonged epileptic seizures died before they got to hospital?
Earl Howe
My Lords, I am aware of a number of those tragic cases. It is, of course, up to each response team to decide on the configuration of personnel and the skill mix on each ambulance that goes out. That judgment often has to be taken quickly. Sometimes it is a difficult judgment and, tragically, it is not always the right judgment. However, I know that every ambulance service in the country is mindful of the need to reach patients in emergencies with the greatest possible speed and the right professional skills.
Lord Hunt of Kings Heath (Lab)
My Lords, can the noble Earl confirm that the average waiting time for the most urgent 999 calls has lengthened in all parts of the country on average in the past three years? What are the Government doing to improve ambulance performance, and particularly could he comment on the very poor performance of the East of England Ambulance Service?
Earl Howe
The noble Lord is right. Ambulance trusts are experiencing high demand and we realise that a handful of services have experienced difficulty. Broadly, we are taking action in the short term and in the medium to long term. In the short term, we are supporting trusts with operational resilience plans so that they are better equipped to manage peaks in demand and we are providing clinical commissioning groups with additional funding, as I mentioned in my original Answer. Over the longer term, the NHS England review led by Sir Bruce Keogh is considering whole-system change, incorporating ambulance services.
With regard to the east of England, I met the East of England Ambulance Service NHS Trust’s chief executive, Dr Anthony Marsh, on 8 July to discuss performance since his appointment in January, and he assured me that the trust is now in recovery stage. Having seen his detailed proposals, I accept that judgment.
Lord Mawhinney (Con)
My Lords, in his original Answer, my noble friend said that a majority of ambulances arrived in less than eight minutes. That majority could be 99% or 51%. Will my noble friend tell your Lordships slightly more precisely what the percentage is?
Health: Dementia
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Baroness Seccombe
To ask Her Majesty’s Government what steps they are taking to improve the early diagnosis, and to raise awareness, of dementia.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, in March 2012, the Prime Minister launched his Challenge on Dementia, to deliver major improvements in care and research. NHS England has set the first ever national ambition to improve dementia diagnosis. By March 2015, our aim is that two-thirds of the estimated people with dementia receive a diagnosis and appropriate post-diagnostic support. In May, Public Health England and the Alzheimer’s Society launched the Dementia Friends campaign, a major social movement to improve dementia awareness.
Baroness Seccombe (Con)
My Lords, all those who have lived with a loved one with dementia know only too well the heartache and unhappiness it brings to the whole family, without mentioning the financial implications for the family and, indeed, for the country. Does my noble friend agree that the Government must do everything in their power in this ageing society to support, wholeheartedly and urgently, research into this horrible condition? Does he also share my view that the probability of there being a test for early diagnosis around the corner does not mean that we all have to rush to the doctor if we have trouble remembering a few names or even, I understand, if one is losing one’s sense of smell?
Earl Howe
My Lords, my noble friend is right on the last point. The advice I have received is that it is perfectly normal for memory to be affected by age, stress and tiredness, and that you should go to your GP only if you are worried. My noble friend is absolutely right about the importance of research because we need to make a step-change in the prevention of dementia and in its treatment and care. Research spending on dementia has increased by nearly 50% since 2010-11. We are on track to meet the target of increasing funding to £66.3 million by 2015 and our ambition is to further double spending over the decade following the end of the present Parliament. My noble friend will also be aware that research was a major focus of the G8 dementia summit last December and the World Dementia Envoy, Dr Dennis Gillings, is leading a World Dementia Council to stimulate innovation in this area.
Baroness Turner of Camden (Lab)
My Lords, I thank the Minister for what he said in response to this Question, but are the Government aware that dementia sufferers should never be left alone too much? I speak from experience because my sister is an Alzheimer’s sufferer. It is not a good idea ever to leave them too much on their own; it simply makes them a lot worse. Many are elderly people who otherwise live on their own and it is not a good idea. I have certainly set up arrangements for people to see my sister regularly, ensuring that she has her medicine and that she sees people every day. In that way, she is getting a lot better than I think otherwise she would, and she is able to participate in the life of the community as otherwise she would not be able to.
Earl Howe
The noble Baroness makes a series of extremely important points about the care of people with dementia. She is absolutely right. That is why we need to place greater emphasis on professional training and awareness, not only among NHS professionals but among social care staff, so that they appreciate the full dimension of the condition. Of course, we must remind ourselves that dementia is not a single condition. There are several conditions along that spectrum and each one has its own particular characteristics. We are emphasising to the NHS and local authorities that individual care planning is vital in this area.
