Homecare Medicines Services (Public Services Committee Report)

Lord Carter of Coles Excerpts

Thursday 2nd May 2024 Lords Chamber

[Lord Carter of Coles (Lab)]

My Lords, it is a pleasure to serve on the committee that undertook this revelatory review, under the sure-footed guidance of our chair, the noble Baroness, Lady Morris of Yardley. I add my thanks to the support we had from the team and to the noble Lord, Lord Blencathra, for drawing our attention to this issue. As others have noted, the horror of it was hidden until he shone a spotlight on it. My interests are those as declared on the register.

Rereading our report was profoundly depressing. On the other hand, when we got the Government’s response in the letter of 25 March, my spirits began to rise because, like other noble Lords, I saw that there could be a way out. There are really two key questions. How did this mess occur? It is a spectacular own goal by the NHS. More importantly, can we be convinced that the NHS is going to do something about it? How do we get through the fine words? My questions are more about the details.

We found a casually overseen service—it was sloppy—which spends over £3 billion a year. Is it £3 billion, £4 billion or £4.1 billion? Who knows, but it is a huge amount of money. To put it into perspective, Defra spends about £2.5 billion on the whole of support for agriculture in this country. I have to say that, if this was a Defra debate, there would be a lot more people here. The point is that it is really significant, and it does not get the attention it needs. It looks after 500,000 patients, many of whom are vulnerable and have experienced appalling care, high levels of distress and, frankly, very confused financial oversight to the system.

Why did this happen? It is obvious: it was caused by a lack of organisational clarity. Who was responsible? Nobody knew. What was the accountability and effective management? There were two failures: one of the management of operations and one of regulation.

Looking forward, in a modern healthcare system, caring for the patient in the right place at the right time is important in that continuum of care, and therefore it is axiomatic and vital that getting homecare services working is central to the future of the NHS. This is not a policy matter—it is good practice: you want to get the patient into the right place. It is not a high-level policy or strategy thing; this is about operations and operational excellence. That must lie with NHSE, and it would be good to hear the Minister confirm whether that is where he thinks the first level of responsibility lies. It would also be nice to hear whether he agrees that this important service would have continued to languish had it not been for the intervention of this committee of your Lordships’ House.

Although the report is succinct, I shall focus on three things: transparency, information technology and accountability. On transparency, any good system that focuses on quality and cost must have data. That is the key to it. The Government’s response was very encouraging. It was nice to read—I think that they understand the issue and they are getting people to work on it. Let us just hope they can come up with something effective.

However, on recommendations 7 and 8 and the question of debundling that other noble Lords referred to, I could not quite understand the response—the point about commercial confidentiality. As other noble Lords commented, this is public money; we should get access. Also, it is remarkable that we cannot get anonymised data setting out these things hierarchically. I cannot understand it, so perhaps the Minister might do that. I encourage him to get his department to look at the P&L accounts of the pharmaceutical manufacturers and those of the people who provide the service. The balance of power seems to lie at the back end with the manufacturers, rather than focusing where the service needs to be at its best. The money should go at the front end where it hits the patient. I think he will be as surprised as I was when I looked at those accounts. Some 80% of homecare is delivered in this bundled fashion, which impedes direct management. If we have intermediaries for various sources, particularly the pharma companies, contracting here and subcontracting there, we have to get a direct accountability framework. I shall come back to that in a moment.

On digital, electronic prescribing has been really slow, and if you cannot get the information out, you cannot get the drugs to the patient. You cannot plan or do these things properly. It is absolutely fundamental. Instead, we have pieces of paper flying around—these are decades-old systems. The key to this is getting the IT to work for electronic prescribing, but also getting that data back into the integrated care record. These patients are not stuck just in homecare; they go back into the acute hospital and the community, and they have comorbidities. The question is: how do those servicing them look across the care spectrum with one record of care? Can the Minister tell us when he thinks we might find some integrated care record so that all those phases can become apparent to support patients?

The nub of the problem is accountability. This was chaos; everybody we spoke to had no idea who was responsible. It was most remarkable, as other noble Lords have noted, and I have never been in a situation like it. But we are where we are. Clearly the Government accept this situation, and clearly our report has been a catalyst for change. How do we get clarity of roles, responsibilities and decision rights, if we are to unwrap this whole shambolic situation? I hope the Minister can tell us whether, when these reports come forward—possibly in the summer, ahead of the recess—he will be able to publish an accountability framework. Until we see that, and see how the pieces fit together, although we might have a lot more words we cannot focus on who we can go to, in the operations particularly. Where will this famous SRO sit? To whom will it be accountable? Who will be accountable to it, and what decision rights will it have? Unless we get that right, all our aspirations will not be met.

As regards regulation, one might say, as the noble Lord, Lord Blencathra, noted, that the CQC has failed in this respect. Light-touch regulation is one thing; dereliction is another. We must be sure of two things. First, there can be only one regulator—multiple regulators always fail. We need a super-regulator, which has to be the CQC—we have not got time for legislation. Secondly, the CQC has to be made effective and has to come to an arrangement with the two other organisations that underwrite quality.

