NHS (Charitable Trusts Etc) Bill

Lord Bishop of Bristol Excerpts

Friday 26th February 2016 Lords Chamber

[The Lord Bishop of Bristol]

My Lords, I am grateful for this opportunity to speak in the gap. For reasons I do not fully understand, my name was missed off the list. I am pleased to stand on behalf of these Benches to say how warmly we support the Bill. I also congratulate the noble Baroness, Lady Massey, on her introduction of the Bill, and her ability to take some of the detail of the legislation and, to quote Garrison Keillor, put the hay where the goats can get it. I am most grateful to her for that.

I also thank the noble Lord, Lord Bird, for his remarkable, spontaneous, interesting and engaging maiden speech. I wonder quite what volume he might muster when his throat recovers.

As I said, I am glad to speak in favour of the Bill. I am in favour both of the principle behind it and of its practical application, as many in your Lordships’ House have said, in relation to Great Ormond Street Hospital, which is a remarkable hospital. These charities—260 of them, I believe—have been of huge significance in the NHS in helping to raise funds for research and for other things. I support the principle of giving those charities that wish it the ability to avail themselves of the provision to release themselves from the oversight of the Secretary of State so that they might grow their work.

The particular issue is the Barrie legacy to Great Ormond Street Hospital. We may not all be famous authors, industrialists or entrepreneurs, but I believe that we can all play our part in getting behind the Bill and supporting its important provisions. I was interested to read that Great Ormond Street Hospital opened in 1852 with 10 beds and a nursing complement of one. This is remarkable, given that in 1845, if my memory is correct, of the 2,400 in-patients in hospitals, only 26 were children, despite the fact that overall deaths in London that year were 50,000, with 20,000-odd being children. Great Ormond Street has not just been excellent in care, hope and research but has played its part in the advocacy of the rights of children.

Many noble Lords will recall in Barrie’s wonderful children’s novel that Peter explains to Wendy that the Lost Boys are lost as they have no one to tell them stories and that they will never grow up because they will not have any stories to hand on. Today, we have an important opportunity to get behind the Bill and make sure that the great, ongoing story of National Health Service trusts, in particular Great Ormond Street, continues. I hope that your Lordships will feel able to support this wonderful piece of legislation.

Residential Care: Cost Cap

Lord Bishop of Bristol Excerpts

Thursday 10th December 2015 Lords Chamber

[The Lord Bishop of Bristol]

My Lords, I join other Members of your Lordships’ House in thanking the noble Baroness for securing this debate. I admired her high-paced delivery of a lot of information without losing any clarity. Like the noble Baroness, I hope that this will not become a debate where we just trade statistics across the House, because in the end, as the noble Lord, Lord Filkin, has just drawn our attention to, this is about people and their lives, and therefore it is a matter that should be, and is, of great concern to us all.

If I stand in my bathroom and look out across the fields in north Bristol, I see the shell of Winterbourne View standing there as a testimony of what can go wrong with residential care when the business model is bust and the whole thing falls apart. It pains me to look at that building day by day.

Your Lordships have made it very clear, through the competence of this debate, that we have to do better. Just this morning when I turned on my radio, I heard that the Nuffield Trust is saying there is going to be a massive crisis this winter in the National Health Service, because a lot of people who are in hospital really should be in residential care but there is no space for them. We all know well—certainly, your Lordships know well—that we have an ageing population. More people now live in single-occupancy homes. People are often, sadly, estranged from or live a long way away from their families. Although I agree with the comments made this afternoon about complementary domiciliary care, we are here to talk about residential care and what that might look like going forward.

The chairman of the Commission on Residential Care, Paul Burstow, having noted, as the noble Baroness, Lady Brinton, said, that there are some very good examples of care, said:

“There are some tough messages. The brand of residential care is fatally damaged. Unloved, even feared, for most people residential care is not a positive choice. Linked in the public mind to a loss of independence, residential care is seen as a place of last resort”.

We heard from the noble Baroness, Lady Wheeler, about the Care Quality Commission’s evidence. We have heard about ResPublica, which has revealed the devastating fact that 37,000 beds will be lost between now and 2020.

