NHS: Nurse Retention

Lord Hunt of Kings Heath Excerpts

Wednesday 17th January 2018 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what steps they are taking to stem the flow of nurses leaving the NHS.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask a Question of which I have given private notice.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, nursing numbers have increased since 2010, including 11,700 more nurses on hospital wards. To retain more of these hard-working staff and to build a workforce fit for the future, the Government are increasing the number of nurse training places by 25%, supporting new flexible working arrangements in the NHS and delivering a new homes for nurses programme.

[Lord Hunt of Kings Heath]

My Lords, even for the Minister, that is remarkably complacent. The overall number of nurses may be rising, but it has nowhere kept pace with the increasing number of patients. For years, the Government have failed to get new recruits coming through, while failed policy decisions such as the NHS pay cap and the ending of the NHS bursary have contributed to the growing crisis. Last year, 33,000 nurses left the NHS. More than half of those who walked away were under 40, and the number of leavers outnumbered joiners by 3,000. There are now more than 100,000 vacant posts in the NHS. Does the Minister accept the need to lift the pay cap, fund proper rises for nurses, restore bursaries and support this precious profession, which has been so unappreciated by this Government?

[Lord O’Shaughnessy]

The noble Lord is quite wrong to say that it is an unappreciated profession; nurses are deeply appreciated by everybody in this country, and that includes members of the Government.

Of course we want to reduce the number of nurses leaving the profession. It is important to point out that the number is down on two years ago, which was the peak in both number and proportion, and that the number of nurses has risen over that period. The noble Lord mentioned the pay cap. He will know, I hope, that in the Budget the Chancellor announced that he would be funding pay increases above the pay cap for nurses and other professionals on the Agenda for Change contracts, which is extremely welcome. We know that pay matters.

The noble Lord is right to focus on under-40s; that was an area that concerned me. The programme whereby we are promising to deliver 3,000 social homes for nurses is an important part of retaining staff, because we know how important housing costs are, particularly in the south of England.

Finally, we have been around the issue of bursaries a number of times, and there is no evidence that their introduction will make a long-term impact on our ability to recruit the nurses we need. Indeed, we are increasing the number of nurse training places from next year by a further 5,000.

Smoking: Vaping

Lord Hunt of Kings Heath Excerpts

Tuesday 19th December 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Viscount is right to highlight the benefits of vaping: it is considerably safer than smoking and is a very effective quitting aid. There is no particular evidence that it encourages people to take up smoking or to transition into smoking. Government policy has, obviously, been made under the EU regulatory framework—and we think that it is pragmatic and evidence based. Direct advertising is, as he will know, banned, but the department, Ofcom and the Advertising Standards Authority are looking at the current guidelines in this area. I should point out that Public Health England includes in its public health campaigns positive messages about the relative benefits of vaping, so that message is getting out. In the end we must beware of renormalising the act of smoking, even if with a different device, particularly for children, so there is a balance to be struck.

[Lord Hunt of Kings Heath (Lab)]

My Lords, lest Brexiteer noble Lords get too excited, will the Minister confirm that it was the British Government who pressed the EU for draconian regulations, and the EU modified what Britain wanted? We should beware repatriation of those regulations.

[Lord O'Shaughnessy]

I will only talk about what I know, and what I know to be coming up, which is that we want to take a pragmatic and evidence-based approach. Other countries are looking at the balance we strike in this country with allowing smoking and vaping to take place—and indeed, positively encouraging vaping. I think our approach is sensible.

Health: Atrial Fibrillation and Stroke

Lord Hunt of Kings Heath Excerpts

Tuesday 12th December 2017 Lords Chamber

[Lord O’Shaughnessy]

I thank my noble friend for making that point. He is quite right that atrial fibrillation is easily diagnosable and treatable. In the end, it has to be a clinical judgment on what kind of medicine is appropriate for any given patient, but the variation in the prescription of anti-coagulants demonstrates that there is not uniform understanding of the options. There are a number of things I could point my noble friend to, such as the NICE guideline which promotes not only self-monitoring systems, which are typically what we have had, but encourage patient choice for the new types of anti-coagulants which have a lower risk of bleeding and are much more popular with patients.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister say why the national stroke strategy has not been updated or renewed? We had outstanding success in London in concentrating hyperacute services in a small number of centres, which improved outcomes and mortality rates. Why on earth has the NHS been allowed to stop proposals in other parts of the country taking that forward so that outcomes there are higher?

[Lord O’Shaughnessy]

On the stroke strategy, a follow-on plan is being developed by NHS England and its partners, including the Stroke Association, which will take forward that approach. The noble Lord will also be pleased to know that it is an integrated-service approach including ambulances, community care and secondary care. On the point about reorganisation, he is quite right that London has seen excellent success through the specialisation and concentration of services, and we certainly encourage the rest of the country to do that too.

Children: Oral Health

Lord Hunt of Kings Heath Excerpts

Monday 4th December 2017 Lords Chamber

[Lord O'Shaughnessy]

I am sure that milk does have those benefits. I should also point out that one of the best things one can do for all bone health is to have vitamin D and calcium supplements, which are recommended for young children.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that we are all grateful to the Minister for his wisdom in advising us on such important matters. I declare an interest as president of the British Fluoridation Society. To return to the point that I have raised with many Ministers over the past few years, the Minister says that it is down to local decision-making. The problem is that the hurdles that have been put in place make it almost impossible for local authorities to get fluoride into their water supplies. Will he look again at the rules and the law and agree that this is a strategic decision that needs to be made by government?

