Adult Social Care: Funding

Lord Crisp Excerpts

Thursday 16th March 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for bringing that to the House’s attention—some might describe it as a hospital pass, if noble Lords will excuse the pun. The Government remain committed to implementing Dilnot from April 2020. My noble friend is quite right that this is not a blank sheet of paper. There have been some really important reforms over the last seven years, including the better care fund and the Care Act. In the Budget, we have more funding for the short-term sustainability of the social care system, as well as a commitment to the Green Paper.

[Lord Crisp (CB)]

My Lords, I would like to ask a question about children’s social care, where I notice there is also a problem. For example, in the last year local authority support for palliative care services for children was cut by two-thirds, and it now provides only 1% of the expenditure on children’s social care. First, does the Minister acknowledge that there is a problem here as well and, secondly, what are the Government going to do about it?

[Lord O'Shaughnessy]

The issue of children’s palliative care came up in the debate the other evening on palliative care. A review is taking place with the charitable sector of the distribution of funding, particularly for children’s hospices, over the next year. In terms of children’s social care—this may come as a surprise to some noble Lords; it certainly did to me—the fastest-growing part of the adult social care budget is for adults with learning disabilities. Of course, that often comes in at the point at which people leave the children’s social care system and the school system and move into the adult social care sector, so there is an important point about continuity from one to the other.

Hospital Beds: Availability

Lord Crisp Excerpts

Thursday 9th February 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is of course quite right about the need for more money. I re-emphasise that an additional £7 billion or more for social care is going to councils during this Parliament. Councils have the ability to raise council tax, although the leverage obviously varies from place to place. This is why the Better Care Fund was created—to provide extra help to areas that do not get the same income from council tax increases as the better-off places.

[Lord Crisp (CB)]

My Lords, a year ago, the Royal College of Psychiatrists published a report which showed that about one-fifth of adult mental health beds were occupied by people who were ready for discharge or who should not have been admitted in the first place. They were only admitted because there were no adequate facilities in the community. Could the Minister tell us what the figure is today and what is being done about mental health specifically?

[Lord O'Shaughnessy]

The noble Lord is quite right to raise the issue of mental health. I do not have the specific figure with me but I will write to him with it. We know that there has been a historic disparity between the two services. This was recognised by the Prime Minister in a very important speech she gave a few weeks ago, setting out some of the ways in which the Government are doing more on this. However, there is clearly a lot more to do.

Health Workers: Training

Lord Crisp Excerpts

Wednesday 18th January 2017 Lords Chamber

Asked by

[Lord Crisp]

To ask Her Majesty’s Government what plans they have to increase the number of training places for doctors, nurses and other health workers.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, on 4 October the Health Secretary announced that from September 2018, the Government will fund up to 1,500 additional undergraduate medical places each year. Reforms to the funding of nursing, midwifery and allied health preregistration training will come into effect on 1 August 2017. The reforms will enable universities to offer up to 10,000 additional training places by the end of this Parliament.

[Lord Crisp (CB)]

I thank the Minister for his Answer and welcome him to what I think is his first parliamentary Question. I am sure that the Government recognise that there is a growing shortage of health workers globally that comes about as countries, particularly in Asia, expand their workforce enormously. There is a global market and global competition for health professionals. The UK was going to be affected by it regardless of Brexit, but the uncertainties of Brexit make it worse. First, what assessment have the Government made of the scale of the risks from those two factors? Secondly, what assessment have they made of the opportunities? The UK is a world leader in the education of health professionals. What are the Government doing to help universities and others take the opportunity to train more health workers both here and abroad to meet both the UK’s and the world’s demand for increased numbers?

[Lord O'Shaughnessy]

I thank the noble Lord for his welcome. The WHO has identified a global shortage of medical staff of more than 2 million, so clearly there is a big need and, as he says, it is being driven by the development of countries, particularly those with large populations, and the need to grow their own staff. At the moment, about 25% of NHS staff in the UK come from abroad and, like all NHS staff, they do a fantastic job for us. Clearly, given the problem that the noble Lord identified, we will need to become less reliant on overseas staff, which is one reason driving our desire to increase the number of training places for doctors, nurses, midwives and others.

