Access to Palliative Care Bill [HL]

Lord Crisp Excerpts

Friday 23rd October 2015 Lords Chamber

[Lord Crisp (CB)]

My Lords, I, too, congratulate the noble Baroness on introducing this Bill and on her very eloquent speech, in which she drew out all the essential points.

The provisions of the Bill are important in themselves but the Bill is also important in raising issues of dying with dignity and good care at the end of life, not all of which, of course, can be legislated for. However, it is significant in another way in that it is about some of the wider changes in priorities in health that are beginning to take place. We are beginning to see both globally and nationally much more focus on disability and on mental health, which I am pleased to see is keeping the Minister busy in this House. There is much more focus on social care, on care more generally and on what are called non-communicable diseases or long-term conditions, where the task is not to produce curative effects but to help people to live with disability and limitations. As the noble Baroness, Lady Finlay, said, it is also about quality, care and costs.

There are things that all those emerging or renewed priorities for health have in common, and I want to mention three of them. The first is the very strong individual, and indeed family, focus. The point has already been made that palliative and end-of-life care needs to be about what individuals want. It is not just about offering a menu of choice; as the noble Lord, Lord Davies, said, it is about control. I am reminded of my father, who, in the last year of his life in his 90s, discharged himself from hospital against the advice of the medical staff. I was quite sure, as I believe were the medical staff, that that act of rebellion—or, if you like, bloody-mindedness—was very good for his morale and probably affected the length of time that he subsequently survived. Therefore, this is about control as well as about a menu of choices, but it is also about families.

Although I agree with the provisions of the Bill, it is a question not just of having a professionalised death but of people being a bit more willing to talk about death, having those sorts of conversations and thinking about death in a much wider way. I am aware of the important point made by the noble Baroness, Lady Hollins: that the person who is dying dies but there is often a serious aftermath, which I guess all of us know something about.

The second important point is variation, and it keeps coming up. We have some absolutely excellent practice—I am sure we all wish to congratulate the UK on coming top of the palliative care table in a recent Economist Intelligence Unit survey—but we also have some awful care. Therefore, it is important to manage variation. The other point that needs to be brought out here is that we need to understand who misses out. We often talk about averages and so on in healthcare but we need to know who is likely to miss out by disaggregating the data and gaining an understanding of whether it is men or women, poorer people or less educated people. Interestingly, in palliative care there is some evidence that one of the groups that seems to miss out is the very elderly—the over-85s. Again, this is a global issue. In the recently agreed sustainable development goals, the great phrase was “Leave nobody behind”, and that must be true of where the noble Baroness, Lady Finlay, is taking us with palliative care.

My final point, which joins up all these emerging priorities, concerns technology—not just assistive technology, pharmaceuticals and so on, which are all extremely valuable, but IT and communications technology. My noble friend Lady Lane-Fox, who is not able to be in her place today, is happy for me to say that her new organisation, Doteveryone, believes that digital health and new technologies can radically transform services. Importantly, Doteveryone will be working on a project focused on older people at the end of life, reaching those traditionally seen as the most excluded—the over-85s. It will be very interesting to see where that project takes us.

I want to make a couple of specific points. First, I know that we have all been lobbied about children’s palliative care. We have not really mentioned it so far in the debate, although I do not know whether others will raise it. It seems important that there is some reference to the particular and specific needs of children when we talk about palliative care.

Secondly, I agree very strongly that this is about all health and social care workers; it is not just about the specialist few. It is about everyone understanding this holistic approach to care.

Finally, in her opening remarks the noble Baroness, Lady Finlay, said that it is time to act and that the Bill is about saying, “These are some mechanisms to make something happen”. That is very important in the context that she and others have articulated—that improving quality is very often about eliminating waste and wasteful procedures. Getting it right and therefore improving quality in many cases also has a beneficial effect on costs. For all those reasons, I very much support the introduction of the Bill to this House.

National Health Service: Sustainability

Lord Crisp Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Crisp (CB)]

My Lords, like others, I agree that the noble Lord, Lord Patel, is right about the need for a fresh look, going beyond politics and all the experts. We need to reframe the arguments and get others into the debate, and to take a long-term view.