I remember, back in the 1990s, when I was more closely allied to investment institutions, there was quite a move for investment institutions to invest in residential care. If I recall rightly, even the Church Commissioners looked at that. Now, we seem to be in a very different place. We have heard about Southern Cross, and about Four Seasons. I know the Minister will be concerned about this issue, but to my mind it does create a massive void in terms of how we are going to deal with it. I am not clear, as yet, from what I have heard from the spending review, that the plan thus far will be able to fill that void.

I am most grateful to the noble Baroness, Lady Brinton, and to the noble Lord, Lord Lansley, for mentioning Dilnot. The Dilnot report was a very important piece of work which I hope will not get lost. I hope the Minister will feel able to comment on exactly where we go with that.

There is a lot of anxiety, especially about documented failures in the care system. I think it was Oscar Wilde who said that biography lends terror to death. One might slightly bastardise his comment and say that residential care lends a bit of terror to those who know or feel that they might need residential care going forward. We have had Winterbourne View and Hadleigh House in Lincolnshire, and we heard the Minister this morning repeat a Statement about the terrible abdication of care in Southern Health NHS Foundation Trust. I welcome the fact that the Government and the NHS are now placing a renewed emphasis on palliative care and end-of-life services, but can the Minister assure us that it is equally essential that the priority being given to end-of-life services be applied adequately to residential care?

There is anxiety about this whole issue. Let me end where I started, by reminding your Lordships, as several noble Lords have reminded the House, that in the end this is about people. It is about the kind of care they might get, and how we face the cost of that. It is a particular anxiety, I guess, for those people who do not have what are called fat pensions or easily realisable assets to pay for their care—in other words, some of the poorest people in our land. The question remains for me: who will care for these vulnerable people when they can no longer look after themselves? We are facing a huge problem and I look forward greatly to hearing the Minister’s response to many of the questions raised by noble Lords.

Health

Lord Bishop of Bristol Excerpts

Thursday 26th November 2015 Lords Chamber

[The Lord Bishop of Bristol]

My Lords, I, too, am grateful to the noble Lord, Lord Crisp, for introducing this debate and this very big idea into the Chamber. Already we start to see that the breadth of material that needs to be thought about in relation to creating a healthy society is indeed vast. I sat here for some of the debate thinking were I the Minister—God forbid—how I might respond to such a plethora of concerns that have been articulated. I wish him well with that.

Of course, what we cannot do, as several noble Lords have noted, is expect the Government to solve this on their own, although I think there is a major challenge involved in this for government. That is what I would call the alignment of policy—how do you align policy over a very wide range of areas in life in such a way that human well-being emerges from it?

Your Lordships are very well aware that the danger of these debates is vain repetition. I have no wish to enter into that. In the few minutes available to me, I will focus on a particular aspect of our society at the moment, which causes great concern and, as we have already heard, has some rather serious health outcomes. I speak of social isolation—loneliness. On the Mind website, loneliness is defined as,

“not feeling part of the world”.

It goes on to explain that it is therefore perfectly conceivable—I sense that I might have experienced this in my own life—to be part of a crowd and yet feel extremely lonely. It goes on to talk about the impact of loneliness on an area of health that several noble Lords have mentioned—mental health.

However, as the noble Lord, Lord Crisp, reminded us with the rather horrendous statistic of the physical health outcomes of loneliness being tantamount to smoking 15 cigarettes a day, loneliness should indeed concern us. It is not just the preserve of the elderly in our society; loneliness exists among a number of groups, including housebound people, those in the dormitory suburbs we speak about, where neighbourliness seems in short supply, young mothers, bereaved people and those who feel discriminated against. Lots of people experience a sense of social isolation and loneliness. A GP in Bristol shocked me recently by saying that a good number of the people who attend her surgery come not because there is anything particularly wrong with them from a health point of view but because they simply want to be heard by somebody for a few minutes and that is their only chance. That is very disturbing, partly because I believe we are social beings. John Donne poetically wrote:

“No man is an island”.

I think we were designed to thrive in community: significant social contacts are very important for us.

It would be very easy for us to sink into a mire of depression around all this, but it is worth saying that there are many groups in society who contribute hugely to creating social networks, or at least the opportunity for social networks and for significant social contact. Here, I think of course of churches, faith groups, charities and clubs, and the many other community organisations that create an environment where people can meet each other and speak. I am also well aware—this is a point that the Government might like to think about—that increasingly some of the bureaucratic apparatus, some of it necessary, is interfering with our need to create a volunteer culture that would service these organisations and, in the end, lead to good health.

