The Long-term Sustainability of the NHS and Adult Social Care
Lord Farmer Excerpts(6 years, 6 months ago)
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Lord Farmer (Con)
My Lords, I add my congratulations to those of others to the noble Lord, Lord Patel, and his committee on this report. I am particularly grateful that the committee took the opportunity to take a long, hard look at what the NHS is now and what we should be looking for in the future. I want to dwell on the report’s emphasis on prevention and to talk about how family breakdown and dysfunctional family relationships contribute to the long-term unsustainability of the health service and the social care system.
We must not allow nanny state concerns to perpetuate the wilful neglect of this issue by successive Governments, including the current Administration, on whose Benches I sit. We have had strategies to address disability, diabetes and dementia—all of which are laudable and necessary. After all, disability affects one in six adults; diabetes around one in 10 adults; and dementia one in six adults over 80 years old. Yet, despite almost one in two 15 year-olds having experienced the breakdown of their parents’ relationship, no UK Government have ever come close to developing a family strategy that acknowledges the repercussions of this and addresses the root causes.
The Select Committee report we are debating describes the short-sightedness of successive Governments and the culture of short-termism that seems to prevail in the NHS and adult social care. This sums up very well the policy approach over the last half century towards the growing trend of family breakdown, which drives need in both these areas. Moreover, the report highlights the false economy of neglecting public health, prevention and patient responsibility and gives short shrift to nanny state concerns.
The quality of people’s relationships, particularly in their childhood, is a significant determinant of health as studies on loneliness and the effects of adverse childhood experiences, among others, make clear. Research from the International Centre for Lifecourse Studies—the ICLS—at University College London measured cortisol levels in thousands of 60 year-old adults to see whether there are long-term effects of psychological stress in childhood. It found that people who had been separated for more than one year from their mother had higher cortisol levels, which indicates a less healthy stress response several decades later, and therefore an increased risk of disease and early death. Other ICLS research found that people who suffer stresses such as parental divorce in childhood are more likely to experience social and psychological problems later in their adult lives.
For children to flourish they need safe, stable and nurturing relationships, not just a good school place and a healthy diet. Nationwide, a million fathers have no meaningful contact with their children and, in some communities, father absence is the norm. This fuels the hunger for belonging, which leads many to join gangs and get caught up in the culture of violence, where life is cheap. Overstretched and understaffed accident and emergency departments then have to deal with high numbers of young men with stab and gunshot wounds.
Many other pressures on our health services can be traced directly back to broken and dysfunctional relationships. Prevention, in the form of family strengthening measures, should be available in every community. This and every previous Government have struggled to provide leadership in this area, yet they find themselves picking up the pieces at every turn. Curing is always more costly than preventing.
Many have gone beyond even being concerned about family breakdown. I met with a Minister this week whose official briefing included a graph showing that divorce levels had become stable and were even beginning to ease off. The implication was that “things aren’t so bad after all”. Yet this one simple set of descriptive statistics obscures the bigger picture: our high divorce rates are still almost at the top of the OECD league table and the growth area in parental splits is among those who are not married. Three-quarters of family breakdown among children under three involves unmarried parents. Three-fifths of parents who were closely involved but not living together when their children were born are no longer together by the time the children turn five, compared to fewer than one in 10 of parents who were married.
No Government have yet been courageous enough to put serious effort into communicating through policy and rhetoric that the best context for childbearing is within a committed relationship. A fear of stigmatising children born outside marriage has unintentionally penalised one generation after another by neglecting to encourage a culture where the norm is for parents, whether rich or poor, to be deeply intentional about bringing a child into the world and raising her together. Neutrality is not an option when the costs of family and relationship breakdown mount up inexorably in so many areas. These include, to touch on just a few: lower resilience among young people and greater susceptibility to them developing poor mental health; lower productivity, which leads to less cash for the NHS; fewer family members available to care for older relatives; and more people living alone in later life due to divorce, and therefore higher social care costs.
So often, and understandably, domestic abuse is a reason for reticence to talk about family stability. NHS Employers has estimated the cost to the NHS of repairing the physical damage to victims to be around £1.25 billion per annum, with the cost to mental health services related to domestic violence estimated at £176 million. A preventive approach is essential. People across the broad range of those impacted by domestic abuse need help to learn how to avoid or step out of unhealthy relationship patterns. That includes not just women victims but couples where abuse is mutual, couples who want the abuse to end but the relationship to be sustained, and male victims and female perpetrators.