I agree with the many people who have spoken, starting with the noble Lord, Lord Fowler, about the importance of understanding and reviewing how the NHS is financed. However, I want to take these arguments a bit further and think about sustainability in the round. Sustainability is not just a financial issue. I shall give two examples. Barely 50% of children have met all their development milestones by the time they start school. This influences children’s future physical and mental health and their ability to learn. The second example is that social isolation and loneliness in old age have the equivalent health impact of smoking 15 cigarettes a day. Moreover, loneliness very much slows the rate of recovery. Your Lordships can see where I am going with this argument. I have deliberately chosen two issues that are not directly about healthcare yet the NHS has to pick up the pieces; in most cases it cannot have a direct impact on these issues, although others can.

Sustainability is wider than that, too. If the NHS and social care are the formal healthcare system—and we have heard the figures for what that costs—the latest figures from carers’ associations is that if we were to monetise what carers provide, we would see that they provide about £120 billion worth of care. If you add into that what civil society, volunteers and all the NGOs and so on do, you see that there is a vast informal care system. My point in raising that is that what happens in the informal care system impacts on the formal care system, and vice versa. If the informal care system gets weaker, it puts more pressure on the NHS, and if the informal care system gets stronger, it takes some pressure off it. These are important points about sustainability, and any future commission needs to be thinking about these as well as how to finance the NHS.

A lot has been said about prevention, but we also need to think about this in a different way as being a positive term, sometimes called “health promotion”. It is about the creation of a resilient, healthy population and society. The Minister knows that I have a debate—later in the autumn, I hope—on what I call “health creation”, which is precisely what we are talking about here. There are two simple points here, and I will not go any further: we need to think about sustainability in the round, and the NHS itself cannot make itself sustainable—others have to play a major role in that.

My second point is that looking at financing is right, and clearly we need to chase improved efficiency at every level. However, we should not hope for too much from a review of a new financial model. I will give just two examples from around the world—again, I do not have time for more. Holland changed its system with great fanfare about five years ago so that it consisted of private insurers which then purchased from anybody. The net result of that, which was probably predictable, was that unit costs have gone down and volumes have gone up, and Holland, which now spends 25% more than we do, is spending more than it did. That was an experiment in changing the financial arrangements.

I will not talk about co-payments—that is, getting people to pay as well—other than to say that all the studies show that if they are to be big enough, they will affect both the poor and the rich: they affect the behaviour of the rich, who then go elsewhere, while the poor cannot afford to pay for services. You can have small co-payments, but large ones have those impacts. My point is that we must look at how the NHS is financed—I understand and agree with that point—but we should not hope for too much from what others around the world have done.

My third and final point is that in the short term you cannot take politics out of the NHS. To go back to Holland, the Dutch Government do not directly run hospitals, but the Dutch Health Minister gets all the questions about hospitals in his Parliament anyway. However, we can have a cross-party consensus about the longer term.

I will quote from a Portuguese report—if noble Lords allow me, I will say it in English; indeed, your Lordships may prefer me to do so. Portugal is trying to transition from today’s hospital-centred and illness-based service system where things are done to or for a patient to a person-centred and health-based one where citizens are partners in health promotion and healthcare. It will use the latest knowledge and technology and will offer access to advice and high-quality services in homes and communities as well as clinics and specialist centres. It will provide a better service with lower infrastructure costs. That is Portugal’s aim over 25 years. It will not be difficult for us to construct that sort of consensus and vision about where we are trying to go, but we need to understand that that is a radical change. If we are to have a radical change and we are pointing in that direction, we need a clearer longer-term plan than the five-year plan we have, and we need the sort of transition fund that some people are arguing about.

My final point is that I absolutely agree with the proposal of the noble Lord, Lord Patel, that there should be an independent reframing of the arguments, which will bring other people into the argument so that the same people are not having the same arguments, which has often been the case in the past. To do that, the starting point is to create that shared vision of where we are going, so at least we have something to steer towards, and we need to understand that sustainability is about these wider social impacts, not just about the efficient management of money within the NHS, important as that is.