The NHS is in a most difficult position; it is under unprecedented pressure on every front. As the noble Baroness, Lady Morris, noted, this is not about money; this is about organisation, management, detail and covering that ground. We are encouraged by the fact that the Government have accepted, or nearly accepted, so many of these recommendations, but the fact remains that this has to be about access and getting things right as we go forward. I hope that the Minister can tell us with some confidence what next steps he intends to take in order, when this comes back in the summer, to tell us that the way forward is there.

I end by saying this. It is clear that the Government have found this report quite useful. Since our committee is always looking for interesting things to do, maybe the Minister will point to one or two other things we could look at in order to help him.

NHS: Long-term Sustainability

Lord Carter of Coles Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Carter of Coles (Lab)]

My Lords, it is a delight to follow the noble Baroness, Lady Boycott. She certainly has a different view on things. I congratulate my noble friend Lady Ramsay of Wall Heath; she gave a tremendous maiden speech and brings great experience to this House, for which I am sure we will be very grateful. I was particularly struck by her comment on reorganisation, which I will return to later. We have had too much of that and a little less performance. I draw attention to my interests in the register. The noble Lord, Lord Patel, made a tremendous, and very knowing, opening speech. It was very clever how he went across the whole spectrum of things. I am perhaps a little less Olympian and will focus on one or two more narrow things.

Modern, high-performing healthcare systems are characterised by high quality, high productivity, and critical, consistent and predictable funding. That then leads to high patient satisfaction. This is being achieved in other parts of the world. For patients, it means access, rapid diagnostics, timely care and rapid discharge, preferably to home. How is that delivered? It is by providing the patient with a seamless journey along the continuum of care. Nowadays, that can be AI-enabled, but that needs an IT system that sits behind it to provide the single view of the patient. It is siloed, and it is very hard to deliver integrated care—I am sure that my noble friend Lady Pitkeathley knows this—unless you have a data system that gives you that access.

In other countries where such a system has been deployed, we have seen diversion away from hospitals—something many noble Lords have commented on. Between 20% and 40% of people simply do not need to go in; they need to be treated in other places. One encouraging thing—the National Health Service gets things right sometimes—is that the integrated care boards stand a chance of delivering this, but we have to focus and get on with it. It will take five years, but it needs to be done.

In the meantime, we must operate what we have a lot better. There are a number of things that are key to that: getting the primary care contract fixed; getting healthcare professionals facing up to patients much more on a substitution basis; and streamlining the primary care back offices. These are simple things—they are managerial, but critical.

Acute hospital productivity must rise, which the noble Lord talked about. Why did it take us so long—perhaps the Minister can say—to go back to payment by results? In a system that is desperate for activity, we went to block contracts, which is as close to lunacy as you can get. Can we go back to payment by results, and can we broaden it to encourage more providers, so that we get diversity of provision and also location? We need to move closer to the patient, and the only way to do so is to create certainty of payment through the tariff system. Those are the straightforward things that we can do.

I suggest doing two things. I have already talked about payment by results but, secondly, we must simply face up to the issue of delayed discharge. As happens in many other countries, we need the National Health Service to pay for the first 60 days post discharge. That would cut it all out and get people out of the hospitals. It is a very straightforward solution. It must be paid for at some point—but better that it is paid for and the arguments are moved out to somewhere else while people consider how to fund it. Long-term care funding and social care funding are, I think, matters for another day.

No healthcare organisation can truly be efficient and deliver at high quality if it has appalling staff morale. According to the last staff survey, only 44% of those employed in the NHS felt valued, which means that 56% did not. Some 25% felt bullied by their colleagues or managers. In most health systems, if that figure got to 5%, they would have the drains up. This is absolutely hopeless.

What all this comes down to is a management problem. We have had a lot of strategies; we have great strategies. Again, Ministers sort of knew what to do, so they commissioned the Messenger report. That report was absolutely tremendous, and had nine things we can do to fix things. Perhaps the Minister can tell us if those nine things will be implemented, because it is two years since the report was published. If we do not get the management right, nobody will put any more money in.

I am short on time, but I just share a little anecdote. If you have a group of NHS managers, and you ask them to name the 20 best-run hospitals in England, you get the usual: Northumbria, Chelsea and Westminster—despite the diet—Leeds and South Warwickshire. People can name eight easily; if they are lucky, they name 10. At best they name 15. There are 135 hospitals in this country. What does that tell us about the depth of management? The critical thing, therefore, if this is to work—I will shut up in a moment—is to get NHSE working properly. I am not sure that I will be as dramatic as the noble Lord, Lord Warner, but we must face up to the fact that we do not have a working management system. It is Soviet, and we are way past Soviet times. Let us hope that we can save the NHS and keep it free at the point of delivery.