On that point, I want to clarify some statistics I cited in the recent debate on domestic abuse led by the noble Baroness, Lady Lister. I mentioned SafeLives data showing that 95% of victims are women and 95% of perpetrators are men. This is based on the 4,500 people accessing independent domestic violence adviser services, and must be set alongside the Crime Survey for England and Wales. In the year to March 2017, the survey found that a little over one-third of victims of domestic abuse were men and slightly under two-thirds were women. For the purposes of this debate, health services—not the police—are often the first port of call. Indeed, the 2012-13 survey found that four out of five victims do not call the police.
The Government are beginning to take note of the damaging effect on children and young people’s mental health of frequent, intense and unresolved conflict between their parents, even when violence is not a factor. In a sample of over 42,000 children attending children and young people’s mental health services, family relationship difficulties were a presenting problem for over half—52%. Their Green Paper, Transforming Children and Young People’s Mental Health Provision, published last December, acknowledges this in its chapter on wider action to support children and young people:
“Children who are exposed to persistent and unresolved parental conflict are at a greater risk of early emotional and behavioural problems, anti-social behaviour as an adolescent and later mental health problems as they transition into adulthood”.
I have one question for the Minister, who is I know is also exercised about the negative effects of relationship breakdown on children. The consultation process asked no questions about this wider action. What is the Department of Health’s response to family breakdown?
Young Women: Self-Harm
Lord Farmer Excerpts(7 years ago)
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Lord O'Shaughnessy
The noble Baroness picks up on a particular interest of mine. She may know that I was involved in setting up three primary schools. It is important to start these lessons early. In the end it comes down to behaviour policies and what is expected from children. Schools with fair and robust behaviour policies do not tend to see bullying. Those which are more lax do. First, it is about making sure that teachers have training and resources and the support they need from the leadership, governors and parents to crack down on it. Bullying now has moved into different domains, particularly online. I think it is very encouraging today—the noble Baroness may have seen it—that His Royal Highness the Duke of Cambridge is launching some actions on cyberbullying. Dealing with bullying is a big part of that and I agree with the noble Baroness about the importance of starting early.
Lord Farmer (Con)
My Lords, the Government’s own research, most notably that commissioned by the DWP from Professor Gordon Harold, conclusively showed a causal link between young people internalising problems, such as self-harm, and conflict and breakdown in their parents’ relationships. Will this evidence be acted on in the forthcoming Green Paper on children and young people’s mental health?
Lord O'Shaughnessy
I know this area is of great interest to my noble friend and he has done very good research on it. He is quite right to highlight the impact that, unfortunately, parental conflict and breakdown has on children. The Department for Work and Pensions, in a cross-government approach, is doing particular work on supporting parents. I also know that the best schools and community health services work to provide that kind of parenting support. There are a number of parenting programmes out there. I assure my noble friend that that evidence takes a proper place in the mental health strategy that we will be publishing for children and young people.
Child and Adolescent Mental Health Services
Lord Farmer Excerpts(7 years ago)
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Lord O'Shaughnessy
Yes, I wholeheartedly agree with the most reverend Primate. We are making up for lost time, unfortunately, with children and young people’s mental health care and there is a lot to do. He will be pleased that the additional funding being provided is helping with the rollout of the children and young people’s IAPTs—the talking therapies. As I said, the intention of the extra funding is to be able to treat 70,000 more young people, on top of those who have already been treated, by 2021—so more young people are being seen. That will increase the 25% of the potential caseload currently dealt with to 35%. Obviously that is better but it is not the whole way.
Lord Farmer (Con)
My Lords, following on from that question, I ask what the Government are doing in relation to preventing children’s mental health problems by addressing parental conflict and family breakdown.
Lord O'Shaughnessy
That is an incredibly important point because good relationships are very influential on young people’s mental health, and the Green Paper will look at the role of family conflicts. My noble friend will be pleased to know that the Department for Work and Pensions is launching a programme to reduce parental conflict in conjunction with the Early Intervention Foundation. I hope that it will have some positive benefit in reducing parental conflict, which is, of course, one of the causes of mental illness.
Mental Health: Young People
Lord Farmer Excerpts(7 years, 9 months ago)
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Lord Farmer (Con)
My Lords, our young people live in a culture that seems to value them for their outward appearance, their achievements and eloquence on social media and, grotesquely, their sexual allure at an even more tender life stage. They are under a significant amount of pressure and need reliable, loving foundations to thrive. Parents have a primary and indispensable role to play in providing these, so I thank the noble Baroness, Lady Massey, for securing this important debate.