[Lord O'Shaughnessy]

I am certainly happy to look again at that issue because we know the benefits of fluoridation. That is one reason why more children are having fluoride varnishes, for example.

NHS: Staff

Lord Hunt of Kings Heath Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to thank my noble friend Lord Clark for allowing us to have this important debate. I also pay tribute to the noble Baroness, Lady Emerton. It was very good to hear her speak today. She threatens retirement, but let us hope that is a little time off yet.

My noble friend spoke in a passionate, informed way of the considerable challenges facing the National Health Service and its workforce, and the link between the workforce challenges and the problem of NHS performance at the moment. As my noble friend Lord Pendry said, the NHS faces its most difficult time since its inception. Not only are targets being missed but the key quango, NHS England, effectively says that it will no longer attempt to meet some of those targets, including the 18-week target.

My noble friend Lord Clark spoke of statements emanating from the leadership of NHS England that it will have to ration treatment. I put it to the Minister that paragraph 16 of the board papers published this morning by NHS England states:

“Our current forecast is that—without offsetting reductions in other areas of care—NHS Constitution waiting-time standards in the round will not be fully funded and met next year”.


I remind the Minister, because we debated this in September, that meeting the core targets, including that of 18 weeks from referral to treatment, is a legal requirement under the NHS constitution. I also remind him of a statement made by the Government on the morning of our debate on 6 September this year. It said that the 18-week standard,

“remains a patient right, embedded in the NHS Constitution and underpinned by legislation. We have no plans to change this”.

Will the Minister today repudiate the action that the NHS commissioning board is being recommended to take, signal to the House that the constitution and associated regulations will be amended to allow NHS England to not meet the standard, or produce the funds so sorely needed to ensure that the NHS can meet it? It is no good for Ministers just to shrug this off; it is a matter for which they must account to Parliament.

That is just one example of why we have such huge workforce pressure. I thought that NHS Providers summarised the situation very well when it talked about mounting pressure:

“Rapidly rising demand and constrained funding is leading to mounting pressure across health and social care”.


My noble friend Lord MacKenzie spelled that out well. It also said that most provider trusts,

“are struggling to recruit and retain the staff they need”,

that the supply of new staff,

“has not kept pace with rising demand for services and a greater focus on quality”,

and that,

“recruiting and retaining staff has become more difficult as the job gets harder, training budgets are cut and prolonged pay restraint bites”.

It also states:

“Even if there were no supply shortages of staff, and provider trusts had no difficulty recruiting and retaining staff to work for them”,


many would,

“be unable to afford to employ the staff they need to deliver high quality services”.

No doubt we will hear the Minister peal out some statistics showing that there have been some increases in staff between now and 2010, but that is not the whole story. First, he must take account of the increase in demand on the health service over those seven years. Secondly, in 2010, the coalition Government made disastrous decisions to cut, in particular, nurse training places. In a panic, they have had to reverse that decision, but we are behind the curve in relating staff numbers, the number of staff training places and the way services are going. The decision to scrap bursaries has proved a disaster—disastrous to the wretched universities that proposed it, because they do not have more nurses coming in, as they thought they would, and a disaster for the Government. It must be reversed.

On pay policy, my noble friends Lady Donaghy and Lord MacKenzie spoke very well about the impact of pay restraint on low-paid workers. The pay review bodies are hardly independent in that it is clear that they have now been told they can go above 1%, but there will be no money to pay for it. Independence? What independence do they have? What prospects are there for so many NHS staff to have decent pay in the future?

I also raise something I find very disturbing. First, there is the attack by Jeremy Hunt on NHS staff over compensating for working anti-social shifts. Apparently, he thought he did so well over the junior doctors’ negotiations that he will bring the same great skill and leadership to the other staff groups in the health service. That will certainly improve morale, will it not?

I also raise with the Minister a disturbing trend being forced on NHS foundation trusts by NHS Improvement, which is designed to take thousands of staff out of NHS employment and, as worrying, out of the NHS pension scheme. This is a growing trend to set up wholly owned subsidiary companies to run a lot of non-clinical services within trusts. Clearly, it is a VAT fiddle—it is designed to reduce VAT payments—although the DH has to make up to the Treasury the VAT return, so it is a false economy by the health service. Staff who transfer to the company retain their employment rights, terms and conditions and NHS pension, but new employees have no such guarantee whatever. I gather that NHS staff who are really being forced to transfer to these subsidiary companies are being encouraged to opt out of the NHS pension scheme in return for a bribe of a higher wage rate. I find it deplorable that this can be encouraged by bodies responsible to the Minister. Staff are being encouraged to come out of the NHS pension scheme. That is absolutely disgraceful. I hope the Minister will say today that that will be stopped.

On resources, what can I say? My noble friends Lord Pendry and Lord Clark clearly think that the bung put in by the Chancellor is insufficient. The Institute for Fiscal Studies said that the NHS was in the middle of its toughest decade ever. It said that after accounting for population growth and ageing, real spending had and would remain unchanged for years. Sir Bruce Keogh, medical director of the NHS, said after the Budget that, “longer waits seem unavoidable”.