Lord Laming (CB)
My Lords, will the Minister reinforce the point that he just touched on, that dementia—as a generic term—affects individuals in very different ways? As we have already heard, individuals’ circumstances vary enormously in terms of the position of their carers. Will the Minister do everything he can to ensure that in the future services will continue to respect the unique qualities of the individual who is affected by this condition?
Earl Howe
Again, the noble Lord makes a central point. As he will know, dementia can range from mild cognitive impairment to difficulties in organising daily life, right through to confinement to bed and very serious cognitive impairment. Knowing this is very distressing for people in the early stages of dementia. All this is why we are laying such emphasis on NHS staff receiving training. By October 2013, 108,000 NHS staff had received tier 1 training on dementia, and more than 100,000 social care workers have received some form of dementia awareness training through workforce development funding. We are aiming to increase those numbers substantially over the coming years.
Baroness Barker (LD)
My Lords, as there are currently no effective drug therapies, will the Minister explain what the incentives are for GPs to make early diagnosis of the condition?
Earl Howe
It is generally recognised—although some GPs disagree—that early diagnosis of dementia is vital. It is vital for ensuring that a person with dementia can access the relevant advice, information and care and support that can help them live well with the condition. My noble friend is right that there is currently no cure for dementia, but there are drugs that can help with some of the symptoms and people with dementia have the right to know that they have the condition so that they can better plan for the future.
Lord Bradley (Lab)
My Lords, I declare my health interests. The Alzheimer’s Society says that one person in five who suffer from dementia gets no support or information after diagnosis. Will the Minister say what specific actions the Government are taking now to try to improve the situation?
Earl Howe
My Lords, NHS England is investing £90 million in diagnosing two-thirds of people with dementia by March next year. We have amended the GP contract so that everyone over 75 has a named, accountable GP and the most vulnerable 2% in each practice will receive an enhanced service. The NHS Choices website has been enhanced. NHS England has provided CCGs with tools and guidance to help them set a local ambition to improve dementia diagnosis. The post-diagnostic support that the noble Lord mentions is absolutely central. There is a post-diagnosis working group to identify what good looks like in this area and roll out best practice.
NHS: District Nurses
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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.
Baroness Brinton (LD)
My Lords, there has been a 47% reduction in district nurses over the previous 10 years. Does the Minister agree that if we are to have real integration of health and social care, then commissioners, NHS England and Health Education England should prioritise support for district nurses and community posts, not least to reduce the pressure on hospital beds?
Earl Howe
These matters are locally determined by commissioners, but my noble friend makes a valid point. It is important to understand that district nursing services involve qualified district nurses leading and supporting multidisciplinary teams which often include staff nurses, community nurses and healthcare assistants, working with allied health professionals. We also need to recognise that social care relies on the same pool of registered nurses for local authority-funded care, and in fact nurses employed by local authorities are not counted in the statistics.
Baroness Pitkeathley (Lab)
My Lords, I recently came across a district nursing service which had been contracted out to the private sector, to the considerable confusion of some of the patients using it. Does the Minister have the figures for how many district nursing services have been contracted out in this way?
Earl Howe
I do not have the figures, but of course this process started under the previous Government with the “Transforming Community Services” programme, which very often hived off the community provision into social enterprises. If I have statistics on this I will gladly send them to the noble Baroness.
The Countess of Mar (CB)
My Lords, I recently received a letter from a lady whose daughter has ME and is confined to bed. She is under the age of 16, and was given a male care assistant who would not perform certain tasks for her. When her mother went to the surgery to ask if a district nurse could come and do those tasks, she was told no because the girl was under 16. Is this correct?
Earl Howe
I am happy to look into that case, but clearly we need to ensure that there are the right skills for the right patients, and this is what the health service increasingly aims to achieve. The district nursing team has to contain those multidisciplinary skills. If there is a case of someone being inappropriately looked after, then that is certainly a cause for concern.
Baroness Manzoor (LD)
My Lords, nearly 50% of district nurses are over the age of 50. I heard what the Minister said regarding the number of nurses in training but perhaps the numbers could be looked at again, because quite a number of district nurses will soon be retiring.
Earl Howe
My noble friend makes a good point, and this was highlighted by the royal college. Health Education England was established precisely to ensure a greater connection between the needs and demands of local employers and the education and training commissions which are made. It takes into account all the relevant variables, such as the age profile of the workforce, to ensure that it sets the appropriate number of training places for district nurses to meet future capacity and capability service needs. As I mentioned earlier, Health Education England has in fact increased the number of training places for district nurses by 7% this year, to 431 places.