In answer to the second part of his question, I think something like 10 of the world’s top universities are based in the UK. We are a world leader in education; that is a great strength of ours and something that we want to continue. Healthcare UK is the government body responsible for working with universities to unlock partnerships with other countries, and there have been a number of successful examples of where that has happened.

Smoking-Related Diseases

Lord Crisp Excerpts

Wednesday 14th September 2016 Lords Chamber

[Lord Crisp (CB)]

My Lords, I, too, congratulate the noble Lord, Lord Faulkner, on his comprehensive and clear introduction to this important debate. I also acknowledge and congratulate everyone, including the Government, on the progress that has been made over recent years. But we must keep the pressure on. It is easy to think that smoking is beaten as it is relatively rare in public, but it is still very common in some parts of the country.

Most key points have been made. I will bring in only one additional point, but I will first reiterate three fundamental aspects that have already been mentioned. The first is the importance of having a tobacco control plan. The evidence is there that those countries that have one, such as Australia and Canada, do much better in controlling smoking than those such as France and Germany that do not have a strategy. Of course, a strategy is only as good as its contents, and a good strategy and a good plan are needed. The important point here is that there is evidence: local smoking cessation works, properly constructed mass media campaigns work, and the use of vaping or e-cigarettes is also important. So when will we see this strategy and plan, and will it be built properly on the evidence?

The second point, simply put, is that smoking hits poorest people hardest. As the Prime Minister said, if you are born poor you are likely to die earlier. There is evidence that 50% of that impact is due to smoking-related diseases.

The third point I will reiterate is that this is of course not an isolated subject and that stopping smoking has an impact on other diseases and on the health of people in so many different ways, including reducing stillbirths, as has already been said. The key point here is that smoking should not be treated in isolation—although smoking cessation clinics are important—but should be part of a properly integrated health promotion policy.

My single additional point is on overseas development. I was interested to see that the Public Health Minister said in December 2015 that the Department of Health had received a grant to help other countries with their tobacco control strategies and was setting up a dedicated team. This is a global problem that is still growing in many low and middle-income countries. I would be interested if the Minister were able to give us an update on this work by the Department of Health and perhaps by other parts of the UK Government.

NHS and Social Care: Impact of Brexit

Lord Crisp Excerpts

Thursday 21st July 2016 Lords Chamber

[Lord Crisp (CB)]

My Lords, I too congratulate my noble friend on securing this debate, on her excellent overview and on the detailed illustration of nursing that she gave us. As she said, there is trouble ahead. The NHS is very vulnerable, but so too is social care. It is too early to be clear about exactly what will happen, but it is evident that there will be both short-term impacts and some very much longer-term implications. It is about future recruitment, as well as about maintaining the current workforce. As many other noble Lords have said, there need to be strong and constant reassurances for health workers from the EU, and from other countries, from Ministers, chief executives, professional bodies and colleagues.

It is particularly sad that, as others have said, the referendum result has released suppressed racism and other anti-social attitudes among some parts of the population, and that it seems to have given permission for them to be expressed. These need to be put very firmly back into the box, but the underlying causes also need to be addressed. The Government have particular responsibility to provide clarity in this respect and not to destabilise the situation by questioning the status of immigrants now coming in from the EU. We need careful and considered public statements and policies.

I am one of the later speakers in this debate, so I shall start from a slightly unusual place by emphasising what is, I think, a potentially positive aspect of the Brexit vote. The UK currently has the most extraordinary strength in health, biomedical sciences and life sciences. Some noble Lords may know that last year the All-Party Parliamentary Group on Global Health, of which I am a co-chair, put together a very large report on this issue, looking at our strengths in four sectors that are all linked: academia, government—by which we mean the work of DfID as well as the NHS—commerce and NGOs. In all those sectors the UK is a real world leader, coming first, second or perhaps third, generally with the US beating us. We argued in that report that we should build the UK as a great health hub or centre for health—rather as we have a great financial centre—for the benefit of the world and the UK.