The King’s Fund, the Nuffield Trust and the Health Foundation, in their post-Budget analysis published two days ago, said that next year the NHS will not be able to meet standards of care and rising demand. Resources are a major issue in relation to the workforce. So, too, as my noble friend Lady Donaghy said, is staff affection for the shambolic system the coalition Government imposed on the NHS in 2012. We knew it would be a disaster; we said so for 15 months in your Lordships’ House. They determined to go on with it and we have ended up with a hugely fragmented leadership, wholly inadequate commissioning and rampant instability in providers. We have reached a point where the Secretary of State himself disowns the 2012 Act. The whole purpose of setting up STPs is basically to circumvent the rules of the market within that Act. No wonder the staff feel unhappy when leadership is so fragmented and hopeless. When will the Government legislate to legitimise what is happening? The 2012 Act is clearly being ignored.

My noble friend Lady Pitkeathley focused very well on social care, of which there was nothing in the Budget. The Green Paper has been put into the long grass and I do not expect to see it for many, many months. For carers there is a whole lack of support and no strategy. No wonder the social care workforce is in such a shambles.

I am sure the Minister will talk about this: we are now promised a workforce strategy. The Secretary of State gave an interview to Health Service Journal recently, in which he said:

“My strong view, having been involved in this job for a while now, is that the big problem with workforce strategies is that both me and predecessors in my role have only thought about workforce in terms of the current spending review and that’s really what has caused us a problem in the past because we only committed to train people for whom the Treasury had given concrete assurance they were prepared to fund. We ended up with very short-termist spending reviews, sometimes they were only a year … My view is, given how long it takes to train a doctor or a nurse, you cannot have a workforce strategy that is anything less than 10 years”.


In 2010 the Government inherited a long-term workforce strategy, and what did they do? They cut it viciously.

The Minister is always fond of sermonising to me, in particular, on the economy, and why the Government did what they did. I remind him that in 2010 the economy was growing at 2% per annum and the Government snapped it off. It took a long time to recover. I also remind him of what the noble Lord, Lord Warner, said: the UK economy is incredibly fragile at the moment. We have low productivity and downward projections on growth. The OBR has revised growth down to 1.5% this year, 1.4% in 2018-19 and 1.3% in 2019-20. The IFS has described this decade of a Conservative Government as the age of austerity and stagnant wages, which it now expects to last for another decade. I say to the Minister that, with the disaster of Brexit to come, the Minister should spare us lectures on the economy.

What are we to do? What is the future? NHS Providers did a very good piece of work, recently setting out a strategy for closing the workforce gap, making the NHS a great place to work and ensuring that we have strong, effective leadership. I commend that report to noble Lords. There is an awful lot to do, and I am afraid I am not confident in the Government’s ability to do it.

NHS: Wound Care

Lord Hunt of Kings Heath Excerpts

Wednesday 22nd November 2017 Lords Chamber

Tabled by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what plans they have to develop a strategy for improving the standards of wound care in the NHS.

[Baroness Wheeler (Lab)]

My Lords, in my noble friend’s unavoidable absence, I shall ask the Question standing in his name on the Order Paper. Wound care is a massive challenge to the NHS, but it currently lacks priority, investment and direction. This debate is designed to press the Government to recognise the need for urgent action and for the development of a strategy across care providers for improving the standards of wound care.

I am delighted that so many noble Lords with expertise on this highly important matter have put their names down to speak. It will ensure that we can cover a wide range of issues across medical, nursing and patient care and the quality of medical supplies. It will also give the Minister the stepping stone for developing the national strategy that I hope he will recognise is sorely needed.

A staggering 2 million patients are treated for wounds every year at a cost of more than £5 billion. The overwhelming majority of this figure goes towards paying for nursing care costs rather than products such as bandages. In other words, the cost is more than, for example, we spend on tackling obesity, which is the centre of major national campaigns. Treatment costs include more than 700,000 leg ulcers and 80,000 burns. Pressure sores also feature highly, with estimates of an 11% increase overall each year.

While 60% of all wounds heal within a year, a huge resource has to be committed to managing unhealed wounds. The NHS response is very variable. Healing takes far too long; diagnosis is not good enough; and inadequate commissioning of services by clinical commissioning groups compounds the problem, with undertrained staff and a lack of suitable dressings and bandages. There has also been a very worrying drop in the number of district nurses, whose role in ensuring safe and effective wound care in the community is crucial.

Ideally, 70% of venous leg ulceration should heal within 12 to 16 weeks and 98% in 24 weeks. In reality, however, research shows that healing rates at six months have been reported as low as 9%, with infection rates as high as 58%. Patients suffer and the cost of non-healing wounds is substantially greater to the NHS. The failure to treat wounds swiftly and effectively can lead to more serious health problems, such as sepsis, which is often the result of an infected injury; we also know that foot ulcers on diabetics can lead to amputations if they are not dealt with properly.

The situation will only be turned around with a nationally agreed strategy to reduce variation, prevent wounds getting worse and improve outcomes. Wound care therapy strategies are needed and national care pathways for wounds must be established to cover the complexity and variety of wounds, using evidence-based health economic data and academic and clinical expertise. The Bradford study and survey that is summarised in the Lords’ Library brief for this debate—a good brief but sadly received only yesterday—underlines the point about the importance of evidence-based care, with nearly one-third of patients interviewed in the study failing to receive an accurate diagnosis for their wound. As the study puts it:

“Wound care should be seen as a specialist segment of healthcare that requires clinicians with specialist training to diagnose and manage. … There is no doubt that better diagnosis and treatment and effective prevention of wound complications would help minimise treatment costs”.