NHS: Hospital Waiting Times
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, hospital waiting times are low and stable, but there are pressures from a growing and ageing population, and some patients are not receiving their treatment as soon as we would like. NHS England, the NHS Trust Development Authority and Monitor are working with the most challenged providers and commissioners. Operational resilience guidance, published in June, will help the system prepare for winter and improve waiting times sustainably for emergency and elective care.
Lord Dubs (Lab)
My Lords, that is a very impressive Answer. The Prime Minister said some time ago that the test will be to get NHS waiting times down. Judged by that test, will the Minister comment on this morning’s statistics from NHS England which showed that over the past year the number of patients waiting six months or longer for treatment has gone up by 20%? Does that not show that the Prime Minister has failed his own test?
Earl Howe
My Lords, I do not believe that that is a fair comment. In the past four years, since the Government came to office, we have substantially reduced the numbers of patients waiting longer than 18, 26 and 52 weeks to start treatment. Those numbers are lower than at any time under the previous Government. However, we need to address the build-up in patients waiting and, as a result, we are directing extra support and money for hospitals to do more than 100,000 additional operations over the next few months to meet the extra demand.
Baroness Gardner of Parkes (Con)
My Lords, is it not a fact that the statement made this morning by the new president of the Royal College of Surgeons makes quite a lot of sense, and that most people would agree with it? People who need life-saving operations urgently should have priority, and people who have conditions that will not deteriorate—I am spreading more words than she actually said—may be asked to wait longer to give that priority to the more urgent cases. Does my noble friend not think that that first ever woman president of the Royal College of Surgeons is talking common sense?
Earl Howe
Yes, she is. I have known the new president of the royal college for some years. She is a very considerable surgeon, and I agree with what she has said. Clinical priority is the main determinant of when patients should be treated, and should remain so. Clinicians should make decisions about the patient’s treatment and patients should not experience undue delay at any stage of their referral, diagnosis, or indeed treatment. That is why we have moved away from targets to standards—to signal the importance of clinical priorities, which doctors should always feel able to act on.
Lord Hunt of Kings Heath (Lab)
My Lords, does the noble Earl agree that, whatever he says about targets, the previous Labour Government reduced the maximum waiting time for in-patient treatment from 18 months to 18 weeks? Was that not a substantial reduction? Is the Minister not concerned that if we take a whole raft of measurements, it shows a health service now under great pressure financially and in terms of waiting times?
Earl Howe
Yes, of course, the previous Government did an enormous amount to reduce waiting times. I also hope, though, that the noble Lord will give us credit for what we have done to reduce waiting times for those who have been waiting the longest, who were never targeted under the previous Government. I acknowledge that the system is under strain at the moment, but we have plans for the short, medium and long term to address that situation.
Baroness Manzoor (LD)
My Lords, the Government have stated that there is to be parity of esteem between mental health services and acute services. Will my noble friend the Minister state whether this will include waiting times for the provision of mental health services to both adults and children?
Lord Turnberg (Lab)
My Lords, there seems to be little doubt that waiting lists will grow. Is the noble Earl aware of the recent King’s Fund report, The NHS Productivity Challenge, which shows that the share of the national cake for the NHS, which was above 8% in 2009, is now about 7% and is set to fall to around 6% by 2021. Is there any justification for reducing the share of GDP for health services?
Earl Howe
My Lords, the noble Lord knows of the economic constraints that this country has to contend with at the moment. Despite that, the Government are increasing the NHS budget over the course of this Parliament by £12.7 billion. That should indicate to the noble Lord the priority that we are giving to the NHS.
Lord McColl of Dulwich (Con)
My Lords, the Minister mentioned that the strain on the NHS is due to old people getting older, but is it not true that the strain is due to young people getting fatter and fatter? Is it not true that the Department of Health misled the nation by saying that the obesity epidemic—the worst for 90 years—is due to a lack of exercise when really it is due to people eating too much?
Lord Patel (CB)
Can the Minister tell us how those trusts that do not report on their waiting times, although they are small in number, are dealt with? How can they be held responsible when they do not report?
Baroness McIntosh of Hudnall (Lab)
My Lords, I do not believe that the House heard the noble Earl address the issue raised by my noble friend Lord Turnberg. It was not about cash but about share. Can he expand a little on why the share of GDP allocated to the National Health Service is set to go down?
