NHS: Targets

Lord Hunt of Kings Heath Excerpts

Thursday 6th February 2020 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House takes note of the National Health Service’s performance in relation to its priority area targets; and the impact of adult social care pressures on patients of the National Health Service, and their safety.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome this opportunity to debate the current performance of the National Health Service. I declare my membership of the GMC board, my trusteeship of the Royal College of Ophthalmologists and my presidency of GS1, the organisation responsible for the “scan for safety” programme. I am very pleased that my noble friend Lady Wilcox will be making her maiden speech in this debate.

I have instituted this debate because I am increasingly worried about the performance of our National Health Service. Despite the heroic efforts of many staff, every key indicator is being missed. Last November saw the worst four-hour wait performance in A&E since figures were first collected in 2010. Two-week waits for GP appointments rose by 13% last year. The target of a maximum wait of 18 weeks for hospital treatment has not been met since 2016. The cancer target of 62 days between urgent referral and first treatment was last met in 2013-14.

I fully accept that these targets are not the only way to judge the NHS, but they reflect overall performance. At the same time, we have seen an increase in the rationing of medicines, and failings in ambulance services and services for people with learning disabilities or mental health issues. The CQC’s review of the Mental Health Act today refers to a number of very worrying problems in that area.

Given this, it is a huge tribute to NHS staff that so much care remains of a very high quality. I absolutely acknowledge that. However, the calamitous drop in performance over the past decade is clearly having an impact on patient safety and leading to those longer waits.

I was very struck just before Christmas by the Norfolk and Norwich University Hospitals NHS Foundation Trust advising staff to make “the least unsafe decision” following a huge rise in admissions. Over the new year, the Royal Cornwall Hospitals NHS Trust told its staff to reduce severe overcrowding by discharging patients, despite the obvious risks involved. These are not isolated incidents. What has caused this? Many factors and pressures are at play. The alignment of austerity with workforce shortages, inadequacies of adult social care and a complete failure to factor in the growing older population mean it is little surprise that the NHS is reeling.

If we look at funding, the lowest five-year period of funding growth was between 2010 and 2014, and the past five years have seen little improvement. It is no wonder that the NHS is cash-strapped, in deficit and finding it very hard to invest the resources necessary to prevent hospital admissions. We can see similar trends in the workforce. In March, the Health Foundation highlighted a shortage of more than 100,000 full-time equivalent staff, including more than 40,000 nurses. The GP workforce has continued to stagnate, despite government promises to increase the numbers, and the GMC’s 2019 workforce survey showed that one-third of doctors have refused requests to take on additional workloads and one-fifth have reduced their hours. It is part of a vicious cycle in the workforce. Fewer doctors and more patients means that doctors are overworked. They get ill from stress and exhaustion. They decide to cut their hours or just leave the profession, and the remaining workforce feels under even greater pressure.

All of this is happening when social care is in meltdown. In 2018, the House of Lords Economic Affairs Select Committee reported that 1.4 million older people in England had an unmet care need. We know that the number of older people and working-age adults requiring such care is increasing rapidly, yet public funding declined in real terms by 13% between 2001 and 2015. We see a second vicious cycle. The level of unmet need in the system increases, the pressure on unpaid carers grows stronger, the supply of care providers diminishes, the strain on the care workforce continues and the stability of the adult social care market worsens.

What is the Government’s response? It seems to be twofold. The attitude of the Secretary of State appears to be to get rid of any target on which the NHS is not delivering, but I remind the Minister that the Royal College of Emergency Medicine has said of A&E that there is

“nothing to indicate that a viable replacement for the four-hour target exists”.

I strongly encourage the Government to think again before they agree to change that target.

The second line of the Government’s defence is essentially to argue that they are dealing with an unprecedented increase in demand. I am the first to acknowledge that the drivers of change are intensifying and that the NHS is clearly caring for a patient population with more long-term conditions, more comorbidities and increasingly complex needs, but this is not a new problem. The Labour Government of 1997 faced the same demographic challenge, but turned it around through investment in 300,000 more staff, 100 new hospitals and new services such as NHS Direct and walk-in centres. Waiting times came down as dramatically as public satisfaction went up. It can be done.