HIV/AIDS

Lord Crisp Excerpts

Thursday 5th March 2015 Grand Committee

[Lord Crisp (CB)]

My Lords, I, too, pay tribute to the noble Lord, Lord Fowler, for his leadership on this issue. It was needed right at the beginning of the epidemic, and he gave it, and it is needed again very strongly now and over the next few years. I am going to talk about the situation outside the UK. I have told the Minister that I am not expecting instant replies to the two questions I have, but I hope that they can be passed on to the Department for International Development.

This is, of course a global epidemic and it is in our interest to see that it is contained and managed globally as well as locally. As the noble Lords, Lord Fowler and Lord Cashman, both said, the UK is very influential in this regard. Globally, there has been amazing progress. The epidemic is coming under control in the sense that more people are going on to treatment than there are new infections each year. That is true even in South Africa, thanks to changes in the political leadership there. But it is still devastating and it will be for years to come, so there is much more to do.

In 2013, 35 million people were estimated to be living with HIV/AIDS, of whom less than half had been diagnosed; 13 million were in treatment; 2.3 million more received treatment; 2.1 million more became infected and 1.5 million died. This is an awful picture. In those countries that are particularly badly affected, HIV/AIDS affects everything about health and health services. In South Africa, there is 5% prevalence and there are huge costs to its health system. It will grow and be more costly over the next few years because the WHO has changed its guidelines about when to put people on treatment, and still many people are not yet receiving treatment. This is a big problem. Nevertheless, UNAIDS aims to see what it describes as the end of the epidemic by 2030. That will require increased funding until 2020, and it will decline thereafter.

There are economic issues as well. This is not just about human devastation, illness and death; it is also about the economy. Conservative estimates suggest that the gross national product of South Africa has decreased by at least 1% per year because of the illness of its people. I shall sum up this quick summary of the situation with the South African Government’s vision for 2030—in 15 years’ time—which reflects this reality. They aim to have life expectancy reaching 70 and a generation of under-20s largely free of HIV. That is a great vision from where they are, but it is also rather sad that is what we are talking about. This is a long march. It is a very long-term issue which needs, as I said, champions like the noble Lord, Lord Fowler, to keep the momentum up globally as well as nationally.

What are the key issues? The first is funding. The noble Lord, Lord Cashman, has already pulled out one extremely important point, which is that most people who are affected are now in middle-income countries, and the development agencies of the world, particularly DfID, do not give money to middle-income countries. Even the Global Fund, which is cash strapped, is having to prioritise the poorest countries. This is a wider issue about development because most poor people now live in middle-income countries. Therefore, we cannot think about this as being aid to poor countries; it is much more targeted.

The response of groups such as the International HIV/AIDS Alliance is to try to raise money locally. This is very difficult. I am proud to be the chair of Sightsavers, which works, for example, in India, where we can raise money because you can raise money for elderly people with cataracts or children going blind relatively easily in any society. It is much harder when you are talking about intravenous drug users or men who have sex with men. It is even harder in those countries than it is in our own country. That is the second big point about prejudice and discrimination against the groups that are most at risk. In purely health terms, this affects treatment and prevention and is very counterproductive economically and in health terms—but, of course, there are other profound ethical and human rights issues here that ought to be addressed.

The third issue that people who work in this area tell me about is the loss of priority that is coming to HIV/AIDS because, at the end of this year, we will move on from the millennium development goals to the sustainable development goals, which I support. Let me be very clear: I think that the sustainable development goals, which put an emphasis on the whole of the health system, are exactly what is needed for the future in low and middle-income countries, particularly in the light of things such as Ebola. I think the case is made by Ebola. However, it raises a very serious issue of transition from HIV/AIDS being central to international development to it not being in quite the same position, and how that transition will be managed. The All-Party Parliamentary Group on HIV/AIDS has just published an excellent report, Access Denied, which identifies these and other more detailed issues about problems in the supply chain, monitoring, pricing, R&D and so on.