Earl Howe
The share of GDP is only one measure. We have to take into account the state of the economy. If the party opposite had been elected to office, it had in fact decided that the share of the cake should be less than the one we have allocated. We have had to strike a balance and I believe that we have done so in a responsible way.
Health: Cancer
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Baroness Gardner of Parkes
To ask Her Majesty’s Government why the number of National Health Service patients treated for cancer by stereotactic ablative radiotherapy has fallen since April last year.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, before NHS England began commissioning specialised services in April 2013, many local arrangements that were in place were outside recommendations issued by the National Radiotherapy Implementation Group, the NRIG. Since April 2013 a consistent national policy has been in place, backed by robust clinical evidence. In line with this evidence, the number of SABR indications commissioned has reduced. It is important to ensure that treatments commissioned are supported by robust evidence of their benefit to patients.
Baroness Gardner of Parkes (Con)
I thank the Minister but, as recently as February this year, I asked him a question on another form of very specifically targeted radiotherapy. He replied that access would be guaranteed to innovative radiotherapy. My Question today relates to another innovative form, one that targets the particular cancer without damaging the surrounding tissues. Can the Minister explain why the figures have fallen and whether these machines, which are very valuable, are being left unused? If they are, is it because of the lack of people being trained to use them? Do we have enough skilled staff to allow patients to benefit from what is greatly improved radiotherapy?
Earl Howe
My Lords, there is no shortage of investment in radiotherapy and no barrier, indeed, to clinically appropriate access to radiotherapy. A lack of trained staff to operate the machines is not the reason that the use of SABR has fallen. The reason is that the clinical and commissioning decisions have been taken to reflect the evidence of what is clinically effective for certain cancers. That is why clinicians are no longer commissioning this form of radiotherapy for cancers which do not respond adequately to that form of treatment.
Baroness Finlay of Llandaff (CB)
Do the Government recognise, though, that there are times when commissioning has to invest to save and has to support evaluation while a treatment is ongoing, and that the new forms of stereotactic radiotherapy have very good local control rates? For example, in lung cancer the rates have improved from 20% to 30%, with 15 to 20 treatments, to about 70%-plus with only three to five treatments. For patients to be treated nearer home, the costs saved to other parts of the care system need to be considered in the commissioning decisions, where you have better local control and lower knock-on healthcare effects.
Earl Howe
Yes, my Lords. Radiotherapy, particularly of this kind, is highly cost effective when it is clinically indicated. In fact, SABR is available in eight radiotherapy centres in England. The number of centres providing this treatment is increasing, with over a quarter having equipment capable of delivering the treatment. Current evidence supports treating only a small number of patients with this treatment: that is, in early-stage lung cancers for patients who are unsuitable for surgery. That is about only 1,000 patients a year.
Lord Hunt of Kings Heath (Lab)
My Lords, the noble Earl will be aware of a pledge made by the Prime Minister last October that this kind of treatment would be available to cancer patients who needed it. He will also be aware of a statement by Mr Lawrence Dallaglio, who was asked by the Government to help in this. He described it as a “national disgrace” that NHS England reneged on a deal to fund these cancer treatments. Is the noble Earl absolutely certain that the reason the number of treatments has fallen is due entirely to clinical reasons?
Earl Howe
Yes, my Lords: that is the advice I received. It goes hand in hand with other advice around other forms of radiotherapy treatment that are increasing very dramatically. For example, intensity-modulated radiotherapy is a similar form of radiotherapy for different types of cancer—head and neck cancers, principally. The use of that radiotherapy has grown very considerably, partly as a result of considerable investment by the current Government.
Baroness Barker (LD)
My Lords, this treatment works for patients caught very early in the stages of their disease. Is NHS England working with GPs to increase the number of people who they suspect have cases that will respond to this treatment getting into these centres in the first place?
Earl Howe
Yes, my Lords. One of the measures we took some months ago was to enable GPs to refer patients directly to diagnostic centres when cancer was suspected, thereby accelerating the pathway towards effective treatment if cancer is diagnosed. The signs and symptoms campaign is specifically directed at not only patients but also clinicians, including GPs.
Baroness Hooper (Con)
My Lords, is my noble friend aware of the important research carried out over the past 30 years at Southampton University’s centre for immunology to create a treatment based on stimulating the immune system? I appreciate that that is not on all fours with the Question, but it has the same parallel advantage of not causing the debilitating side-effects that traditional chemotherapy and radiotherapy treatments can.