The Government have their own long-term plan with a new five-year settlement of around 3.4% per annum. However, as the right reverend Prelate the Bishop of London said in the debate on the Queen’s Speech, the additional funding is not a bonanza; it will serve only to stabilise NHS services, and the right reverend Prelate knows what she is talking about when it comes to the NHS. Yesterday, the NAO warned that NHS trusts reported a combined deficit of £827 million and clinical commissioning groups reported a £150 million deficit in the financial year ending 31 March 2019. The NAO said that short-term fixes have made some parts of the NHS seriously financially unstable, with trusts in financial difficulty increasingly relying on short-terms loans from the Minister’s department.

As we look at the funding promised—we will have a Bill on it in your Lordships’ House soon—I refer noble Lords to a letter written by NHS leaders to the Times on Tuesday, which pointed out that this funding does not include areas crucial to the Government’s election promise to provide more hospitals, nurses and GP appointments. The additional funding does not cover investment in buildings and equipment, so there is very little relief for our crumbling infrastructure or money to fund new technology to improve care. We know that the NHS is facing a workforce crisis but the funding does not cover education and training budgets to help with recruitment and retention. Nor does it offer any relief for public health and social care services, which would, I hope, if properly invested in, keep more people healthy and independent.

Therefore, the question before us is how to turn this around. I am sure that noble Lords will come forward with many ideas in this debate but I would like to propose four key measures. First, we have to plan for the long term—not five but 20 or 30 years ahead. I want to come back to the House of Lords Select Committee report on the long-term sustainability of healthcare. It was published three years ago and chaired by the noble Lord, Lord Patel. The committee said that we have to get away from the short-term fixes that we currently see and have seen in the past. It suggested that we set up an office for health and care sustainability to look at the likely funding and workforce requirements for up to 20 years ahead. Like the Office for Budget Responsibility, which has now been well accepted as giving authoritative, independent advice to government, this body could give advice to government, Ministers and parliamentarians on the likely demands on health and social care over the next 20 years. I believe that would be the start of a much more fundamental way of ensuring that we have a high-quality healthcare service in the future.

Secondly, alongside those kinds of projections, of course we need the commensurate funding. The funding challenge is immense. No one in the health service believes, for instance, that the 3.4% being given will allow them to invest in services for the long-term five- year plan. The money is not there to invest in services to keep people out of hospital; we have a crumbling primary care service because of the pressure from patients coming through the door; and people who work in the health service regard the local plans—the STPs—as a flight of fancy. They have had to publish them and have had to agree the figures with the Government because, if they do not, they will get their heads chopped off. However, Ministers are living in a dream world if they think that these plans will be delivered. Therefore, we have to find a way of funding the health service seriously in the future, but at the moment I see no indication that the Government recognise the scale of the challenge they face.

Thirdly, on the workforce, we need better recruitment and retention, and we need to increase our training numbers, but much of the problem is due to what I am afraid I have come across many times—a bullying and blame culture. It is very off-putting for many staff in the health service. I know that Ministers are concerned about this but it starts with them, their attitude and the way they deal with the health service and the bodies responsible for it. They have to lead from the centre.

Fourthly, we have to find a solution to social care. The Government have promised to come forward with one but, as we know, the last 20 years have seen a failure of nerve and an absence of political consensus. Frankly, at the moment we seem no nearer to a solution. I must acknowledge that it is a wicked problem. However, can we really wash our hands of the pernicious situation in which many people receive no care at all and many face the loss of not just their homes but their savings as the price of their long-term care?

In this debate noble Lords will raise many other issues, including improving outcomes, developing a more robust approach to public health, targeting health inequalities, and prioritising mental health and learning disability services. However, at heart, I hope the debate will come back to the issue of performance. The targets were not plucked out of the air. They were chosen because they were a very good proxy for the overall quality and performance of the NHS as a whole. In 1997, we inherited something called the Patient’s Charter, which said that there should be a maximum waiting time of 18 months for hospital treatment. The Conservative Government at that point had come nowhere near meeting that target. We turned that around and delivered an 18-week maximum wait. We hit other targets as well. I fear that it will not be too long before we go back to those bad old days if we carry on as we are at the moment. I ask the Government to think seriously about the kind of health service that they want for the public in the future. Based on current trends, I am afraid the situation is deteriorating. I beg to move.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I first thank the Minister for her comprehensive response, and I thank all noble Lords who have taken part in what has been a wide-ranging and excellent debate. I congratulate my noble friend Lady Wilcox on what was, on any count, a brilliant maiden speech. I hope that she will speak many times in your Lordships’ House over the coming months.