What should Her Majesty’s Government do? There are many recommendations from that All-Party Parliamentary Group, but I shall draw out three. In asking questions, I want to congratulate the UK on its global leadership on this issue and, indeed, on development in global health generally. It is because DfID is so influential globally that the signals it gives on aid are fundamental. It is supporting the Global Fund. Indeed, it increased its support, and it needs to use its influence to make sure that there is continuing support from other countries. However, its recent decision to stop funding work on an AIDS vaccine is counterproductive. Will Her Majesty’s Government reassess the decision to stop funding an AIDS vaccine, as was proposed by the All-Party Parliamentary Group?

The second issue is that as the needs move to middle-income countries from low-income countries, the funding gap needs to be addressed. It is important not just that external parties such as DfID do something about this but that the countries themselves are encouraged to take up the slack. There were, after all, the Abuja agreements of 2003 and 2001, whereby every African Government committed themselves to spend 15% of their expenditure on health. Only six have yet hit that target. So there is a great challenge that should be put to the middle-income countries.

My second question is: what are Her Majesty’s Government doing to help facilitate continued access to funding for countries moving to middle-income status? That includes encouraging national Governments to play an increased part. My final point is not in the form of a question. The UK is also very influential on civil liberties, and it needs to argue the case about discrimination louder than it has. I know that that is difficult. I have spent a lot of time in Africa. I was recently in Uganda, where I came across a situation where Ugandan doctors were extremely annoyed—with the Americans, I am happy to say, rather than the Brits—because on the one hand Americans from various gay groups were arguing their case and on the other, Americans from various church groups were arguing their case. They said: “The last thing that we need is an American war on our territory”. They likened that to some other things that had happened earlier in their history.

It is difficult to intervene in any other country, but we need to take a stance as a nation about who we are as well as who our friends are and how we work with other people. There is a vital health case to be made here, because this is about health and the economy as well as people’s beliefs about society. The right to health is fundamental. It is also ultimately an economic case. Healthy populations can be productive and prosperous.

Finally, I support the call made by the noble Lord, Lord Fowler, at the end of his excellent book, where he says that there should be some sort of international convention based here in London—something that this Government or a Government formed after May should take up—on protecting the rights of people who are discriminated against in that way.

NHS: Medical Staff

Lord Crisp Excerpts

Monday 15th December 2014 Lords Chamber

[Earl Howe]

My Lords, as the noble Lord is aware, we rely on Health Education England to determine the number of training places that the NHS needs going forward, looking at not just the short term but also the medium to long term, informed by the work of the local education and training boards. That is as good a system as we believe we can get. Health Education England is properly funded to do that and we must rely on its expertise.

[Lord Crisp (CB)]

My Lords, I understand that the NHS in recent years has made it harder to employ people coming from poorer countries in Africa and elsewhere to work here. However the NHS, as the Minister has already stated, has a large number of people working within it from those backgrounds. I have two questions. First, what are the Government doing to aid countries to train more people in their own countries? Secondly, what are the latest figures for the international medical graduate scheme for people coming from Africa training in this country?

[Earl Howe]

The international postgraduate medical training scheme is only just starting and we hope to launch it very soon with one particular Middle East country. As regards the noble Lord’s first question—he will have to remind me of it.

[Lord Crisp]

I hope I can remember it. It was very simply: what are we doing from the UK to support the training of people in their own countries, where they will often stay longer than if they come and train here?

[Earl Howe]

I beg your pardon, my Lords. DfID has a number of programmes designed to support the health economies of developing countries. They have been in place for many years. They can take the form of training, not just of doctors but of all healthcare professionals. I am aware that DfID is extremely supportive of those programmes.

Mental Health Services

Lord Crisp Excerpts

Wednesday 26th November 2014 Lords Chamber

[Earl Howe]

My Lords, it is unacceptable for a child in a mental health crisis to be taken to a police cell. The mental health crisis care concordat, launched in February this year, reinforces the duty on the NHS to make sure that people aged under 18 are treated in an environment that is suitable for their age, according to their needs. It also makes it clear for the first time that adult places of safety should be used for children if necessary so long as their use is safe and appropriate. We have seen a reduction in the use of police cells across the country but there is still further work to do.