Back in 1942, the Beveridge report named the five giant evils that the welfare state was set up to tackle. They were want, disease, squalor, ignorance and idleness. I certainly would not want to describe loneliness as an evil but it is a growing fact of life in our society, and its destructive impact on human well-being needs further research and further understanding, as well as further imagination in seeking to combat it. How do we create communities of wholeness where people take responsibility? I realise that some of the questions asked this afternoon by me and others might fall into the realm of essay questions, but I look forward to hearing what my noble friend the Minister has to say.

Prisons: Mental Health

Lord Bishop of Bristol Excerpts

Wednesday 24th June 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Lord raised this in his report five years ago and in the follow-up report that was published more recently. A very early assessment of a prisoner when he arrives in prison is of course extremely important.

[The Lord Bishop of Bristol]

My Lords, given the complex needs of so many prisoners and the fact that those needs have to be addressed consistently, does the Minister agree with me that the risks associated with such prisoners could be greatly reduced were all operational staff in prisons given training on mental health awareness?

[Lord Prior of Brampton]

The right reverend Prelate’s comments are true throughout the whole healthcare system and would also apply to nurses in physical health surroundings. Training in how to recognise and deal with people suffering from mental health problems would be a huge benefit.

Health: Palliative Care

Lord Bishop of Bristol Excerpts

Tuesday 23rd June 2015 Lords Chamber

[Lord Prior of Brampton]

I thank my noble friend for that question. Perhaps I could suggest that he and I meet outside this Chamber, along with some colleagues from NHS England, to discuss his proposal in more detail.

[The Lord Bishop of Bristol]

My Lords, given that both NICE and NHS England have commended the services of spiritual, pastoral and religious care in the care of all people and in delivering great services to patients, clients and staff, can the Minister give us any assurances that a chaplaincy will be funded, going forward, in all NHS facilities that provide palliative care?

[Lord Prior of Brampton]

I thank the right reverend Prelate for that question. I share his sentiments entirely but that is a decision for local hospitals and local trusts.

Health and Social Care Bill

Lord Bishop of Bristol Excerpts

Tuesday 11th October 2011 Lords Chamber

[The Lord Bishop of Bristol]

My Lords, what is clear from the vast volume of correspondence that has arrived in my office in recent weeks is that there is something deep in the psyche of our nation which is extremely anxious about the reforms to the NHS being proposed by the Government in this Bill. Some of that concern is based on a misunderstanding of what is being proposed, but much of it is, in my view, substantive criticism and, significantly, often being voiced by organisations that represent thousands of healthcare professionals. The Government have argued with force that reform is necessary given that the projected costs of the health service going forward are not sustainable. In varying degrees, this observation carries some support. Their stated aim to improve the quality of care is to be welcomed.

The Government made a number of welcome changes to the Bill following the first report of the NHS Future Forum in June 2011. Those changes went some way to addressing concerns, particularly with regard to the composition and remit of commissioning groups, and to the expansion of competition within the NHS. Some outstanding issues, however, still remain to be resolved.

First, despite the reassurances given by the Minister, I wish to make a foundational point which I hope the noble Earl will take into account in his further deliberations on this matter. The Health and Social Care Bill as is runs the risk, I believe, of breaking the obligation of the Government to take responsibility for healthcare in the nation. This is not merely a matter to be judged on the grounds of efficiency or effectiveness, although both are important and, of course, as yet there is no evidence that the proposed changes set out in the Bill will promote either. Rather, the Government’s responsibility for the welfare of the people, including healthcare, is part of the fundamental legitimisation of the state, and a main reason why individuals should subordinate themselves, within limits, to the state. Is it too much to say that a state which withdraws from the responsibility to deliver the welfare of the people loses its legitimate claim on the lives of its citizens? There can be no more fundamental aspect of welfare than healthcare. For this reason, as well as for reasons of practical accountability, it is absolutely essential that the Secretary of State for Health retains final executive authority for the delivery of healthcare and does not relinquish ultimate responsibility either to Monitor or to the NHS Commissioning Board.