Dedicated wound clinics in the community are also needed, alongside a co-ordinated treatment plan to achieve best outcomes for patients. A focus on the prevention of wounds, as well as treatment and healing of wounds, is also very important. The NHS must also invest in high-quality bandages and dressings, in contrast to the current skimping that takes place in many areas. We know, however, that with the NHS as financially hard pressed as it is, there is huge pressure to reduce the costs of medical equipment and clinical supplies such as dressings. The result is that in the procurement of dressings and other forms of treatment, there is not enough emphasis on the cost of patient care and too much focus on the unit cost of products. Not only does this lead to poorer and more costly outcomes for patients but there are a number of unwelcome side-effects. Products will be less innovative and effective; a reduced amount of educational support will have a detrimental effect on patients; there will be fewer appropriate treatments available; and all this will lead to job losses if there is less sourcing from high-quality British suppliers and manufacturers.

With cost as the primary driver, suppliers to the NHS will have a race to the bottom, compromising quality. Poor-quality dressings simply cannot withstand the rigour required to produce effective healing. It is massively counterproductive. Reduction in the availability of clinically appropriate dressings, which comprise only 10% of costs, will result in patients suffering as wounds take longer to heal. An increased burden on the NHS will follow and the result is longer hospital stays, particularly for the elderly, more readmissions, compromised quality of life and repeated visits to GPs and community services.

Of course, we fully support improvements in the way that medical equipment and other supplies are procured. I am not sure whether, in his absence, I have to declare my noble friend Lord Hunt’s interest and commitment to these matters as president of the Health Care Supply Association but I am sure he will value it being mentioned. We also support the work of my noble friend Lord Carter and his 2015 review on how the NHS can avoid unwanted and unnecessary variations in the cost of supplies. The overall aim of his review was to see how the NHS could reduce spending by £5 billion by the 2020-21 financial year. It proposed £600 million in savings for supplies, half of this to be saved before October 2018; limiting the NHS to 40,000 products instead of 300,000, with an overwhelming majority of this—80%—going towards a newly revised supply chain process; as well as replacing local formularies with a national formulary.

Although we welcome the report’s efforts at saving the NHS money, we need to ensure that any shift in focus to the short term will not lead to the knock-on effect of costs rising in other clinical areas. There is also strong concern that the short-term focus could lead to a scarcity of supplies in the future. I would be grateful to hear reassurances from the Minister on the steps being taken to guard against these two unwanted outcomes. Evidence clearly shows that the current problems can only worsen. The average number of adult wounds that every CCG will have to manage is expected to rise from 11,200 in 2012-13 to 23,000 in 2019-20.

The Government urgently need to get a grip, with a nationally driven strategy. Without it, patients will receive worse care for their injuries and the financial burden on other parts of the NHS will continue to increase because patients will develop chronic wounds or catch an infection that could lead to potentially life-threatening illnesses. I look forward to the contributions of noble Lords to this very important debate and to the Minister’s response.

National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017

Lord Hunt of Kings Heath Excerpts

Thursday 16th November 2017 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017 do not clarify how upfront charging can work without increasing barriers to healthcare for vulnerable groups, how they will not breach equality legislation through the potential use of racial profiling as a means to identify chargeable patients, and how the extension of charging to community services will not lead to patients being prevented from accessing preventative care programmes; and further regrets that they have been introduced without sufficient assessment of the effectiveness and value for money of the bureaucratic process proposed (SI 2017/756).

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am moving this Motion because I believe the regulations on charges for overseas visitors do not clarify how up-front charging can work without increasing barriers to healthcare for very vulnerable groups. They do not explain how they will not breach equality legislation through the potential use of racial profiling as a means of identifying chargeable patients. The regulations do not show how the extension of charging to community services will not lead to patients being prevented from accessing preventive care programmes. I also believe that it is a matter for further regret that these regulations have been introduced without sufficient checks of the effectiveness and value for money of the very bureaucratic process proposed.

Let me say at once that, on the face of it, charging overseas visitors to use our hard-pressed NHS is entirely reasonable. But the Government’s latest plans to extend charges to community services will raise very little money, place a huge bureaucratic burden on the NHS and deny healthcare to very vulnerable people. The UK already charges some overseas visitors for most hospital care after treatment. Patients who are not eligible for free care include short-term visitors, undocumented migrants and some asylum seekers whose claims have been refused. There are already processes in place for hospitals to identify and bill such patients. We understand that in addition to these regulations, the Government are considering extending charging to A&E and GP services.

Under the regulations that came into force last month, all community services receiving NHS funding, including charities and social enterprises, are now legally required to check every patient’s paperwork, including passports and proof of address, before they receive a service to see whether they should pay for their care. Charges are up front, with non-urgent care refused. As a person will need to provide paperwork and/or a passport to prove eligibility, there is a distinct possibility that people who are entitled to free care on the NHS will be denied treatment because they do not have it at hand. Particularly vulnerable groups here include the elderly, asylum seekers, homeless people and mentally ill people. Moreover, if patients continually have to provide details every time they need healthcare, this risks them waiting longer, with an inevitable increase in bureaucracy.

Asylum Matters, in conjunction with a number of other organisations, has commented in response to the Minister, who has written both to Members of this House and to MPs in the House of Commons to allay fears about how patient ID checks will be carried out. He says that the changes do not require a patient to provide a means of identification to qualify for free care. He says that, while that may be helpful in demonstrating eligibility, other information will be used by trained NHS staff to ensure that the residency status of a patient is identified. He says that the regulations simply require that a relevant body must make such inquiries that it is satisfied are reasonable in the circumstance to determine whether charges should be made. The problem is that those protections are not built into the regulations. They may be in the guidance but guidance can be changed at any point, and they cannot be enforced if NHS organisations choose to insist on further proof of a patient’s ID.