We have a great tradition. Over the years we have produced many great global public goods in health. I think of the work on malaria, on the genome, on neglected tropical diseases and on a whole range of areas, some of which have no immediate or direct relevance to us in this country. As a result of all that work, we have the most astonishing range of global partnerships. One sees that particularly in our academic work but also in these other areas. All that is good for UK influence and UK commerce—for the UK’s status and economy.

Most obviously, Brexit provides an opportunity as the UK seeks to find a new role in the world. It gives extra emphasis and importance to this vision of an outward-focused country and of a world leader in health and related sciences—influential and respected. It is good for our security and prosperity, for trading, influencing and leading, and for spreading a clear set of values. It seems to me that this is a vision that needs to be given greater energy as a result of the vote. That is very positive but there are also enormous risks, of which I shall draw attention to just four.

First, as has been said by many noble Lords, the NHS is in trouble. The Prime Minister’s vision of working for those struggling and just managing applies very much here. We need to expect the NHS to be there for everyone in the country. The NHS as it stands needs to be given a much higher priority than has been the case. I too applaud the piece by Simon Stevens in the Telegraph and his call for some special treatment for, and indeed infrastructure investment in, the NHS in the future. The NHS needs to be part of the future of our country in the way that it has been in the past.

The second risk is to staffing, which we have talked about very largely in terms of the NHS and social care. However, it applies also to staff in our research teams—our biomedical lifeblood, if you like. Where is the immigration policy that will allow us to sustain those fantastic research and scientific partnerships around the world?

Thirdly, there is a risk that has not yet been mentioned: that we must maintain the UK commitment to the World Health Organization’s code of practice for international recruitment. Many noble Lords will recall that we signed up in 2010 to this global code, following on from earlier UK and Commonwealth codes, which essentially said that we should be recruiting people only from countries where there was not a shortage of health workers and, indeed, in some cases, where the Government were keen for us to recruit people. While we have done reasonably well, others around the world have not. However, one can well imagine the pressures coming from this debate leading to us seeking to recruit in ways that are not consistent with that code of practice and perhaps taking us back to where we were before.

The fourth big risk is to research. We already know anecdotally—I suspect that many noble Lords are aware of the fact—that university researchers applying for EU grants now are being told by their EU collaborators, “Please don’t bother; we don’t actually need you and we certainly don’t need you as the lead partner in this application”. The impact is already being felt in that very important area.

Although I might want to try to paint a vision of us as a great health leader in the world, we are vulnerable, for all the reasons that we have talked about. Not only is the NHS vulnerable, as my noble friend’s debate is leading us into discussing, but so is our place in the world in this developing field. Health is the biggest industry in the world now and one of the fastest growing, at 5.2% annually.

The last comments that I made are all very negative and make it difficult to see how we can alleviate these problems. But let me finish with two points. First, what are we doing to become more self-sufficient in health staffing? What are we doing to boost training? We have been, over many years, on a rollercoaster of increasing and reducing training—for example, of nurses, although I do not just mean of nurses. It seems to me that this needs to be given much more priority so that we can approach being self-sufficient. Secondly, the effect of Brexit and the staffing shortages we can already see starting to happen add extra impetus to the need to be innovative, in both service and staffing models.

I will deal briefly with the latter point, which is about how we deploy and use staff within the NHS and within health and social care more generally. We have heard already about nursing associates—bearing in mind my noble friend Lady Emerton’s strictures, I hope I have got it right when I say nursing associates rather than associate nurses. Another example is one that my noble friend Lady Watkins and I have been working on together in the all-party parliamentary group, looking at the role of nurses. By and large, and not just in the UK but globally, nurses are undervalued and not enabled to operate to their full extent. The extraordinary fact is that we train people up to a certain level and then do not let them operate at that level. There is enormous waste in training people and not using them fully. We will be publishing some proposals about that and hope that the Government will not just listen to those proposals but think even more about how the impact of Brexit is forcing people, or can be used as an impetus, towards greater innovation.