As a sponsor-governor of the Ark School in Camberwell, I know about a whole-school approach where anti-bullying policies are not just words on a page but part of a culture that prizes nurture, encouragement and mutual support, all of which are vital. Equally, on-site counselling and therapy when children are clearly struggling with specific issues is needed. However, my heart sinks when the solutions to young people’s mental health problems are deemed to begin at the school gate given that much support, and in many cases the underlying contributors to their difficulties, is to be found at home. While there is an important parenting dictum that says, “Don’t take all the credit, don’t take all the blame”, another aspect of our culture which erodes so many young people’s sense of well-being and good mental health is the pervasiveness of contingent commitment in adult relationships—the sense that, “I will be there for you only as long as my needs are being met”.
The noble Lord, Lord Giddens, who will contribute to the debate later, describes how this transition in the ethics of personal life flows from living in a society with a high divorce rate, yet the toll this takes on our children’s mental health means we must not treat current levels of instability in parental relationships as inevitable. In the past, many children had to face the world alone because of the death of one or more of their parents, but today’s high level of family breakdown can feel like a much more intentional wound. Professor Brad Wilcox’s new research shows that we have more children living in unstable families than anywhere else in the developed world. Researchers at the Institute of Psychiatry showed that experiencing family fracture and separation from a parent in childhood are risk factors for later serious mental health disorders. Finally, US research found that low-conflict separation can also cause great harm. Children blame themselves and assume that relationships are fundamentally unreliable. Strong, stable families lay the foundations for life. Family breakdown has implications for population-wide mental ill health—we ignore this at our children’s peril.
Will the Minister let us know what the Government are doing to strengthen and stabilise families? Does he agree that every government department has a role to play in tackling our big cultural problem of family breakdown?
Mental Health: Young People
Lord Farmer Excerpts(8 years, 1 month ago)
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Lord Farmer
To ask Her Majesty’s Government how they intend to amend the 2012 national suicide prevention strategy to take account of the mental health challenges faced by young people.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, we will publish later this month the next annual progress report of the national suicide prevention strategy, which will set out details of how we are strengthening the strategy in key areas, including to target specific groups such as children and young people. The national strategy recognises children and young people as a group with specific mental health challenges that require a tailored approach to meet those needs.
Lord Farmer (Con)
I thank the Minister for that informative Answer. Front-line clinicians and local authorities are very aware of the role that family dysfunction and relationship breakdown frequently play in the onset of pronounced mental illness in adolescents. What steps are the Government taking to prevent mental health problems from developing, particularly where family breakdown is a root cause?
Lord Prior of Brampton
My Lords, in his recent national confidential inquiry, Louis Appleby reported that in 36% of all suicides of people aged under 20, family breakdown or family circumstances were part of the cause. My noble friend is absolutely right that families are critically important. That is very much part of the strategy in our Future in Mind paper. I was horrified by the figure that 43% of all people who took their own lives under the age of 20 had had no prior contact with any agency—no contact with GPs, no contact with CAMH units, no contact with schools—about their condition. Nearly half the people who took their own lives were completely below the radar. That is a shocking figure.
Palliative Care
Lord Farmer Excerpts(9 years, 1 month ago)
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Lord Farmer
To ask Her Majesty’s Government, in the light of the Parliamentary and Health Service Ombudsman’s report Dying Without Dignity, what steps they are taking to ensure that everyone who needs it has access to good palliative care and a level of social care that ensures the end of life is valued.
Lord Farmer (Con)
My Lords, I am sincerely grateful for the interest you have shown in this issue. To be honest, this is not least because it is the first Question for Short Debate which I have asked in your Lordships’ House, and one is always slightly nervous that it might end up being just oneself and the Minister. I am also appreciative because many of you will be here again tomorrow to discuss the Private Member’s Bill of the noble Baroness, Lady Finlay, on the same deeply important subject.
I hope that our debates will be complementary and not duplicate each other, because I want to range somewhat away from a legislative approach and focus more on the cultural and social aspects of palliative care. Indeed, I am particularly pleased that we have been joined by the right reverend Prelates the Bishop of Rochester and the Bishop of Carlisle because I hope they will touch on the area of spiritual care and comfort, which is sorely neglected in many policy discussions. After all, Jesus spoke more of eternal life than anyone else in the Bible.
This is not a fringe issue but very much at the heart of what it means to be sensitive to the needs of the patient and their family as death draws near. Let us be clear from the outset about the profundity of what we are dealing with here, as individuals approach the moment when they are coming to the end of their human existence in this universe. We might be surprised by how many want this to be acknowledged and are grateful when they are offered spiritual help. “Do you want me to pray for you?” is a question that recognises the fears many are feeling about what is happening.