I have been written to by many people, and I would like to refer to a very important paper sent to me by Natalie Bloomer, in which she refers to the father of a newborn baby who recently received a letter from his local hospital demanding to know whether his eight day-old child was entitled to free healthcare. The parents wondered if they had received the letter due to the mother’s foreign-sounding maiden name. When the father went back to the hospital, it quickly told the family to disregard the letter. For me, this highlights the whole problem of this wretched and miserable policy. It is quite clear to me that, apart from the dreadful impression and reputation it gives of our country, many people who legitimately live here and have every right to NHS treatment are going to be challenged by the NHS. I find this absolutely despicable.

I gather that the Secretary of State has claimed that charging regulations simply bring us into line with our European neighbours. Of course, this is complete nonsense. The work done by Doctors of the World, which I have seen, has been researched comprehensively, and the fact is that many European countries, particularly the ones we tend to compare ourselves with, actually provide a more comprehensive package of free healthcare—for instance, to undocumented migrants.

I receive many briefings and letters from reputable organisations. This regret Motion has been backed by many trusted and well-respected bodies, including the BMA, the Royal College of Midwives, Doctors of the World UK, the National AIDS Trust, Asylum Matters and Freedom from Torture. Many of them represent groups which will be intimately affected by the regulation introducing and extending overseas charges.

They are not the only ones to oppose this new policy. An open letter addressed to the Secretary of State, published by 193 organisations and 880 individuals, has called for the regulations to be dropped as soon as possible. Among the signatories were 300 doctors, 50 nurses, the former NHS chief executive Sir David Nicholson, the Royal College of Paediatrics and Child Health, and Amnesty International. Not only were they all agreed that the introduction and extension of charges will place a greater burden on the NHS, but this is the kind of thing that the Conservative Government pledged to cut down—the wretched bureaucracy involved and the time that will be spent by staff trying to make these charges work. The Royal College of General Practitioners has flagged up the possibility the new system could end up overstretching already strained family doctors at medical centres. The Catholic Bishops’ Conference, in its letter, spoke of the catastrophic consequences of the new regulations and asked for them to be suspended.

Not only is this a ludicrous action by the Government, it will have no impact whatever on the finances of the NHS. The estimate is that it will bring a £200,000 saving—how ridiculous. The point I want to make in the debate tonight is that these rules are now already law. The Catholic Bishops’ Conference has asked for the regulations to be suspended, and I hope the Minister can announce that he is going to do that, but at the least there should be an early independent review of how the new charges are operating. Until then, there can be no question of extending charges to yet more services. I beg to move.

[Baroness Hamwee (LD)]

My Lords, I thank the organisations that have briefed us. Sending a joint briefing was particularly helpful, not because it reduces the paper but because it increases the force of the content. It came from Asylum Matters, Doctors of the World UK, NAT and Freedom from Torture. We have had briefings from others too. I also thank the noble Lord, Lord Hunt. Like him, I understand that some charging of visitors is entirely reasonable, but—and it is a very big but—the noble Lord has raised some very pointed questions wrapped up in the text of his Motion, and I hope that the Minister will be able to respond to those point by point.

This is not a new problem for some groups but it is now worse. During the passage of the Immigration Bill, now the Immigration Act 2014, the points were put forcefully—especially, I remember, by those concerned with maternal health and by doctors who were working with a wide range of immigrants. I remember hearing from Doctors of the World UK that, before the regulations which followed that Act came into force, there were queues round the block at its clinic of people who were anxious about what their position would be afterwards.

The charging then was presented as an innocuous extension of the system, and really very beneficial. There was a lot of talk about health tourism blocking access for those of us who are not tourists. I began to think that the world must be full of people who had had their pregnancy confirmed and immediately booked a flight for the due date minus however many weeks the chosen airline applied as the cut-off for carrying pregnant women. At that time, it became clear that many hospitals found the charging system then in force so burdensome that it had simply defeated them, and there was a good deal of criticism of those that were defeated, I recall. This time around, again there has been considerable protest from people who have seen at first hand the effect of what the pre-23 October regulations require.

When I looked for the government impact assessment on the regulations, I found an evaluation by Ipsos MORI of the overseas visitor and migrant NHS cost recovery programme, published in January this year but apparently started in 2014. The paragraph on the costs and benefits of implementation made startling reading—which I found difficult because I printed it off in such a small font. It made me doubt whether there really was benefit to the implementation. What continued valuation will there be? This is another way of asking the question that the noble Lord, Lord Hunt, asked: will the Government consult before extending the charges into other health services, including A&E and GP services? The letter that the Secretary of State wrote in response to the open letter seems to say these things are so because they are so. I am sure that there cannot be as relaxed an attitude as that seems to suggest.

--- Later in debate ---

[Lord O’Shaughnessy]

For clarity, they are not covered under the exemptions.

The second change the amendments make is to the requirement that any care not deemed immediately necessary or urgent by a clinician is paid for up front. The published guidance, again, for nearly 30 years, has recommended this. This practice ensures that a chargeable patient can make an informed choice about their care and therefore does not unwittingly incur debts when they could instead, for example, choose to wait for treatment until they have travelled home. Given that our NHS is facing unprecedented levels of demand, I hope noble Lords will agree that mandating this position is a sensible approach and that it will help make sure that all users of the NHS make an equitable contribution to ensure its continued success and viability.