Although I and others have many questions for the Minister, let me finish with the four that I have highlighted already, if I may—as opposed to the 10 that I had written down. First, will the Government maintain their commitment to the WHO code of practice on international recruitment and report on their performance against it? Secondly, what are they doing to develop the UK’s role as a global hub and centre for health, biomedical sciences and life sciences? Thirdly, what are they doing to increase training and move towards self-sufficiency? Fourthly, what are they doing to develop the role of different groups of health workers, and particularly to enable nurses to fulfil their potential?

Mental Health: Ensuring Equal Access to Mental and Physical Healthcare

Lord Crisp Excerpts

Thursday 26th May 2016 Lords Chamber

[Lord Crisp (CB)]

My Lords, I congratulate the noble Baroness, Lady Brinton, on her very impressive speech in which she laid out the issues extremely well. I also congratulate the noble Lord, Lord Oates, on his personal and moving speech which reminded us of what this is all about and that this affects individuals. We sometimes talk quite blandly about policies and forget that this is all about individuals.

I will start with a third congratulation, to the Government and all the political parties on having pushed this agenda so hard that we are moving towards parity of esteem between mental and physical health. I do not know whether this is the first country in the world to do that, but this is an enormous commitment with enormous implications; it is not just about access to healthcare, which the Motion in front of us is about, but about access to outcomes and a whole range of other aspects of the health system, including access to research funding and so on.

I will take a moment just to comment on the global implications. The UK has a leadership role here. Some 25% of disability globally is connected with mental illness, yet globally only 1% of health funding is spent on it. That is completely disproportionate, even more so than the figures for the UK mentioned earlier by the noble Baroness, Lady Brinton. Some changes are happening globally: there is a new World Health Organization action plan, and the sustainable development goals recognise that health needs to be thought of as a bio-psycho-social concept and not just thought of in terms of the biological health aspects. However, DfID does no better than other donors in promoting mental health, and its spend on mental health is very low. I have a question, not for the Minister but for the Government: will DfID adopt the same policy of parity of esteem between mental and physical health in its work locally?

On the UK and the five-year plan, as the noble Baroness, Lady Brinton, has already said, there is still uncertainty about what is meant in practice. I know that it is early days but there are all sorts of questions about implementation. One gets the impression from talking to people involved in mental health in England that people take very different views about what this means. As has already been said, only just over 50% of providers this year reported a real-terms increase in funding, and there is low confidence among providers that the £1 billion will find its way to mental health. I would like to hear the Minister’s comments on these points in his response to the noble Baroness, Lady Brinton.

As the Minister knows, I chaired a commission on acute care that coincided pretty much with this five-year working party and which was referred to in the five-year plan. Three issues arise from that, which I will ask about specifically. The first is that out-of-area treatments—the practice of sending people long distances across the country for admission, not for specialist care but for general acute emergencies—is a significant problem for patients, carers and the system. The latest figures suggest that this may be getting worse. In our commission we believed that this could be dealt with quite quickly, and we suggested that it could be eliminated by September 2017. We also said that in many cases it would save money to do so, because people are kept at very significant expense, often a long way away, where they get stuck because it is difficult for social workers or health workers to visit them. We therefore believed—and we saw evidence from a number of trusts around the country—that it was possible to do this quite quickly and that in many cases it was a cost-neutral option. I understand that the Government propose to set a target for achieving this by 2020, not by October 2017, as we suggested. I suspect that putting it off will mean that people will not start even thinking about this until 2018 or 2019, and it is a great pity that this is a missed opportunity to do something that is probably very symbolic as well as important as regards showing that we are serious about improving mental health.

I also predict that, in the meantime, complaints about this will grow. This will become a bigger issue and will happen more and more, and I suspect that we will have this sort of debate in your Lordships’ House more often. My first question to the Minister is: will he and the Government reconsider that timetable and move the timetable for eliminating out-of-area treatments forward? We suggested September 2017, but certainly 2020 is far too far away.

Turning from a four-year wait to a four-hour wait, our commission suggested that written into the NHS constitution—not purely as a target—should be the constitutional right for people with mental health problems to be admitted to hospital or be received by a crisis resolution and home treatment team within four hours of being assessed. At the moment that happens in some cases, but in very many cases people are kept hanging around, often in police stations and all kinds of other locations, waiting to be admitted. We believe that this is very important. We do not yet have a baseline figure for the average time that people wait for admission once it has been decided that they should be admitted. We think that work needs to be done to measure this and that there should be a commitment to deal with this waiting time. Will the Minister let us know what progress is being made on that recommendation?