[Lord Crisp (CB)]

My Lords, I understand that child and adolescent mental health services are under pressure anyway, and therefore that puts greater pressure on those who are hardest to reach. Perhaps I may therefore ask the noble Earl two specific questions. First, what is being done to ensure that private children’s homes have as good access to CAMHS services as local authority homes? Secondly, when a looked-after child is placed out of an authority or experiences a change in placement, what measures are in place to ensure that he or she receives priority in the new waiting list?

[Earl Howe]

My Lords, both of those issues will be looked at by the task force. There have been concerns on both fronts that the noble Lord raises about access to services, and we are clear that the task force must come up with recommendations in those areas.

National Health Service

Lord Crisp Excerpts

Tuesday 17th June 2014 Grand Committee

Asked by

[Lord Crisp]

To ask Her Majesty’s Government what plans they have to give citizens and patients more power in the National Health Service.

[Lord Crisp (CB)]

My Lords, I am very glad to have the opportunity to initiate this debate and I am very grateful to noble Lords who are taking part. I am looking forward to hearing what they have to say. People are coming from a range of different backgrounds and experiences, which should be very illuminating. I am also conscious that the Government have already said a great deal about patient empowerment and patients taking a greater role. Therefore, to some extent I am pushing at an open door in this debate. I am trying to make sure that the progress being made is accelerated and that specific things happen to change the dynamic.

We are talking about one of the most important things happening in health over this decade. I know that discussions about patient and citizen empowerment have been going on for much longer than that but there is a building global momentum. Most noble Lords will know that six all-party parliamentary groups have recently published a report on patient empowerment in which we looked at the global picture as well as the UK picture. I will come back to that.

The UK is part of, and can be a significant leader in, what is happening globally. There is a change from everything within health and healthcare being defined by the professionals to things being defined much more by the citizens, the public and the patients; that is, everything, including what quality consists of in healthcare, being defined much more by the patients, the citizens and all of us, involving of course the professionals.

I have a confession to make. As the NHS chief executive for some years I, like lots of other people, said that patient empowerment was a top priority. But in reality, although we said that for a number of years, not a great deal has happened in this area. As I will say in a moment, I think that England is ahead of much of the rest of the world, but there is very much further to go. We all said it because we were sincere about it, but we did not well understand how to make it happen in reality. It is now beginning to be well understood. I think that people can understand how to make the change. Of course, we now have technology and science that is literally putting things into patients’ hands in ways that enable them to be more empowered as patients and citizens.

I deliberately included patients and citizens in the Question, recognising that both are the same people. I wanted to draw attention to the fact that patients have particular roles but there are particular roles for citizens as well. I mean the whole range of citizens, including the very important group of carers, whom I suspect we may hear more about in due course.

Before turning to the specific all-party parliamentary group report and its recommendations, which I will ask the Minister about, I will say a few things about citizens and why it is really important that citizens have more power. I will give three reasons although there are others. There is enormous epidemiological change going on, as every Member of the Committee will understand as well as I do. We are moving towards a world where the biggest issues facing us are non-communicable diseases. As we all know, those will be significantly affected by people’s behaviour. People themselves will be part of the problem and part of the solution as well.

However, this is not just about individual behaviour but about societies and serious changes in society. Programmes are developing across Europe that come under the title of “Health in all Policies”, which are about making sure that education, employment, commerce and every other part of society has a role to play in improving health and in not damaging health. Over this parliamentary Session, we will no doubt see examples such as discussions about the impact of sugar on people’s health. Wider society has a significant role in improving health. The best estimate that people make is that health services contribute about 20% to our health improvement and wider society contributes about 80%. That in itself is an argument for citizens being much more empowered within our NHS.

The second argument is about carers, which I will not dwell on very long. The last time I looked at the figures, if you monetised the informal care systems and attempted to estimate their value in cash terms, the amount that they contributed to England was roughly equivalent to the total cost of the NHS. As we all understand, if those informal systems were to fail for whatever reason, the burden would fall on the NHS. If those informal systems were to be strengthened, as they should be, that would help the formal health system to become more sustainable. We need the engagement of carers and citizens as carers—and most of us will be carers at some point in our lives—within the NHS for its continuing success.

However, this is also about democracy, values and priorities. Here in England and in the UK, we have had in recent years debates about the future of the NHS—what it is and what its core values are. Those will no doubt continue. For all those reasons—the epidemiological, the role that informal care plays in our society and democracy—it is fundamental that citizens have more power. It will be interesting to hear what the Minister has to say about that.