In my preparation for this debate, I talked at length to palliative care clinicians who have been with many at the end of their lives. One said, counterintuitively, that it is not those who have an active faith who appear most in need of spiritual comfort. The last words of one woman who died a very painful and prolonged death from cancer but who was a fervent Christian were, “God is good, all the time”. It is the people who have a nominal faith, who suspect there’s something out there but have never quite nailed what it is, who often seem to feel confused, anxious and abandoned. Having someone there who can help them make peace with their maker—if that is what they are seeking and, obviously, nothing should ever be imposed— can be incredibly beneficial. In our secular society it is all too easy to brush over this, perhaps especially for clinicians who have so many other aspects of patient care on their minds. The World Health Organization’s definition of palliative care refers to the need for,
“impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.
Earlier this month, the Economist Intelligence Unit placed the UK at the top of its international league table for palliative care, and I do not want to gloss over the very good work that many are doing across the country. However, this Question for Short Debate highlights the Dying Without Dignity report, which summarises investigations by the Parliamentary and Health Service Ombudsman into complaints about end-of-life care. It identifies important themes that I will touch on here.
The number one priority for improvement, because it is the prime mover of palliative care, concerns the lack of recognition that people are dying and the poor response to their needs. For many people that will mean changing the way they are cared for to focus wholly on relieving pain, but also making sure that they have a real choice about where they are going to die, and about how and with whom they would want to spend their time if they had the foreknowledge that death was close. It would enable families to prioritise and mean that symptom control could become the top priority, with care being better planned and co-ordinated. This, perhaps most importantly, can mean that the wish of many patients to die at home can be respected.
Hospice UK believes that the number of people dying in hospital could be cut by 20%. Can the Government do more to help make it possible for more people to die at home, which is the first choice for so many? Sometimes there is only a very short window of time, but being at home for even the last 24 hours can make all the difference.
In one area in the north-east, a clinical commissioning group is contracting with a hospice to support community teams so that district nurses and GPs can ask them to assess patients within two hours. These hospices are acting as one-stop shops in the community—and, if noble Lords will forgive the phrase, “death hubs”. They do not just help those who come through their doors—and only 5% of people in this country die in hospices—but they take their expertise out to people in the area so that people’s closeness to death can be established and proper care can be given.
This approach has kept people out of hospital—always the most expensive place to be—and could be the answer to inadequate out-of-hours services. Even in hospitals, palliative care teams may not come on duty until 9 am, so extremely ill and dying people may be forced to see out the dark watches of the night while suffering in severe pain, with profound nausea and in an agitated state.
I cannot overemphasise the importance of attentive care, not least because basic nursing care can, in some cases, lead to recovery. The inappropriately applied Liverpool care pathway—or lack-of-care pathway—meant that there were many desperately sad cases where people did not receive this. Earlier this year, the Royal College of Nursing and Macmillan Cancer Support reported that some hospitals had not changed their practices, despite the Liverpool care pathway being officially phased out. A distinguished neurologist who first sounded the alarm about the LCP said only a couple of months ago that he regularly hears from relatives who are desperately trying to obtain “active” care for very ill relatives who have been denied it because they are deemed to be dying.
A compassionate approach asks what will make a dying patient make the most of the life remaining to them and how clinicians can work with family and friends to ensure that that happens. Good-quality and honest conversations between GPs and their elderly and sicker patients are essential. Many clinicians who routinely work with very ill patients are reluctant to commit themselves, either to relatives or patients, as to how long someone probably has left, even though this would enable them and their families to make plans. Surely this has a lot to do with our cultural aversion to talking about death.
Your Lordships may have heard of the Dying Matters Coalition’s community initiatives to help people,
“talk more openly about dying, death and bereavement”,
and to make these issues,
“accepted as the natural part of everybody’s life cycle”.
Until I prepared for this debate I had never heard of these, yet the role of the community is incredibly important. When communities, volunteers and families take on more responsibility for care, the costs associated with hospital stays and emergency admissions can be significantly reduced. I therefore have a specific question for the Minister. What, if anything, is the Department of Health doing to create the incentives and support systems needed to encourage more community involvement?
When a dear friend of mine died recently, his loved ones were able to say that he had a comfortable death. I think that that is what all of us would want for those who are close to us, and obviously even for ourselves. I look forward to hearing from the many other speakers in this debate and from the Minister about how we can get this right as often as possible so that a badly handled death becomes almost like a “never event”—incredibly rare because it defies belief that it should happen in a modern and compassionate healthcare system.