My third and final question concerns a matter to which I know the Minister is very committed—ethnicity and race. For a long time there has been a problem with both real and perceived racism within mental health services. We certainly came across a large number of people from black and minority-ethnic communities who felt that they were disadvantaged or discriminated against in some way within the services. We found it very difficult to decide how to deal with this, because mental health services by themselves cannot deal with what are often societal problems. Incidentally, we also found that there was a large amount of discrimination against gay people in a number of institutions around the country.

We concluded that the way to deal with this was to introduce a race equality standard for patients and carers—such a standard is applied for staff across the whole of the NHS—as a means of measuring the differences between the treatments that people from different communities receive. We believe that that could be done relatively quickly. There are only 50 or so trusts in the country, and it would be very easy to pilot it with five or 10 of them over the next few years. I know that this is something that the department is considering and I would be very interested to hear from the Minister what is happening in this regard. We believe that showing that this issue is taken very seriously within mental health will not only be a very significant gesture but provide the sort of information that trusts need to identify the problems and plan how to deal with them.

Finally, I turn to something that was not directly mentioned in the five-year review, although there was reference to people not being given a full understanding of the side-effects of medicine. I refer to dependence on prescribed drugs. My noble friend Lord Sandwich has been a pioneer in raising the profile of this hidden and often invisible problem affecting many thousands of people, causing pain and grief, and wasting millions of pounds within the health system.

I draw particular attention to the rising levels of pharmaceutical treatments for mental health conditions. Data published in April show that anti-depressant prescription numbers rose by 7% last year to 61 million prescriptions—enough for more than one for each of us in the country, and five times the number that there were 25 years ago. There has also been a significant increase in the number of prescriptions for drugs used for psychosis, as well as for ADHD, which are usually given to children. While of course these drugs can be helpful in the short term—and that is why they are given—there is worrying evidence of an increase in long-term use of anti-depressants, as well as reports of many individuals suffering from disabling withdrawal symptoms, which can last for several years. There are also concerns that long-term use can be harmful and lead to disability.

I should therefore like to draw the attention of the House to the work of the All-Party Parliamentary Group for Prescribed Drug Dependence. Among other things, it is campaigning for a national helpline to help patients who are having problems with these drugs to come off their medication. Currently they are unable to access appropriate support. I therefore ask the Minister for his comments on the request for support for a national helpline.

Mental Health Services

Lord Crisp Excerpts

Thursday 28th April 2016 Lords Chamber

[Lord Prior of Brampton]

It is partly a question of resource, although I point out to the noble Lord that the country that spends the most money on healthcare and has the worst results is America. It is not just a question of resource. It is how we spend it as well as the amount of money.

[Lord Crisp (CB)]

I am sure that the Minister well understands that people working in mental health see this as a very negative signal, given all that has been said before. Will he answer two questions, please? First, what would he say to people working in mental health to reassure them that the Government are still giving this level of priority to mental health? Secondly, as he has already said, these quality premiums are intended to incentivise quality. What impact does he think removing mental health from the national priorities —the national quality premium—will have on quality in mental health?

[Lord Prior of Brampton]

What I would say to people in the NHS is that the Government are committed to spending a lot more money—more money than has ever been spent before on mental health—so we are putting our money where our mouth is. We are the Government who signed up, with the Liberal Democrats, to putting parity of esteem in law in the 2012 Act, and we are absolutely committed to doing that. There is no ground for thinking that we are deprioritising mental health. The quality premium that NHS England uses to focus the attention of CCGs will change every year. It had mental health in it last year; it had other issues in it this year; and I hope that it will have mental health in it next year.