In such a wide-ranging debate, one cannot do justice to what has been said, but I would identify three core themes. First, on social care, we are united in wanting to see a solution. The Minister is reassuring about the proposals that will come from the Government at some point in the year. I say to her that it is very important that these proposals deal with the now as much as they do with the future; it is now that so much pressure is being felt. I say to the noble Baroness, Lady Brinton, that if she is really looking for a quick solution, she just has to go back: you legislated for Dilnot. Raise the means test cap; implement Dilnot; and put more money into adult social care—that at least would give you a fundamental way to go forward. Your Government legislated for it; this is the remarkable thing about capping the cost of social care for individuals. It is quite remarkable that we are here, still desperately hoping that we will get a solution for the future, when we had it.

Secondly, I echo all noble Lords who have spoken so highly about the work of staff and so many great things happening in the health service. There is no doubt about that. The noble Lord, Lord Bates, referred to the US Commonwealth Fund designation of the NHS as the number one healthcare service in the world. He was right to do so. As he will know, the reason for this is that we came out very highly on cost-effectiveness and access to services. He will also know that we came bottom, with the US, on health outcomes. My concern about the issue of targets is that our continuing failure to meet them will lead to worsening health outcomes in the future.

This brings me to my final point. The Minister referred to the pressures that we are under. These are not going to go away, whether demographic pressures, growing health inequality or the fantastic opportunities of new medicine and treatments, which cost additional money. This is the way that health will go over the next period; it is not until the 2060s that the population demographic will start to change again. At the moment, the health service is reeling under huge pressure. It is simply not sustainable to think that we can go on like this over the next 10, 20 or 30 years. We have to level with the public that, if they want the NHS—and I think they do—they will one way or another have to pay for it.

We cannot run away from the kind of debate that the noble and gallant Lord, Lord Stirrup, said that we ought to have. I go back to what the House of Lords Select Committee on Long-term Sustainability of the NHS said three years ago: that we must face up to the long term to have any hope at all of getting through this and landing the NHS in the excellent shape in which we want it to be. I thank noble Lords for the opportunity to debate this.

Motion agreed.

Paterson Inquiry

Lord Hunt of Kings Heath Excerpts

Tuesday 4th February 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

I thank my noble friend for that question, and for his important contribution. He is of course very experienced in this area. Obviously we are looking for time in the legislative agenda to bring forward HSSIB. It is appropriate that we consider the patient safety elements of this report’s recommendations in the context of that Bill. In the previous Second Reading debate, which we look forward to repeating, we discussed the issues around the independent sector. But we will also separately, and perhaps in conjunction with that, consult on the key changes necessary to enable data on admitted patient care to be transferred from the Private Healthcare Information Network and independent providers directly to NHS Digital, which should start to take us in the direction of closing the gap, which I know that many noble Lords in the House are rightly concerned about.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare an interest as a board member of the GMC. I also chaired the Heart of England Foundation Trust from 2011 to 2014. Mr Paterson worked for the trust as well as in the private sector hospital that the Minister mentioned. I would like to add my personal apology to that of the Minister to the patients and families for the suffering that they endured. Mr Paterson was suspended shortly after I became chairman and we instituted Sir Ian Kennedy’s review. We now have a second inquiry and I pay tribute to Bishop Graham for his work. I have only had the chance to read the Statement quickly, but it seems a thorough piece of work and has many far-reaching lessons and recommendations for the health service.

I have a couple of suggestions for the Minister. First, one of the recommendations is around the way that regulators work together, or not. At the moment, legislation is rather out of date and sometimes gets in the way of collaborative working, although one should never use that as an excuse. As part of the legislative review, I wondered whether the need for reform of the whole regulatory system will be kept closely under review.

Secondly, I want to follow the Minister on this issue of NHS bodies being reluctant to own up to things that have gone wrong because of the potential legal liability. I have discussed this with bodies at the national level and they all say that that is nonsense and organisations should not fear apologising, but it is heavily in the culture of the NHS not to apologise because of potential liability. As part of the consideration of these recommendations, I suggest that the Government seriously look at giving an explicit statement to the NHS on the facts of this and encourage those working in the NHS always to be open about things that have gone wrong.

[Baroness Blackwood of North Oxford]

I thank the noble Lord for that important and knowledgeable contribution. His point about the sharing of lessons between regulators was well made. Part of the reason for proposing HSSIB is for systemic learning of lessons that might otherwise not be available because an inquiry might happen in one trust or group of trusts and lessons might not transfer across the entire system. The whole principle of HSSIB is cross-system learning. We already have evidence that that is working.