The noble Lord, Lord Hunt, has asked whether this practice will not create barriers between vulnerable patients and treatment and result in racial profiling as the front line seeks to determine eligibility for free care. I have already drawn noble Lords’ attention to the exemptions in place and the fact that all GP and A&E services remain free for all. I am also clear that immediately necessary or urgent treatment—such as all maternity services—will never be withheld, regardless of the patient’s ability or desire to identify themselves or pay. To reassure the noble Baroness, Lady Taylor, and other noble Lords, it is for clinicians, and no one else, to determine whether a treatment is immediately necessary or urgent.

On whether patients may face discrimination, this is always unacceptable and not compliant with anti-discrimination legislation. As my noble friend Lord Leigh pointed out, our guidance is clear that simple, short questions should be asked by trained staff of all patients whose records do not already indicate residency status to assist in identifying those not eligible for free care. That information can then be captured in the patient record for the future.

To support the implementation of these regulations, we have developed with front-line staff a “cost recovery toolbox” containing extensive guidance and template letters to patients and clinicians, as well as patient and staff-facing leaflets and posters and a web-based forum for peer support. As my noble friend Lady Redfern pointed out, working with NHS England and NHS Improvement, the department has published operational guidance to support the introduction of the regulations. This includes an average price list to provide consistency in up-front charging. The department has recruited a senior, experienced cost recovery team of NHS professionals who have led improvement visits to over 20 NHS trusts over the last six months. Action plans are in place for each trust and the team will support improvement and the sharing of best practice across the wider NHS.

I would like to end on an issue which has been raised by many noble Lords in this debate: the assessment carried out before we introduced these changes. As I have explained, up-front charging did not represent a change in policy, but instead has existed for many years before the consultation on other amendments. Over the course of the consultation and decision-making process, the Government carefully considered the impact the charges may have and published a full impact assessment alongside the regulations. This concluded that the package of changes would identify up to £40 million a year for the NHS. This is additional income and takes into account any administrative costs associated with the changes. I will also place in the Library copies of the equality assessments carried out by my department to inform the regulations, so that Members of the House will be able to review how the impact on vulnerable and protected groups was very carefully considered prior to the introduction of these changes.

All noble Lords have asked about the implementation of these changes and it is right, of course, that we proceed cautiously and sensibly and that we review how we are doing. So I am very aware of the need to keep the impact of these regulations under careful review in order to make sure they are implemented as planned and with no unintended consequences. My department will therefore undertake a full, formal review of how these amendment regulations are implemented, and monitor delivery closely, particularly where healthcare is provided to the most vulnerable. If further action is needed I will commit to update the House accordingly.

I hope I have been able to reassure all Members of this House about the long-standing principles that underpin our approach to cost recovery, the care that has been taken to protect vulnerable groups, and the reflective approach we will take during the implementation of these policy changes. I believe that they provide an equitable and reasonable step forward in making sure that all the NHS’s users, wherever they come from, make a fair contribution to the sustainability of the NHS, which is what British citizens expect. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to all noble Lords who have taken part in this debate. The fact we spent nearly an hour on it as last business on a Thursday is testimony to the importance of the matter, which is why I welcome so many noble Lords having stayed to take part. I will not push this to a vote, and I will withdraw the Motion, but I do think it is an opportunity to raise some very important points with the Government.

First, the noble Baroness, Lady Hamwee, made some very important points about the analysis of the impact assessment, the doubtful financial benefits set against the bureaucratic costs, and the impact this may well have on some of the most vulnerable people—the very people who, not just from their point of view but the public health point of view, need to access these services.

Secondly, from the evidence that I have received—and I have received many such examples—there is a real concern that people who are legitimately entitled to NHS services may get turned away. The noble Baroness, Lady Hollins, rightly asked what the safeguards were to prevent this.

I think it right that we talk about racial profiling because again there is some evidence that, in spite of what the Minister said and what is promised in guidance, this is taking place in some parts of the country. The NHS has many organisations—we have a lot of community organisations—but it turns out that staff who are given such responsibility may not be aware of the importance of this issue and its sensitivity. The obvious case here is British people with foreign-sounding names being challenged in a way which I think is inappropriate.

The Minister did not respond to the point from the noble Baroness, Lady Hamwee, about the Home Office requiring medical records. I do not know whether he will be prepared to respond to her in writing; I understand that the question goes much wider than his brief today, but I am concerned about the ethics of the Home Office requiring people to open their medical records.

The noble Baroness, Lady Hollins, was of course right to point out the barrier to people with mental health and other disabilities. This is not just about who is eligible: having to produce evidence to legitimise a right to treatment could prove difficult for vulnerable people who find everyday living hard and challenging.

Like my noble friend Lady Taylor, I say to the Minister—the noble Baroness, Lady Redfern, and the noble Lord, Lord Leigh, both spoke about this—that I have no problem with the principle of cost recovery. I accept that it is right that the NHS seek to recover costs from the people who are not eligible for NHS treatment. My problem, particularly with these regulations, is that I have a feeling they will be counterproductive and I doubt they will raise very much in the way of resources. My noble friend also teased out the point about the position of failed asylum seekers, who seem to be particularly vulnerable. I welcome what the Minister said about unintended consequences; that is a very important point.

Operational guidance, which the Minister referred to, is one thing. I would have preferred to see some of the points he has made and reassurances he has given in the regulations, rather than operational guidance. I also noted with great interest what he had to say about accident and emergency and GP services. From the confidence with which he said it, can I take it that the Government intend that they will remain free for all in future? Perhaps I can ask him quite what he meant by that, because in the briefings that I have had people have emphasised that it is the Government’s intention to extend the charges to accident and emergency services and GP services.