NHS (Charitable Trusts Etc) Bill

Lord Crisp Excerpts

Friday 26th February 2016 Lords Chamber

[Lord Crisp (CB)]

My Lords, I have very little to add to that extremely eloquent and clear speech, which sets out precisely what the Bill is about and why it is so important. Indeed, the Bill is sensible, practical, simplifying, and in essence we should just get on with it in your Lordships’ House. However, I will say a little about NHS charities and their importance, although I will not detain your Lordships’ House for too long.

All of us in this House will be familiar with the work of some of these charities and the way in which they provide facilities; however, they are also able to do things which the NHS cannot do as regards making improvement and change. I will pick out three particular areas. Charities can very often fund innovation in ways which the public sector cannot always do. Secondly, they can support staff, which is incredibly important, particularly at times like now, when the NHS is under such pressure; and they can also do what the great charity across the water from us here, Guy’s and St Thomas’ Charity, does, which is not just to look at the hospital but at the community itself as well, to develop and support innovation and community service. Those are all ways in which charities have modernised and innovated in recent years, and this Bill is very important in bringing about less bureaucracy and more scope for them to do those things.

There is one other way in which charities are moving in this direction globally, nationally and, I hope, within the NHS. When I am not in your Lordships’ House, I am quite often engaged in development activities in Africa. We are very well aware that charities are extremely important in Africa, but alongside those charities it is equally important to enable people, giving them the tools to look after themselves and develop their own solutions to their problems. I hope that in future NHS charities will go even further by developing the way in which they help the NHS to adjust during this current massive period of change.

I am delighted that my noble friend Lord Bird is to speak in this debate. I wonder whether he will have something to say about the very important question of how people can do things for themselves rather than just rely on charity. I think that the two things go together. This Bill will be a great help in ensuring that NHS charities have the freedom to use their imagination and creativity to support the development of health and social care in this country.

Health: Adult Psychiatric Care

Lord Crisp Excerpts

Monday 22nd February 2016 Lords Chamber

Asked by

[Lord Crisp]

To ask Her Majesty’s Government what is their response to the report Old Problems, New Solutions: Improving acute psychiatric care for adults in England.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, the Government very much welcome this report and are considering its recommendations. We have asked NHS England to reduce out-of-area treatments and eliminate their inappropriate use. NHS England published its independent Mental Health Taskforce report last week, backed by a £1 billion investment announced in January. NHS England will develop standards on access to mental health treatment.

[Lord Crisp (CB)]

My Lords, I thank the Minister for that reply, and I am delighted to see the commitment to parity of esteem between mental and physical health and to the funding allocated last week. Parity of esteem means equal standards for people with mental and physical conditions. The report recommends that requiring people to travel long distances to be treated should be phased out within 18 months, and there is evidence as to why that is a good target; and yet the Government have indicated in their response to the task force that it would take four years to phase it out. Will the Minister explain why that is and say whether there is scope for the Government to reconsider the timing?

[Lord Prior of Brampton]

My Lords, I reiterate my thanks to the noble Lord for his excellent report: it is 134 pages and reads very well and very quickly. It is obviously highly unsatisfactory that so many people have to travel long distances to get in-patient care. The noble Lord’s report shows that, in one month—in September, I think—500 people had to travel more than 50 kilometres to get to in-patient care. It is a priority for the Government and we are considering the noble Lord’s recommendations. I cannot give a commitment that we can reduce the four years to 18 months now. I can only repeat that we fully understand the importance of addressing this issue.

National Health Service: In-Patients with Learning Disabilities

Lord Crisp Excerpts

Monday 18th January 2016 Lords Chamber

[Lord Crisp (CB)]

My Lords, the new learning disability strategy, Building the Right Support, proposes that people with learning disabilities should get their mental health treatment from mainstream mental health services—which as noble Lords will know are already under considerable strain. Can the Minister let us know what assessment the Government have made of the likely impact that this will have on mental health services and how they envisage that the financial and other implications will be managed?

[Lord Prior of Brampton]

The noble Lord refers to the paper Building the Right Support, which I think he will be very supportive of. It is designed to treat and look after many more people with learning difficulties outside institutional settings—in their own homes or in special purpose, much smaller homes. Where necessary, they will of course need to receive mental health services. I am not aware that we have done a particular impact study on that, but I will investigate it and write to the noble Lord.