Furthermore, the principles at the heart of the patient safety agenda that my right honourable friend Jeremy Hunt put in place were to embed a culture of learning and not blame within the NHS so that apologies can be forthcoming. We have some way to go in achieving that change of culture, but the noble Lord is quite right that leadership starts from the top and having the right statements is a good start. The principles around the place of safety, the protection of whistleblowers and allowing people to come forward and say when they think that things are going wrong without fear of retribution are steps in the right direction. The right action after that is transparency and the recommendations in this report about transparency lead to the right actions being taken from that point.

NHS: A&E Waiting Time Target

Lord Hunt of Kings Heath Excerpts

Tuesday 21st January 2020 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what plans they have, if any, to change the four hour accident and emergency waiting time target.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, the existing standard is still in place. NHS England and NHS Improvement are reviewing access standards in four key areas, including urgent and emergency care. The Government will respond to recommendations from the review once it is concluded.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in December, for 68.6% of patients the four-hour target was met, against the actual target of 95%. That is the worst month ever. The Government’s response, behind the warm words of the Minister today, is that they want to get rid of the target, yet research published last week by Cornell and the IFS shows that the current target saves at least 15,000 lives a year. The Royal College of Emergency Medicine has said that there is no viable alternative to the current target. The college says that the Government should get on with getting this target back on track. Will the Government do that?

[Baroness Blackwood of North Oxford]

The noble Lord always asks astute questions. Winter is a challenging time. Over 2 million people attended A&E last month, and we have to pay tribute to the dedicated NHS staff for seeing over 70,000 people every day—the highest number in December ever. Although we have more NHS beds open this winter than last, our A&Es have had to treat more people. The A&E waiting standard is being looked at by clinicians, who are considering whether it is appropriate, given the changes that have occurred in clinical standards. The five key reasons considered for moving away from the standard include: the standard does not measure total waiting times; the standard does not differentiate between the severity of conditions; the current standard measures a single point in an often very complex patient pathway; and there is evidence that processes, rather than clinical judgment, are resulting in admission or discharge in the period immediately before a patient breaches the standard, which is a perverse incentive. The Government will not do anything without public consultation and clinical recommendation. We will wait to see that, and no decision will be made until that comes forward.

Health: Vaping

Lord Hunt of Kings Heath Excerpts

Tuesday 14th January 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

The Government have consistently highlighted that quitting smoking and nicotine use completely is the best way to improve health. Although they are not risk free, research shows that e-cigarettes are effective in helping smokers to quit. That is why we committed in the long-term plan to roll out “stop smoking” services in the NHS, to support improvements even on our smoking cessation rates—smoking is now at its lowest level on record, down from 18.4% in 2013 to 14.4%.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Baroness agree that, looking back over the past 10 or 20 years, apart from the ban on smoking in public places, vaping has been the most successful intervention to reduce smoking? Does she therefore agree that we need to be cautious before we rush into trying to ban or overregulate its use, as some campaigners want?

[Baroness Blackwood of North Oxford]

As I said, more than 50,000 additional people quit smoking through e-cigarette use each year. We see e-cigarettes as an effective and safer route to quitting smoking than other routes. However, we understand that, at the moment, there is no evidence on the impact of long-term vaping, which is why Public Health England continues to update and publish the evidence base on e-cigarettes annually. We will continue to monitor the impacts of that use.

Queen’s Speech

Lord Hunt of Kings Heath Excerpts

Thursday 9th January 2020 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have to say that the Conservative Party did not do so well in Birmingham.

It is a great pleasure to declare my interests as a member of the GMC, a trustee of the Royal College of Ophthalmologists and president of GS1, the barcoding association responsible for the Scan4Safety programme.

I greatly welcome my noble friend Lady Blower. She made a brilliant maiden speech, and debates on education will be very much strengthened by her presence.

I welcome the emphasis in the Queen’s Speech on the NHS but it is the absence of any concrete proposals on social care that causes most concern. Frankly, the search for cross-party consensus seems to be no more than a promise to put it once more into the long grass. A number of my noble friends have talked about this. I urge the Government to go back to Dilnot. They commissioned Dilnot. He produced an excellent report, which was acclaimed. We legislated for it in this House. It is on the statute book. If we were to combine Dilnot with a more generous means test and more resources to local authorities to fund adult social care, it would not be perfect but, my goodness, it would be an improvement on the current iniquitous system.