Health and Social Care Act 2012: Risk Register
Earl Howe Excerpts(11 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
The Government’s position has not changed since the noble Lord asked the same Question last December. We are not proposing to publish the risk register. This decision is based on the principle that Governments and their civil servants need to be able to consider the risks associated with policy formation in private. It remains our view that a full and candid assessment of risks and their mitigating actions should be carried out within a safe space.
Lord Brooke of Alverthorpe (Lab)
My Lords, the logic of that is that no risk register should be released to the public and I do not believe that is the Government’s policy. Given the Secretary of State for Health’s recent encouragement and support for NHS whistleblowers, and as the original risk register was released into the public domain by a whistleblower, what would the Government do if the continuing cover-up was then blown by a whistleblower before the next general election?
Earl Howe
My Lords, I am sure the noble Lord would expect me to say that hypothetical situations are not in my domain, and that is true in this case. The Government’s position is that there is a balance to be struck between transparency of activity in government and the safe space required for effective policy-making. That is why, in November 2011, I laid out for this House a comprehensive list of the areas covered by the transition risk register, but also why, at the same time, the Government decided to withhold publication of the register itself.
Lord Marks of Henley-on-Thames (LD)
My Lords, my noble friend will well remember the concerns of my party on this issue in 2012. I wonder whether he considers now, two years after the Act, that even if the private advice of civil servants should retain protection, the factual information in the register could now be published. That would enable everyone to monitor how the Act is working against what was predicted in 2012.
Earl Howe
My Lords, it is possible to monitor how the Act is working without publishing the risk register. It is quite true that the transition to the new commissioning system is over. However, the risk register related expressly to the implementation of the reforms and the system is still bedding down. Therefore, we are still of the view that it is inappropriate to publish the register.
Lord Kakkar (CB)
My Lords, I declare my interest as professor of surgery at University College London and chairman of UCL Partners. At the time of its Second Reading, the Minister was kind enough to indicate that the Health and Social Care Act would enjoy post-legislative scrutiny after three rather than five years. Does that remain the intention?
Lord Hunt of Kings Heath (Lab)
Referring to the noble Lord, Lord Marks, methinks the Lib Dems are trying to rewrite history. They underpin this dreadful change that the 2012 Act brought to the NHS and they bear responsibility for the shambles that it has caused. I am very confused by the approach of the Department of Health. It has berated the National Health Service for not being open and transparent; in fact, it published a league table of those who are good and those who are not good. The NHS bodies are required to publish risk registers, so why should it be different for the Minister’s own department?
Earl Howe
The Government of which the noble Lord was such a distinguished member took the same approach to risk registers. Of course, transparency is an important principle in health and care. It is important to drive up performance and expose institutional failure, and I believe there is a revolution taking place in the level of transparency and access to health and care information. I am sure we are agreed on that. The point that I sought to make earlier is that when it comes to policy-making within government, Ministers and civil servants are entitled to some safe space, so the principle of transparency has to be moderated to a certain extent. That is the balance that we have struck.
Baroness Knight of Collingtree (Con)
My Lords, is it not the case that a recent independent Commonwealth Fund report said that Britain had the best and safest healthcare system of all the 11 wealthiest nations? Since we know that the NHS is the biggest organisation and business of its kind in Europe, with all the opportunities for it to go wrong, is this not an extremely telling assessment of the real situation?
Earl Howe
I agree completely with my noble friend. The Commonwealth Fund report covers the period from 2011 to 2013—exactly when we were in the middle of reforming the NHS. The findings of the report were a credit to all those working on the front line of the healthcare system throughout that period of change.
Baroness Farrington of Ribbleton (Lab)
My Lords, the Minister is right to refer to that report, which I believe was based on 2011 figures. Does he accept that it is not politicians who are entitled to see the risk register but the public, particularly when the coalition Government promised separately and together that there would be no top-down reform of the health service? Are the public not entitled to know what regard this coalition Government have to the public’s need to know? The public want to know if the risk register identified risks post-2011.
Earl Howe
The noble Baroness is absolutely right. The public are entitled to know the areas of risk identified by the Government at the time that the transition risk register was drawn up. That is exactly why I laid out for the House a comprehensive list of the areas covered by the risk register on 28 November 2011. That was a full list, which nevertheless did not disclose the actual content of the risk register. That is the balance that I believe any Government are entitled to strike. The public are therefore in a position to judge how well the system has done.