I turn specifically to the patient empowerment review. First, I put on record my thanks to the many people who contributed from six all-party parliamentary groups and to Meg Hillier MP, who chaired the review. As we noted in that report, the NHS is ahead of the field in many ways. There are many good examples, from personal budgets to expert patients’ programmes and so forth. The NHS has been moving, but it has not yet reached a position where this is central to where the NHS is and wants to be. As we noted in the report, there are many good global examples as well. Those come from low and middle-income countries as well as from rich countries. Our simple message in the report is that we need to give renewed emphasis and investment to patient participation to improve health, satisfaction, quality and sustainability.

Let me touch briefly on two examples which illustrate that very well. The first is the pure and simple example of diabetes. A patient with diabetes—a person with diabetes—may be involved in something like 500 hours a year of self-care, but have only two 15-minute sessions with a professional. It is just as important that those 500 hours, or however many they are, are handled well and appropriately to improve health and, indeed, keep pressure off the formal health system.

I turn to satisfaction and quality. Maureen Bisognano, who is president of the Institute for Healthcare Improvement in America, has a very good expression about what the future should look like. The question between the clinician and the patient has often been, “What’s the matter with you?”. She says that the future question should be that, but also, “What matters to you? What are the things that you need in terms of your request for help, if you like, from the National Health Service?”. She makes the very simple point that most patients have complex conditions. If you have something such as Parkinson’s disease, you may have many different symptoms and, therefore, many different things that can be done to control them. It should be about your choices, not just the clinician’s choice. “What matters to you?” seems to me to be the watchword for the future.

My questions for the Minister are, first, of course: what are his plans, as the title of the Question asks? Secondly, I would like his response to the modest four recommendations that we make in the report. The first is that patient empowerment should be a top priority and that that means that all the systems and incentives should be aligned behind it to make it happen—something we have not done satisfactorily in the past. The second is to ask whether the Government will revive the revolution that was started in decision-making tools earlier this century. Decision-making tools are about helping patients to be able to make shared decisions with their clinicians. That is the area of “What matters to you?”, which I just talked about. The third is to ask whether the Government will give patients co-ownership of their records, by which I mean that they should own their health records. The only other co-ownership should be that the anonymised information is available for research. That is where we were coming from as an all-party parliamentary group. We see no reason why patients should not just have access to records—why should they not own them? Fourthly, what are the Government going to do to encourage patients to ask more questions and support them? That happens in some countries: the example we give is Denmark, which has a programme called Just Ask about encouraging patients to do just that.

With that list of questions, I am delighted to have the opportunity to initiate this debate and look forward very much to hearing what noble Lords have to say.

NHS: Black and Minority Ethnic Nursing Directors

Lord Crisp Excerpts

Monday 10th February 2014 Lords Chamber

Asked by

[Lord Crisp]

To ask Her Majesty’s Government how many Executive Directors of Nursing in the National Health Service are of black or minority ethnic background.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

Data from September 2012 estimate that there are 195 nursing directors. Of these, five, representing 3%, identified themselves as being from a black or minority ethnic background. The Government recognise that there needs to be better progress in promoting talented BME nurses to senior and influential positions. Last month, NHS England launched a coaching and mentoring scheme, and it is currently working on a strategy alongside the Chief Nursing Officer’s Black and Minority Ethnic Advisory Group.

[Lord Crisp (CB)]

My Lords, I thank the noble Earl for that detailed response, and I am pleased to know that NHS England is taking some steps on this. This is a hidden problem, with fewer than 3% of nursing directors coming from black and minority ethnic backgrounds. This underrepresentation, which is mirrored elsewhere in the NHS, is particularly important because it affects morale, and staff morale in turn, as noble Lords will know, inevitably affects patient care and outcomes. In other words, this is a health issue and not just an equal opportunities one. Will the Minister say a bit more about his plans to deal with this problem and, crucially, whether he will arrange for progress to be monitored and reported on publicly by the Care Quality Commission, the Equality and Human Rights Commission or some other independent body?