I also welcome the return of the health service safety investigations Bill. It will be eagerly anticipated. Of course, it calls into question the Government’s patient safety strategy as a whole. I express my concern to the Minister that the strategy published just a few months ago claimed that the past 20 years have seen great progress in patient safety but no evidence was given. Talking to people on the ground—doctors and nurses—they are concerned that patient safety is compromised every day because of the huge pressures on the system. I was struck by the note sent out by the Norfolk and Norwich University Hospital just before Christmas, which told staff to make the “least unsafe decision” following a huge rise in admissions. Every day, up and down the country, NHS staff are having to make unpalatable decisions about priorities and about how to deal with the pressures and patient safety is clearly being brought into question.

I very much agreed with the noble Lord, Lord Hunt, when he talked about financial regulation. I believe the same sentiment should apply to medicines and medical devices regulation. We are promised a Bill, but the key question is whether regulation in the UK will continue to be aligned with the EU. We have had great advantages from that. Many overseas companies have invested in the UK, partly because of our life science sector and partly because regulation—either licensing or receiving a device’s charter mark—has meant that they could go into Europe and the licensing would be accepted. Despite the fact that the NHS is a poor adopter of new medicines, devices and innovations, it made the UK an attractive country in which to do business.

The Government say that they no longer want us to be aligned to the EU. What does this mean for medicines and medical devices regulation? Let us say that a US global pharmaceutical company had invested a lot of money in the UK; does it mean that, in future, it can continue to invest in the UK and get a licence from our regulator but would then have to seek a separate licence with different criteria in the rest of the EU? If that is the case, I can tell the Minister that investment will stop. If companies have to come here first, invest in R&D, go through all our regulatory procedures and then have to go to Europe and go through different processes, they will simply not come to the UK any more. This is a very important issue, which I look forward to debating when we get the Bill.

On NHS funding, I simply echo the right reverend Prelate the Bishop of London. The 3.4% per annum over five years can do no more than stabilise the current situation. As she said, we are failing lamentably on all the core targets and there are no signs as yet that we will get anywhere near meeting them. I welcome that Bill because we will want to amend it to ensure that the NHS has funding for the long term to meet all the pressures that it needs to face.

NHS: Nurses

Lord Hunt of Kings Heath Excerpts

Tuesday 7th January 2020 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government when they expect to meet the Conservative party manifesto commitment to deliver 50,000 more nurses in the National Health Service.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, we expect to increase nurse numbers by 50,000 by 2025. Eligible preregistration students on courses at English universities from September 2020 will receive additional support of at least £5,000 a year, which they will not need to repay. Additional payments of up to £3,000 will be available for some students in regions or specialisms struggling to recruit and to help students to cover childcare costs. We encourage everyone considering this incredible career to apply before the deadline on 15 January.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister, but the manifesto pledge and what she said today seem to me to have a whiff of fantasy, due to double counting, uncertain finances and a less than precise timetable. Of the 50,000 extra nurses, it turns out that only 30,500 will actually be additional nurses, of whom 12,500 will have to be recruited from other countries. Of the 18,500 that the Government are so magically going to persuade to stay on against the current trends, 12,400 were already pledged in the NHS plan published earlier in the year. It all seems to be on a bit of a wing and a prayer as to whether the Government will get anywhere near a net increase of 50,000. How can the Minister be confident that they are going to succeed when the student nurse attrition rate is at 25% and 14,000 qualified applicants were turned away from nurse courses last year?

[Baroness Blackwood of North Oxford]

My Lords, first, I thank the NHS staff who have worked so hard over the Christmas and new year period. I point the noble Lord to the recent record; the NHS now has over 20,300 more nurses on our wards than in 2010 and over 52,000 more nurses in training. We have increased our training places by 25% since September 2018 and made available 3,000 more midwifery places to ensure that we can achieve this outcome. We have put in place several actions on recruitment and retention, because we need to retain our extremely experienced and excellent nurses and to recruit more nurses to support them. That is why we have announced this new package, which will not only increase nurse payment by 12% but provide support for those in training, attracting more nurses in to support those already in place.