Lord Grocott (Lab)
Can the Minister confirm that one of the unarguable costs of the reorganisation has been the number of people previously employed by the health service as administrators who received their redundancy settlements and pay-offs but were subsequently re-employed by the health service? Will he tell the House how much this has cost—the initial redundancy settlements, the subsequent salaries that are being paid and the number of people involved? If he does not have that figure to hand, and as he will not publish the risk register, will he at least make available in the House the precise figures of the cost to the taxpayer of this aspect of the reorganisation?
Earl Howe
I am certainly happy to write to the noble Lord with whatever figures I have on that front but, of course, those who were made redundant as a result of the reorganisation received payments of no more and no less than they were entitled to under their contracts of employment. There are more than 19,300 fewer administrative staff in the NHS than there were when we came to office, but more than 16,300 more clinical staff, including 7,400 more doctors and 3,300 more nurses.
NHS: Rural General Practitioner Dispensing
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Lord Lea of Crondall
To ask Her Majesty’s Government whether they will hold talks with NHS England about steps that could be taken to slow down the closure of rural dispensing general practitioner practices, against the background of the operation of the one-mile rule covering new free-standing pharmacies, and the phased withdrawal of the minimum practice income guarantee.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
I and my ministerial colleagues are in regular contact with NHS England. We are not aware of significant closures of rural dispensing practices. The “one-mile rule” is a long-established precept under NHS pharmaceutical services legislation, which determines whether patients in designated rural areas remain eligible to receive dispensing services from their GP. We have no plans to review or amend that precept. NHS England is asking practices that believe they may be adversely affected by the phased withdrawal of the minimum practice income guarantee scheme to contact their local area team to discuss their concerns.
Lord Lea of Crondall (Lab)
I thank the Minister for that reply, but the British Medical Association, at its conference last week, produced a statement citing NHS England as expecting scores of closures of such dispensing practices. I have a supplementary question and a proposal, but I think that the House may find it useful if I give the background.
Lord Lea of Crondall
Given the loss of income from the double whammy of what is called the one-mile rule and the phased withdrawal of the minimum practice income guarantee, many practices will go below the red line of viability. Will the Minister therefore hold talks with NHS England and suggest that, when there is such a double whammy, the one-mile radius rule could be applied to new patients but not to existing patients—so numbers would be reduced through mortality over the years?
Earl Howe
My Lords, the phasing out of the minimum practice income guarantee is being gradually implemented over seven years to give adequate time for GP practices to adjust. In fact, most practices stand to gain under that arrangement. I would encourage any practice to take the matter up with the local area team at NHS England if it has particular concerns. The provisions governing whether a doctor can continue to provide dispensing services to eligible patients when a new pharmacy opens nearby, which is a separate issue, have been in place for a long time and are subject to a long-standing agreement. If an application for a new NHS pharmacy is made to NHS England that would affect, for example, the noble Lord’s dispensing practice, that practice is able to make its views known. There is an appeals process as well. If a new pharmacy were approved that does affect the practice’s dispensing patients, it is open to NHS England to phase in gradually the shift from using the practice’s dispensary to a pharmacy for those patients affected.
The Countess of Mar (CB)
My Lords, does the Minister agree that this agreement arose from the 1911 Act—well over 100 years ago—and that there is extreme unrest among patients who are forced to go to a pharmacy when they have been used to using a dispensing doctor? Does the Minister intend to continue subsidising what are known as essential small pharmacies and not give patients a choice?
Earl Howe
My Lords, I do not think that it is a question of opposing choice against the rules that we have in place. The rules are there as a result of very long-standing agreements between the medical profession and the pharmacists. I do not think that there is an appetite on either side to open those rules up for renegotiation. A balance has to be struck somewhere and the professions are content with the balance that has been struck.
Baroness Brinton (LD)
My Lords, given that half of patients who use dispensing GP services include at least one person over 65 and that one in six is a disabled person, can the Minister tell us whether the one-mile rule makes sense in very rural areas, where public transport may be very sketchy, especially as the one-mile rule is as the crow flies, not via the roads?
Earl Howe
My noble friend makes a good point. That is why the rules contain an exception for those who find it difficult to travel and who may therefore wish to have medicines dispensed from their own dispensing GP practice. Those rules do apply to disabled people and to those whom my noble friend describes.
Lord Hunt of Kings Heath (Lab)
My Lords, does the Minister not regard it as somewhat ironic that yesterday we had the Government trumpeting their Deregulation Bill but today he defends what essentially is an uneasy truce between the BMA and the pharmaceutical interest, in which often the public are the losers? Is it not time for that to be reviewed again?