[Earl Howe]

My Lords, I fully agree with the noble Lord about the importance of this issue. A strong focus on equality and diversity is essential to create services and workplaces that are equitable and where everyone feels that they count. The position at present is highly unsatisfactory. The Chief Nursing Officer has personally assured me that this is a priority for her, and she is working closely with BME nurse leaders to address how to support BME nurses to prepare themselves for promotion. Forty-six million pounds has been invested at the NHS Leadership Academy in schemes on leadership development being led by the Chief Nursing Officer. At last year’s BME nursing conference, she made a public commitment to renew efforts to develop BME nurses more effectively, and that will include monitoring.

World Innovation Summit for Health

Lord Crisp Excerpts

Monday 16th December 2013 Lords Chamber

Asked by

[Lord Crisp]

To ask Her Majesty’s Government what is their response to the recommendation for improving mental health globally made at the World Innovation Summit for Health.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, we welcome the recommendations made at the World Innovation Summit for Health and outlined in its report, Transforming Lives and Enhancing Communities. Mental health and well-being is a priority for this Government. Our overarching goal is to ensure that mental health has equal priority with physical health, and that everyone who needs it has timely access to the best available treatment. We hope that other countries will afford it equal priority.

[Lord Crisp (CB)]

My Lords, I thank the noble Earl for his reply. I should have made it clear when I tabled the Question that I was really looking for a reply from the Department for International Development. I will, however, ask two questions.

I know that the Minister will be as appalled as everyone else by this report and its finding that 700 million people with mental health problems worldwide are not getting treated, as a result of which some find themselves chained up or caged. Does he think the report’s findings and recommendations are relevant in the UK as well as elsewhere, although, obviously, not in relation to being chained up or caged? DfID currently spends, essentially, nothing on mental health. What is it planning to do post-2015 to make sure that nobody is left behind, as the Prime Minister has set out in his report?

[Earl Howe]

My Lords, the principles espoused at WISH do indeed apply with equal force to mental health services in this country. Those principles are several, but I would draw the noble Lord’s attention to the need to draw on evidence-based practice; to strive for universal mental health coverage; to respect human rights and to take a life-course approach. We try to embody all those things in our mental health services. Regarding DfID, I can tell the noble Lord that there are a number of multilateral and bilateral programmes which are in train and supported by the Government. We are supporting work in the Caribbean and Bermuda and promoting work in a number of countries in sub-Saharan Africa. I would be happy to write to the noble Lord with a complete list of these.

NHS: EU Legislation

Lord Crisp Excerpts

Monday 21st October 2013 Lords Chamber

[Earl Howe]

My noble friend makes an extremely good point, which I shall ensure is not lost on the president of the Royal College of Surgeons as he conducts his review.

[Lord Crisp (CB)]

My Lords, this argument has been going on for a very long time—at least a decade. Will the Minister let us know when he expects the review to report and when he thinks that some action will come about as a result of it?

[Earl Howe]

We have asked the review to report by the end of January next year. We believe that that is an achievable target from the point of view of those carrying out the review, and the Government will not be slow to react to any recommendations made.

Ageing: Public Services and Demographic Change Committee Report

Lord Crisp Excerpts

Thursday 17th October 2013 Lords Chamber

[Lord Crisp (CB)]

My Lords, this is an excellent report. I very much agree with the recommendations and with the disappointment of the noble Lord, Lord Filkin, at the Government’s response. I add that I am not a member of the committee that produced the report. I also agree with many noble Lords who said that this issue cannot be avoided or just left to muddle through. I congratulate the committee on not letting it go, and on continuing life after its committee proceedings.

I speak as a former permanent secretary of the Department of Health and chief executive of the NHS, and declare that I work in health, although globally, not in the UK. This is, of course, a global issue, as the noble Lord, Lord Livingston, said in his excellent maiden speech. I agree with the analysis that the committee has made of the problem. Very simply, we are using a 20th century model of health and social care to deal with 21st century problems of health and social care. It does not work, and we see that every day in the newspapers and will continue to see it in the newspapers, in our A&E departments, in the number of elderly people who are stuck in hospital—and in everything that we all know.