Health and Social Care: Malnutrition

Lord Hunt of Kings Heath Excerpts

Tuesday 5th November 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Baroness is absolutely right to identify some of the very significant health consequences of malnutrition. This is one of the reasons why it has been taken on board as a top priority by not only NHS England but the care system from top to bottom. The start is to have the right screening and to gather the right data so that we can identify where this needs to be improved. She is right that it needs to be integrated into nursing practice so that we not only prevent malnutrition in the first place but, where it does occur, provide the right support to put it right and the right care where there are health consequences for individuals due to clinical, social or economic problems.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I must confess to the House that I am president of the Hospital Caterers Association. Would the noble Baroness agree that there is no shortage of good advice on dealing with malnutrition and good food in the health service; nor is there a shortage of good catering professionals? The issue is trust boards that will not invest sufficiently in this area. Will she start to instruct the NHS to get serious about this if we are going to deal with this big problem?

[Baroness Blackwood of North Oxford]

The noble Lord is quite right that this is about leadership not only at board level but from the very top. It has been instructive that not only the Secretary of State but the chief executive of NHS England, Simon Stevens, have made it one of their priorities to ensure that the quality of food and food safety standards throughout the hospital and care systems should be improved. This is one of the key ways that we will drive out malnutrition from our health and care sector.

Health Service Safety Investigations Bill [HL]

Lord Hunt of Kings Heath Excerpts

2nd reading (Hansard): House of Lords
Tuesday 29th October 2019 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to follow the Minister, and I thank her for her introduction to this important Bill. I declare an interest as a member of the board of the GMC, a trustee of the Royal College of Ophthalmologists and president of GS1, which has overseen the Scan4Safety programme in the NHS.

I warmly welcome the Bill. As the Minister said in her introduction, the scale of adverse incidents in the health service makes it imperative that we try to develop a systematic approach to safety. In looking for inspiration, I came across something James Titcombe wrote recently. He conducted a remarkable campaign, following the tragic death of his baby under the auspices of the Morecambe Bay NHS Foundation Trust, and he fought and fought to get answers. He wrote:

“Where healthcare professionals perceive a blame-seeking response to incidents and error, the conditions for learning can never exist. It is paramount that the NHS is able to strike the right balance between ensuring there is accountability where appropriate, and fostering a culture where staff can report and openly discuss error with the confidence that they won’t be blamed unfairly”.


For me, that sets the foundation for the whole concept of the HSSIB. The safe space provisions are so important for the confidence of staff, in ensuring that information they provide will be treated fairly, without them feeling that their employing organisation will come after them because they have disclosed it.

I first became convinced of the need for a systematic approach when the former Chief Medical Officer Liam Donaldson chaired an expert group which produced, in 2000, the report An Organisation with a Memory. This then led to the establishment of the National Patient Safety Agency, and I can tell the Minister that that was actually the first organisation in the world to tread this course. The noble Lord, Lord Patel, was its first chair, and I had the pleasure of following him as chair from 2005 to 2007. Very disappointingly, when the coalition Government came to office—it is good to see the noble Earl, Lord Howe, in his place—we had the predictable bonfire of the quangos, which all Governments seem to go through before they set up their own, and the NPSA was abolished. Disappointingly, and remarkably, the decision was made to place the national reporting and learning system, which is the key mechanism by which people reported incidents, within NHS England, with the NHS Commissioning Board. Clearly, putting it within the compass of the organisation responsible for managing the NHS was the wrong thing to do. We should acknowledge that that has now been seen; hence the Bill today and why I welcome it so much.

There are a number of issues. We have the benefit of the organisation having been in shadow form for some time, so we can see the quality of the reports it has already produced. We have also had pre-legislative scrutiny, which has been very helpful in identifying some of the key issues. As the Minister said, the first issue is: what areas should the Bill cover? At the moment, it covers NHS patients, who can be treated in the private sector, but there is a restriction on private health services where patients are not NHS patients. The noble Baroness says that the Government want to await the Ian Paterson report, and I can see why, but I think it would be perfectly possible to provide in the Bill for the right of the Secretary of State, by order, to extend the provisions to the private sector in the light of the Paterson report. This may well be the only stage of the Bill we will take, and we may have another Bill fairly soon, so there might be time to reflect on that. I think it is very odd that the Bill as it is being brought at the moment does not encompass private healthcare. I think it should.