Viscount Tenby (CB)
My Lords, I am grateful for the assurances that the Minister has given so far in respect of possible closures as a result of the change in the financial arrangements and also, of course, of developments in towns, which inevitably result in the creation of new general practices and new associated pharmacies. On the question of rural practices where a proportion of patients are very old indeed, I ask the Minister to reiterate that great care will be taken that they will not be disadvantaged in any way by the future arrangements.
Earl Howe
Yes¸ my Lords. As I have described, there is a provision in the rules to take account of elderly and infirm people who find it difficult to travel and who may therefore still wish to have their medicines dispensed by their own dispensing GP rather than be forced to travel a longer distance.
Health: Polypill
Earl Howe Excerpts(11 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank the noble Lord, Lord Hunt, for giving us the opportunity to debate a particularly interesting subject and for having elicited a number of very well informed speeches. In calling for this debate, he has done the House a considerable service by enabling noble Lords, including myself, to bring ourselves up to date on what progress has been made in the development of the polypill concept. As has been said, heart attacks and strokes are major health issues in the western world and a growing issue in the developing world. Reducing mortality for people with cardiovascular disease and improving their outcomes is a key priority for the Government. We have made it clear, through the NHS and public health outcome frameworks and the Government’s mandate to NHS England, that we want to see action taken across the health system to reduce avoidable premature mortality from cardiovascular disease.
The 2013 call to action on premature mortality set out the Government’s ambition for England to be among the best in Europe in tackling the leading causes of early death, including cardiovascular disease. In April this year, we published Living Well for Longer, which brings together what the health and care system will do to meet this challenge.
There has been a great deal of interest in the polypill and its potential for reducing the risk of heart disease over the years. It may surprise some noble Lords that the concept was first introduced into the scientific and public domain as far back as 2003. It was proposed in an article in the British Medical Journal by two people whose names have been mentioned already, Professors Nicholas Wald and Malcolm Law of the Wolfson Institute of Preventive Medicine. Using mathematical modelling, they estimated that a polypill comprising a statin, aspirin, a combination of three blood pressure lowering drugs and folic acid, could reduce heart disease events by 88% and stroke by 80%. Their article concluded that their proposed polypill could,
“largely prevent heart attacks and stroke if taken by everyone aged 55 and older and everyone with existing cardiovascular disease.”
Although the effectiveness of the combined drug and any possible side-effects had yet to be evidenced though patient trials, this captured the imagination of the public health research community, particularly for the prevention of non-communicable diseases such as cardiovascular disease.
Essentially, the polypill is a combination of multiple medicines which aims to prevent or reduce the risk of cardiovascular disease: that is, strokes and heart attacks. Each of the constituent medicines is either at the current recommended dose or at lower doses. The premise is that these combinations should be used in preference to using the same medicines separately. In practice, the polypill can refer to either the fixed-dose combination medicine to reduce cardiovascular risk, patented as the polypill, or any other fixed-dose combination medicine, such as the red heart pill. However, any discussion of polypills is complicated by the huge range of drugs which might be included in any combination.
Polypill active ingredients are licensed separately as medicines and well established in their own right; their use together in fixed combination is what is novel. Just like any other medicine, any application for a marketing authorisation for a polypill needs to be supported by data demonstrating that its quality, safety and efficacy are satisfactory and that the risk-to-benefit profile is favourable for the proposed treatment before such an authorisation or licence can be granted.
My noble friend Lady Brinton drew attention to the side-effects of polypills and statins. She was absolutely right to do so. My information is that the evidence is not yet there on the side-effects of the polypill. Patient safety must of course be paramount in that context.
No polypills are currently licensed for use in the UK for the prevention of heart attack or stroke. I understand that the Medicines and Healthcare products Regulatory Agency has provided scientific advice to a number of sponsors and companies for combination products of this type. However, no application has yet been made to the licensing authorities. In the event that a marketing authorisation proposal is submitted, the data supporting any claims for benefit in the stated patient population, together with any evidence of adverse events, will be carefully reviewed. Only if the overall balance of benefits versus risks is favourable will a marketing authorisation be granted.
Without a marketing authorisation, as the noble Lord will know, doctors can prescribe an unlicensed medicine under their own professional responsibility. That addresses one question raised by the noble Lord, Lord Turnberg, as to whether it is in theory available on the NHS. The answer would be yes, in those circumstances, but any national action to promote the use of a drug that is not licensed is out of the question, as I am sure he is aware. I understand that there are several clinical trials of polypill products in progress in various countries and it will be interesting to see the results.