Moving on to the NHS Constitution, the Bill now places an onus on both the NHS Commissioning Board and the clinical commissioning groups, formerly the GP consortia,

“to take active steps to promote the Constitution”.

The NHS Constitution contains seven key principles which include providing a “comprehensive service to all”, and providing services that,

“reflect the needs and preferences of patients, their families and their carers”.

This new role of promoting the NHS Constitution through commissioning strategies and decisions is to be welcomed. It means that the commissioning of services cannot be based solely on a traditional medical model of care. The whole needs of patients and others must be met through the provision of comprehensive services. This includes, among other things, meeting their spiritual needs. For many people, spiritual needs may be met only through the provision of religious care. Chaplains are uniquely trained and qualified to provide both religious and spiritual care and, as such, it ought to be explicitly understood that both commissioners and providers should take into account the need for spiritual care where appropriate.

Similar consideration ought also to be given to ensuring that the range of services provided by allied health professionals are maintained and protected, and that the viability of small specialist departments is not compromised through financially driven reorganisation. In a proposed environment of competition, there is a real risk that providers may compromise the quality of their services in order to obtain a contract. It is essential that the requirements of the NHS Constitution are rigorously adhered to by both commissioners and providers in order to minimise this risk.

Concern with regard to providers cutting corners in order to obtain contracts extends also to the nursing profession. Both the Queen’s Nursing Institute and the Royal College of Nursing have noted the real risk of underskilled staff being used by providers in the community and in care homes, partly to enable their bids to be competitive. Commissioning bodies, in order to provide adequate services, need to understand the breadth and quality of nursing care required to meet patient and carer needs.

I have an anxiety about the complexity of the NHS structures that will be created by the Bill. Part of the rationale for reconfiguring the NHS was to simplify its structures and management. At present, the Bill envisages a health service that has a much more complex structure and a greater array of interlocking organisations than before. In addition to the Secretary of State, whose function is to become one of oversight rather than of direct involvement, the new look NHS will encompass the NHS Commissioning Board, clinical commissioning groups, health and well-being boards, Monitor, the Care Quality Commission, the National Institute for Health and Care Excellence, HealthWatch England, Public Health England, clinical networks and clinical senates. In addition, local authorities will have direct input into both public health and the proposed health and well-being boards.

The main problem with the proposed structure is that it may render it difficult to determine precisely where, in practice, decision-making powers lie. The proposed remits of these organisations not only interlock, but frequently overlap. There is a twin danger of the NHS Commissioning Board retaining too much control so that the clinical commissioning groups and health and well-being boards are stripped of any real decision-making powers, or conversely of the checks and balances within the system becoming so cumbersome that decision-making becomes frustratingly difficult to achieve. For example, local authorities and health and well-being boards will, on occasion, be at variance with clinical commissioning groups. The proposed mechanisms for resolving such disputes are complex and may result in the NHS Commissioning Board being drawn into a level of micromanagement that it never envisaged. There is a real danger that the complexity of the proposed structures could lead to a paralysis in decision-making that would be reflected in compromised patient and client safety and care.

I want to make a further point about clinical commissioning groups. The change from GP consortia to clinical commissioning groups reflects the need for the involvement of other health professionals as well as patients and clients in the commissioning of services. The proposed establishment of governing bodies within each clinical commissioning group is to be welcomed both for governance and transparency reasons. So, too, is the requirement that these governing bodies must include two lay members, at least one registered nurse and one secondary care specialist. The failure, however, to prescribe in detail the wider professional membership or the ratio of GPs to other professionals is an error. While there ought to be flexibility to co-opt members according to the requirements of local need, it is important that all clinical commissioning groups have the same core membership. There is a huge difference in having a place at the table by right and being invited to sit there by a pre-existing statutory group. Professionals such as pharmacists, allied health professionals, chaplains and psychologists provide valuable and essential insight into the health needs of populations. This ought to be reflected in the core membership of clinical commissioning groups.

There is much more I could say, but I will adhere to the time limit by concluding that I believe, along with many noble Lords, that some reform of the NHS is necessary to enable it to face the challenges of the future. Aspects of this Bill are to be welcomed, such as the desire to bring greater transparency and patient choice into healthcare, and the desire to involve health professionals more fully in commissioning services. None the less, there are still major problems with the Bill, including those outlined above, that require to be addressed before it can be supported.