[Lord O’Shaughnessy]

We are talking about the regulations that we are implementing, and they do not introduce that. That is the point I was making.

[Lord Hunt of Kings Heath]

Noble Lords will interpret that response in the way they wish to. That is a bit disappointing.

The Minister has promised a review. I very much welcome that. He said it would be a full, formal review; let us hope it will also be an independent one. Asylum Matters has reminded me, in the most efficient way that that organisation works, that of course in 2016, a review was promised. I hope this time, we will actually get such a formal review.

Having said that, this has been an important debate. A lot of people are looking with great interest at what your Lordships have discussed tonight. We knew we were not going to be able to stop these regulations but I hope we have expressed those legitimate concerns. I am grateful to noble Lords for taking part and beg leave to withdraw the Motion.

Motion withdrawn.

Greater Manchester Combined Authority (Public Health Functions) Order 2017

Lord Hunt of Kings Heath Excerpts

Tuesday 7th November 2017 Lords Chamber

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

I beg to move that the draft Greater Manchester Combined Authority (Public Health Functions) Order 2017, which was laid before this House on 20 July 2017, be approved.

The draft order we are considering today, if approved and made, will confer local authority public health functions on the Greater Manchester Combined Authority as agreed in the devolution deals, and support Greater Manchester’s programme of public sector reform.

The Government have, of course, already made good progress in delivering their commitment to implement the historic devolution deal with Greater Manchester. Since agreeing the first deal with Greater Manchester in November 2014, we have passed the Cities and Local Government Devolution Act 2016, followed by a considerable amount of secondary legislation for Greater Manchester, including: establishing the position of an elected mayor; new powers on housing, planning, transport, education and skills; transferring fire and rescue functions and assets; and setting out the operation of the police and crime commissioner function, which transferred to the mayor on 8 May.

The draft order we are considering today provides a further significant step for Greater Manchester. Greater Manchester has identified public sector reform and population health improvement as priorities. This draft order provides for the conferral of certain local authority public health functions on the combined authority. Once the order is made, the combined authority will be able to exercise those public health functions concurrently with the 10 metropolitan district councils in its area.

The main new function is conferral of a local authority’s duty to take such steps as it considers appropriate for improving the health of the people in its area. The effect of the order will be to treat the combined authority as if it were a local authority, with the same duty to improve population health and the same consequential requirements to comply with guidance and the NHS constitution, and with the ability to enter into partnership arrangements with local authorities and NHS bodies.

Conferral of local authority public health functions will enable a Greater Manchester-wide strategic leadership approach to the delivery of agreed public health functions and commissioning responsibilities—for example, public health intelligence, health needs assessment and health protection. It will support a Greater Manchester-wide approach to tackling health inequalities, variation in quality and service improvement to promote fair and equitable access and to achieve an upgrade in health outcomes for the population of the wider city. It will also support strengthened collaborative decision-making for population health through the identification of city- wide commissioning priorities and intentions, underpinned by shared principles and common commissioning standards —for example, commissioning for whole-system sexual health and substance misuse services. Finally, it will enable population health to be embedded across the city’s health, social care and wider public services through the Greater Manchester strategy and the population health plan.

Noble Lords will want to know that the statutory origin of the draft order before us today is in the governance review and scheme prepared by the combined authority in accordance with the requirement in the Local Democracy, Economic Development and Construction Act 2009. Greater Manchester published this scheme in March 2016 and, as provided for by the 2009 Act, the combined authority consulted on the proposals in the scheme.

The consultation ran from March 2016 to May 2016, in conjunction with the 10 local authorities in its area. The consultation was primarily conducted digitally, including promotion through social media. In addition, of course, respondents were able to provide responses on paper, and posters and consultation leaflets were available in prime locations across Greater Manchester. As statute also requires, the combined authority provided to the Secretary of State in June a summary of the responses to the consultation, and the Secretary of State concluded that no further consultation was necessary.

Before laying this draft order before Parliament, the Secretary of State has also considered the other statutory requirements in the 2009 Act. He considers that conferring these functions on the Greater Manchester Combined Authority is likely to improve the exercise of statutory functions in the area, and he has had regard to the impact on local government and communities, as he is required to do. Also, as required by statute, the 10 constituent local authorities and the combined authority have consented to the making of this order.

In conclusion, the draft order we are considering today, if approved and made, will confer local authority public health functions on Greater Manchester Combined Authority, enabling it to play a key role in improving the health of the population in Greater Manchester. I commend the draft order to the House.

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I thank the noble Lord for his explanation of the order. As I am going to touch on oral health in Greater Manchester, I declare an interest as president of the British Fluoridation Society.

The order is unexceptional and we support it. It takes a sensible approach, enabling the combined authorities in Greater Manchester to undertake public health duties which at present fall just to individual local authorities. The Greater Manchester Health and Social Care Partnership has published a very interesting population health plan, which has a lot of very good things in it, and I commend the local authorities and the combined authority for what they are doing.

I mentioned my interest in oral health. It is well known that Greater Manchester has very poor oral health. It is also well known that, at a stroke, this could be dealt with by the introduction of fluoridation in the water supply in the north-west. All I would ask is that when the order has gone through, Greater Manchester be gently urged, through the Minister’s good offices, that an improvement in oral health be one priority that the combined authority—and indeed the mayor, who I know is a passionate believe in fluoridation—might take on. I hope the Government will encourage them in the right direction.