As noble Lords have said, and as the report says, we still do not have a clear strategic vision for the future of health and social care, and that is fundamental. I will mention two areas where the report could go even further—and I hope that the Government will. There is a lot of agreement, as has been said already in the House, about the nature of the problem. People are all aware that we need a much more community-based system that is much more focused on prevention. We also seem to accept a lot of the implications of that, which will involve bringing together health and social care much more closely, closing some acute hospitals, and investing in technology and in the community. However, agreement falls apart when we get to some of the detail, and the issues of winners and losers. Because we do not have a strategic vision that spells out all the implications, we have too many initiatives that are piecemeal and that often tackle symptoms rather than causes. Camilla Cavendish’s review of healthcare assistants, which was mentioned in the government response, is a good case in point. It was a good review, but it would have been even better if it had been in the context of a genuine, strategic vision for the workforce. Healthcare assistants do not operate in a vacuum.

This is the biggest failure at the moment. The biggest factor to take into account is the workforce. I do not think that it is mentioned in the report or in the Government’s response. I may have got that wrong, but clearly it is not in any of the headlines. Of course, the workforce never is. If you are going to have radical change in the service that is provided, you will have to have radical change in the workforce, as well. I will give some radical examples, although I am not necessarily advocating them. Are we going to be talking about having far fewer specialist doctors and more generalists? Are we talking about nurses doing many more of the things that doctors do now, and other people doing things that nurses have done in the past? We need graduate nurses, but do all nurses need to be graduates? What about the links between health and social care and the workforce? How radical are we going to be in taking this on? I am a member of the Lancet commission on the future of professional education. That has produced some radical notions about the role of senior professionals and team leaders as agents of change who are constantly searching for quality and cost improvements. Are we going to be that radical?

Of course, this is the biggest cost in the NHS; around two-thirds of the cost is in the workforce. In Africa, where I work, we have long recognised that the scarcest commodity is not money but skilled health-worker time. Do we in the UK use skilled health-worker time to best effect? Do we always make sure that people are working, as the Americans say, at the top of their licence, as opposed to doing things that other people in the system can do? This is not just about getting rid of paperwork for professionals; it is about making much more radical changes.

While Africa leads the way in changing health roles globally, the UK leads the way in developed countries—for example, with the expanded role of nurse prescribers and of nurses more generally. As I said, this is the highest cost, which is one reason why it is the most difficult area to tackle, and why people never tackle it. I understand the political traps of taking on the doctors or nurses to make some of these changes, and I understand that it would create winners and losers. However, it is not good enough to leave this to the local level. First, they cannot do it; you cannot make the changes necessary at local level. The headquarters has the responsibility of ensuring the capacity and capability of an organisation, and it is not doing so at all at the moment. Of course, this need not be top-down; it should be developed with practitioners and people at local level. However, as many people have said, the Government have a responsibility to ensure that there is an appropriate framework here for the future. Of course, if it is not sorted out, we will not see change.

My point is that this is not just about economic costs. The other question that needs to be looked at alongside it is: who will give the care? I will take 30 seconds more to refer to the fact that this is not just about professionals. We must not slip into the lazy assumption that the NHS is like a commercial insurance system, and that patients are simply customers. Care is not given just by professionals but by many carers. It is given by neighbours and voluntary organisations; it is given in a wide range of different ways. The NHS and social care form a social system rather than an insurance system. There are roles for carers, patients and families, and we need to redefine those as well. People can do more for themselves. We see examples in other countries of people doing much more in the way of monitoring. We see them delivering dialysis for themselves. Of course, these examples also produce improvements in quality and in cost.

In conclusion, I would be very interested to hear what both the Government and the Opposition say about the challenges that the report sets them in setting out the position for the future and a long-term vision. I will also ask the Minister a specific point, as a first step towards that. Does he accept that a changed, new NHS of the type described here will require a new, radically different workforce strategy, with changed roles for doctors and nurses, and changes in professional education? If he says that that is the responsibility of NHS England, as I suspect he will, will he then ensure from the Government that NHS England, in developing its strategy, will take proper account of the 60% of the NHS budget and of the changes that need to be made there as well as elsewhere?