Health: Palliative Care
Lord Farmer Excerpts(9 years, 5 months ago)
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Lord Farmer
To ask Her Majesty’s Government, in the light of the Parliamentary and Health Service Ombudsman’s report Dying Without Dignity, what steps they are taking to ensure that everyone in need has access to good palliative care.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
The cases highlighted in the ombudsman’s report are appalling. Everyone deserves good-quality care, delivered with compassion, at the end of their life. Last year we introduced five priorities for care—the key principles that underpin the care that all people at the end of life receive.
Lord Farmer (Con)
My Lords, I thank the Minister for his reply. In the light of the parliamentary ombudsman’s report, Dying Without Dignity, is it the Government’s policy to encourage all schools of nursing to ensure that their graduates have core skills in end-of-life care by having the subject included in the formal assessments of their students’ competencies?
NHS: Maternity Care
Lord Farmer Excerpts(9 years, 9 months ago)
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Lord Farmer (Con)
My Lords, I am grateful to the noble Lord, Lord Harrison, for initiating this debate on steps to improve maternity care. One aspect of maternity care which shows marked variation across the country is staff willingness and ability to involve fathers. This depends to a very much larger extent on culture than on budgets. I wish to make a plea for the very many fathers across the country who have felt thwarted in their best efforts to support their wife or partner throughout pregnancy, during childbirth, and in the earliest days of their new family.
A poll carried out by Bounty found that 96% of mothers considered it to be very or quite important that midwives and health visitors include fathers as well as mothers, yet research reveals that fathers still feel excluded, frustrated at the helplessness this engenders, and fearful because of the risks and uncertainty of labour. Much of this is due to a lack of consideration by maternity staff contrary to guidance from the Royal College of Midwives. This is not so much about their rights as parents as the need for the great majority of new mothers to have their husbands and partners respected and considered part of the labour team. If they are calm and supportive, this can free up extremely pressurised maternity staff to look after any more pressing needs in the delivery suite, yet this requires fathers to have been well prepared from much earlier in the pregnancy.
Feeling needed and helpful rather than surplus to requirements can be a game-changing experience, especially for young fathers who have serious doubts about whether they should be involved at all in their new babies’ lives. The time of the birth and shortly afterwards can be a very special moment—the point when a young couple may decide to try to make co-parenting work, even if they sense that they are unlikely to survive as a couple. It can mean the difference between a child growing up knowing his father and that same child growing up thinking that his father did not care enough to be involved. A million children in this country have no contact with their fathers. Who knows, with a bit of relationship support, that child may even grow up living with a mother and a father.
I have never forgotten the first time I held each of my children while my wife was resting and recovering. The hard work starts immediately. Having the father 100% on board, helping with the practical aspects of baby care, such as walking inconsolable newborns around in the early hours, may protect untold numbers of new mothers against developing postnatal depression. Maternity services are uniquely positioned to help get things off to a good start.
Some noble Lords may be thinking about the recent headline which claimed that,
“it’s better for mothers coping with the pain of childbirth if their partner is not around”.
Personal experience and much other research tells me that it is comforting and reassuring to have that other person present at the birth, and immediately afterwards, who is utterly invested in the well-being of the new member of the family.
When I looked more closely, it was clear that the University College London study was not primarily concerned with childbirth at all, but with how women cope more generally with pain and the effect of their relationship with their partner. Extrapolating this to their experience of childbirth and making any generalisations at all about the desirability of fathers being present is not at all justified and very misleading. There have always been women who, for whatever reason, have preferred not to have the baby’s father present at the birth. This might be because of strains in the relationship or safety concerns. However, the norm is for the father’s presence and support, before, during and after birth, to be very much welcomed because researchers have established that it tends to lead to less anxiety, lower rates of postnatal depression and less perceived pain, so surely this is what maternity staff should be fostering. Doing this as early as possible in pregnancy, without adding to existing high workloads, is not just about holding antenatal classes at convenient times for fathers. Communicating directly with fathers-to-be is now particularly easy through digital means such as Maternity Assist. Health and well-being-related advice and information is sent to both expectant parents on their phones and tablets, which they can both read, discuss and make joint decisions about. It is a world away from a letter addressed solely to the mother which the dad might feel awkward about reading.
To conclude, and to reiterate my plea, can the Department of Health add its voice to that of the Royal College of Midwives and many others to ensure that maternity services are in no doubt at all that they have a key role to play in drawing fathers in as early and effectively as possible?