I am very supportive of the safe space concept, particularly as Clause 2(2) makes it clear that the purpose of the HSSIB is to focus on system issues and not to determine individual blame. It is clear though, from the briefs we have received the last few days, that many organisations do not agree with that. I have had briefs from the ombudsman, from the Association of Personal Injury Lawyers, from the Campaign for Freedom of Information and from the News Media Association on behalf of media outlets. All have sent submissions arguing that the restrictions on access to information held by the board are too strong and ought to be modified. Obviously, we will test this in Committee, but I think there is a clear tension between an approach that looks at systems safety, which tries to learn from errors and mistakes to say how we can put this right by a redesign of equipment or practice, and the absolute right of individuals to pursue cases against the health service and the right of regulators to regulate professionals appropriately.

Clearly, the Bill seeks to get the balance right. Clause 15 enables the Chief Investigator to disclose protected information,

“to address a serious and continuing risk”,

to safety. Clause 17 allows for a person to go to the High Court for an order of disclosure. In my view, that is the right balance: the safe space concept is set out in legislation, but there are circumstances where information can be disclosed. Where I question it, I must say, is in relation to Clause 19, which makes specific provision for a senior coroner to require disclosure. The noble Baroness has given some explanation of that. My understanding is that there are 95 coroners’ areas in England and Wales, employing 87 senior coroners. That seems rather a lot of people to be given special provision. Again, I think that in Committee we need to test whether coroners should be given this special provision. I remain dubious at this stage.

On maternity investigations, the Joint Select Committee was concerned that the board was being given a different remit in relation to these local investigations. The noble Baroness says that the Government need more time to consider what is to be done with those investigations, but I hope that during the passage of this legislation—however long that takes—there will be some kind of conclusion. Given that we are asking the board to do a specific job in relation to system safety, I wonder whether this is the right place for local investigations into maternity services.

The fundamental question of course is: what happens as a result of the work of the board? One of the NPSA’s problems was that it produced lots of reports, but nobody in the system actually took responsibility for implementing them. Here, there is clearly a mechanism whereby the board sends its reports to relevant organisations, and the Bill also makes provision for those organisations to respond to the board. I think that is a very useful suggestion, as is the requirement for a review of the board to be undertaken after four years’ work. I welcome that. However, we have heard it said that the board might produce up to 30 reports a year. Looking at the first two or three—on piped air, oxygen and mental health in emergency departments—the responses from the organisations that received them were very positive. However, in the report on electronic prescribing, the recommendations are extensive. They would be costly in money, human resources and managerial effort. I begin to worry that if over, say, four years it really produced 30 reports a year, which would be 120 overall, the risk is that they would tend to lie on the shelf. It would be a tick-box exercise, and the impact would be far less. I wonder whether the board ought to be less ambitious in the number of reports it produces, in order to get a bigger impact.

However, the fundamental question I put to the Minister is this: whose feet will be held to the fire if the board produces a report and it is clear after two or three years, when new safety incidents have emerged, that the health service has not actually responded? It is not at all clear to me who has responsibility for making sure that these reports have bite. In the airline industry, where this has come from, the experience is that when safety reports such as these are produced, they are acted upon. The big risk here is that, knowing the health service as we do, the number and range of adverse incidents is so wide that in the end the reports will become simply good practice guidance which people can take or leave. In the end, at heart this is the most fundamental question.

I will talk briefly about governance issues. I note that there are non-execs to be appointed, and I strongly urge the Government to make sure that NHS commissioners are appointed as non-execs to the board. We know that a lot of the expertise on this board has come from other sectors, and it is vital that there are people around the top table who understand the NHS. The best way to do this might be to appoint top clinicians to the board as non-executives. Secondly, the provision in Schedule 1 is for the Secretary of State to approve the appointment of the Chief Investigator, which is made by the board itself. I do not understand why the Secretary of State has to give his or her consent. This is not normal in the way that we generally do public bodies; I fully understand that the Secretary of State appoints the non-executives, but it should then be just for the non-executives to appoint the Chief Investigator.

Finally, the Joint Select Committee suggested that, because of the importance of these roles, both the chair and the Chief Investigator ought to be subject to pre-appointment scrutiny by the Health Select Committee. That is an excellent suggestion. Have the Government given this further consideration? When they responded to the Joint Select Committee, they said that they would discuss it with the chair of the Health Select Committee. It would be very good to know the outcome of those discussions.

Overall, this Bill is enormously welcome. I wish the board very good luck in the future, but I also look forward to some of the scrutiny that needs to take place.