The noble Lord, Lord Hunt, questioned whether it was the fear of additional workload that was deterring doctors in the context of the polypill. My information is that the evidence on that front is as yet unavailable one way or the other, as regards the primary prevention setting, but that clinical studies are now under way. Indeed, I have in front of me the details of three polypill phase 3 clinical trials which had either completed or were close to completion as of May 2014. I can let the noble Lord have details of those trials if he would like me to do so.
The noble Lord, Lord Turnberg, raised the possibility that the polypill could be prescribed to those people who do not fall into the risk group. That is, of course, the primary prevention group. I am advised, though, that as age advances, the risk of side-effects also increases proportionally. I suggest that before embarking on a course of this nature, we would need evidence that the polypill influences benefit more than risk. We therefore come back to the issue of clinical trials in order to demonstrate that.
Having said that, to answer another of the noble Lord’s questions, I accept that the polypill could be more convenient for some patients and could help them to adhere to their medicines. Whether it would prove cost-effective is something that NICE might in due course consider.
I know that not everyone is convinced by the polypill. There are, for instance, concerns about the medicalisation of otherwise healthy people. Even by its proponents it is seen as secondary to other forms of prevention. Professor Wald himself is quoted as saying:
“This is not the solution for primary prevention … Primary prevention requires education of the public. As a priority this is much more important than any polypill”.
There is a range of population-based interventions that could be put in place to reduce the risk of cardiovascular disease. Each has its pros and cons and may be suitable for some patients and in different circumstances. We know that many premature deaths and illnesses could be avoided by improving lifestyles. The Government’s public health programme includes national ambitions to reduce smoking, obesity, physical inactivity and the harmful use of alcohol—all with appropriate metrics included in the public health outcomes framework.
In addition, through the NHS Health Check programme people between the ages of 40 and 74 are offered a range of tests that include measuring their cholesterol and blood pressure levels. The check has been designed primarily to help healthcare professionals identify cardiovascular risk in the adult population earlier so that steps can be taken to reduce it, but it is worth emphasising that it is also targeted at a range of other conditions.
All 152 local authorities are now offering the NHS Health Check programme, which is a significant milestone in the programme’s evolution. In 2013-14 a total of 2.8 million people—almost 20% of the eligible population—were offered an NHS health check, and just over 1.4 million of them received one, giving a take-up rate of 50%. This is the greatest number of NHS health checks offered and accepted in one year since the programme began.
Lord Turnberg
That is all extremely credible. However, the polypill is aimed at those who have passed the health check with flying colours—that is, they have normal cholesterol and blood pressure, do not smoke and are not overweight. It is with this group of individuals, who are not suspected of having the liability to develop a heart attack or stroke, where it seems to have its place.
Earl Howe
Again, that is the primary prevention group, and the point that I was seeking to convey earlier was that we would need evidence that the benefit-to-risk ratio was sufficiently positive before proceeding down that course. That is not to say that it is not, but there is work to be done to prove it.
In March 2013 the Cardiovascular Disease Outcomes Strategy was published. This set out possible actions within the current legislative framework, systems architecture and financial settlement to deliver improved outcomes for people with CVD. It set out a framework for 10 actions that would make a real difference in improving outcomes for patients and their families. While I could expatiate on that subject, I am told that my time is drawing to a close, so suffice it to say that I hope that noble Lords have found today’s debate as interesting as I have.
The polypill is certainly an interesting concept. It may be that this type of approach would be more suitable in developing countries, where the real epidemics of cardiovascular disease are building up and where clinical trials are taking place, rather than in a more sophisticated healthcare system such as ours, where prevention and tailored therapy are more the norm. Time will tell.
On the issue of market failure, which was introduced by the noble Lord, Lord Hunt, I am not convinced that the same arguments apply to the polypill as apply to antimicrobials. For one thing, there are a number of clinical trials of polypills in progress, as I mentioned, and the MHRA has provided scientific advice to a number of companies, so clearly there is commercial interest out there. We do, however, welcome any technologies that contribute to providing the best treatment for people with cardiovascular disease.
In answer to the main question of the noble Lord, Lord Hunt, of whether the Government will consider playing a more active role in this debate, I would certainly be interested in looking at the noble Lord’s proposals in more detail and would be happy to discuss the matter with him at a suitable moment. With that, I thank him once again for introducing this extremely interesting topic for our consideration.