Queen’s Speech

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare my membership of the GMC, trusteeship of the Royal College of Ophthalmologists and presidency of GS1, the barcoding association. I too pay tribute to the noble Baroness, Lady Emerton; she was an undoubted tour de force over decades of leading the nursing profession. I particular remember her kindness in attending the badge-giving honours at the Heart of England NHS Foundation Trust, which I chaired; she came and spent about three or four hours with the nurses before travelling on to a meeting in Leeds. She is an extraordinary woman who gave so much to our health service.

The Queen’s Speech promised a Bill on the long-term plan, which I suppose is really a cover for getting rid of the calamitous Health and Social Care Act 2012. Any of us should welcome that, but the problem is that it does not answer the much more substantive question of how we will fund and develop a sustainable health and social care system over the next three decades.

The NHS has done wonderfully well in meeting many of the challenges it has faced over the last nearly 70 years or so, but no one can be in any doubt that, with the growing number of older people with comorbidities and the kind of good pressure that new technology and invention bring, the health service is struggling hugely. The CQC’s annual State of Care report, published only last week, shows that there is huge pressure on all health and care services. Waiting times for treatments are going up, and I fear that we will return to the bad old pre-1997 days unless we take decisive action. We have the wholly unstable adult social care market, which noble Lords have already referred to, and there seems to be general agreement that about 1.4 million people who ought to be receiving care at the moment are not.

The question is how we will respond to this issue. The Government’s immediate response is their own long-term plan, a new five-year settlement of around 3.4% growth per annum. That is of course welcome, in contrast to the years of austerity; when the demand was going up, adult social care was being reduced in real terms and for five years the health service received its lowest ever funding level since its foundation. Obviously, 3.4% real-terms growth is a great improvement on that. The problem, as anyone reading the IFS report on public finance going ahead will know, is that this is a temporary blip—we will return to austerity.

The report of the Long-Term Sustainability of the NHS Committee, excellently chaired by the noble Lord, Lord Patel, was very clear that we cannot go on having this short-term upfunding followed by reductions without any serious attempt to solve the real problem of funding health and social care over the next 20 or 30 years. There are no easy answers: it is pretty clear that the public and the political class as a whole will not see any change in the basic premise of a publicly funded service free at the point of use as far the NHS is concerned; it is also clear that public opinion does not favour any increase in charges. One way or another we have to persuade the public to pay more money through taxes to get us back to a sustainable growth figure.

The only possible way that we can do this is through some kind of hypothecated health and social care tax. It is probably not popular with the Treasury, or with many noble Lords. National insurance is the obvious way to do it; the UK take for national insurance roughly equals the amount we spend on health and social care in England, so it is probably the easiest way to do it. There would have to be changes—as my noble friend reminded me just now, the fact that many of us do not pay national insurance any more while still earning is clearly unacceptable. However, we have to think radically about whether we seriously want to go on funding our health service and whether we want a sustainable, excellent health service.

The committee of the noble Lord, Lord Patel, did not quite recommend a hypothecated tax, although I think that perhaps it was trying to get there. However, it recommended that we set up an OBR for health and social care as well. That is an excellent idea: an independent body giving advice on the long-term funding needs of the health and social care system, alongside workforce projections and demographic challenges. If you put the two together, that would be about the only hope we have of maintaining an excellent health and social care system in the future. The alternative is a long period of austerity with a little bit of growth, no certainty and a continuation of some of the pressures we see at the moment.

National Health Service: Bullying

Lord Hunt of Kings Heath Excerpts

Wednesday 3rd July 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Baroness asks an important question. There are structures built into the NHS to enable those people to speak up. There is a “freedom to speak up” champion and a system of champions, so that it is perfectly clear to those experiencing bullying by senior managers who they can speak to.

[Lord Hunt of Kings Heath (Lab)]

Does what the Minister suggests apply to the actions of Ministers? She will recall, from when he was Secretary of State, Mr Jeremy Hunt’s practice of insisting on a weekly Monday morning meeting with the key national regulators, at which the sacking of chief executive officers was often discussed. Bullying starts at the top. If Ministers take a bullying attitude towards the NHS, they can hardly be surprised if that behaviour is followed at local level.

[Baroness Blackwood of North Oxford]

I am afraid I do not recognise the characterisation set out by the noble Lord. One of the key characteristics set out by the former Secretary of State in his leadership was that the NHS should be open and not have a culture of blame, and that people should feel free to speak up, so that when mistakes are made they should be corrected.