The order proposes that for some interventions, there can be reductions in visits to urgent care, a reduction in the number of people with chronic conditions, and that 700,000 people will be able to manage their chronic conditions more effectively. But of course, this takes place in the context of a very rocky position for the NHS and social care. The funding gap and the demographic pressures on the health service are severe. Inevitably, this is going to impact on the effectiveness of what Greater Manchester can do on health and social care as well as public health.

--- Later in debate ---

[Lord O’Shaughnessy]

I thank noble Lords for their contributions and for their broad support for the order before the House today. As I outlined, it represents another significant milestone in the Government’s devolution agenda and I am glad that that has been welcomed across the House. I will try to respond to the various points that noble Lords have made.

Like the noble Lord, Lord Hunt, we support the idea of the population plan, which will clearly differ from place to place where there is this kind of devolution. I stress that an important and distinctive part of this plan is that it confers on the combined authority the same powers and responsibilities as a local authority. It is therefore about them acting concurrently, rather than in an overbearing way, or seeking to override.

I have been in your Lordships’ House long enough to know that fluoridation is an area of particular interest. I wonder only why it has taken so long for me to have to answer a question on it. This is a devolution deal, and it is therefore about those powers being taken locally and acting in concert. I do not think it is consistent with the idea of devolution for me to urge any combined authority to point in one direction or another, and it sounds like my noble friend Lady Gardner has been doing plenty of urging already. Any such move would have to be made in concert by all 10 of the local authorities and the combined authorities and be done through the usual processes of consultation and so on, with regard to all the responsibilities that attend on those public health powers. I hope that provides some reassurance to my noble friend Lady McIntosh.

[Lord Hunt of Kings Heath]

After the Strathclyde case and the ruling from Lord Jauncey, the then Conservative Government took legislation through both Houses of Parliament to make sure that fluoridation was legal and above board. That was based on evidence that has not been undermined since.

[Lord O’Shaughnessy]

I am trying to make the point that there is an established regulatory framework around such proposals. As noble Lords can tell, I am trying to avoid coming down on one side of the argument or the other. In the end, this is an issue both for local areas and for clinical opinion and research. On the broader position of public health, difficult decisions had to be made about local authority budgets as a consequence of the financial crisis and the deficit which it brought about. It is still the case that local authorities are getting £16 billion to spend on public health over the five years from 2015 to 2020. Alongside that, power and decision-making have been devolved to local authorities on using that money and combining it with other functions that have an impact on public health. One of these would be housing, the quality and condition of which has a huge impact on the public health of local people. You cannot both welcome devolution and say that local authorities should not have the power to act in different ways, so long as they comply with their statutory obligations. From that point of view, local authorities should not act outwith those obligations, whether in the case of contraception clinics or any other public health responsibility.

The noble Lord, Lord Beecham, asked about integration: I stress the point about pooling of budgets. As he will know, a chief officer for health and social care has been appointed in Greater Manchester. That person is an NHS England employee, because the NHS is a national health service and NHS functions have not been devolved. We are clearly trying to achieve greater integration of services, through the sustainability and transformation programme. We hope that doing this at a level where there is a degree of integration by the relevant local authorities will be fertile ground, and that it will provide evidence for and leadership in the move towards accountable care systems, which NHS England is now leading through its five-year forward view.

On the final point about information being spread to epidemiological centres, I again stress that this measure confers the powers of a local authority on to a combined authority, so it will absolutely have the responsibility to share data. Indeed, it will not be able to assume responsibility for any functions if the 10 local authorities do not want it to do so. Obviously, we hope that they will. Indeed, by committing to support this order, they have signalled their intention to do so. I reassure the noble Lord that there is absolutely no risk that these kinds of responsibilities will be watered down as a consequence of this order.

In conclusion, I hope that I have answered noble Lords’ questions and inquiries about the impact of this order on fluoridation and many other issues. It is an important order and I hope that all—

[Lord Hunt of Kings Heath]

I am sorry to intervene again but I have just reflected on what the noble Lord said about fluoridation. He seemed to say that he was not prepared to come down on either side. That sounds to me like a new statement of government policy, as traditionally government has been in favour of fluoridation.

Veterans: Mental Health

Lord Hunt of Kings Heath Excerpts

Tuesday 7th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I reiterate the point I made in my Answer: NICE guidance on the treatment of post-traumatic stress disorder is clear that clinicians should take into account a range of factors when seeking to make a diagnosis. That should include the patient’s detailed case history, including medicines taken and under what circumstances. Regardless of whether the person is treated while serving or afterwards, that should be on their patient record, be accessible for anyone giving them direct care, and influence any prescriptions of treatments given. I also point out to the noble Countess that veterans’ issues are now in the training curriculum for all GPs. That came out of the Armed Forces covenant.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the treatment of veterans is clearly important, but so is prevention. Will the noble Lord confirm that for the drug the noble Countess referred to, whatever geographical area you are in in the world, there is always an alternative? Will he also confirm that the Surgeon-General told the Defence Select Committee last year that he could not guarantee that every member of the Armed Forces had a face-to-face risk assessment before the drug was given to them? Have the Government now ensured that face-to-face risk assessments take place?

[Lord O'Shaughnessy]

For the drug in question, Lariam is the brand name and mefloquine is the generic name. There are indeed alternatives available, and only 1% of antimalarial drugs prescribed to the Armed Forces are of mefloquine. There are instances when alternatives are not available, which may be because of a particular response to individual drugs or because the prescribing details are different—mefloquine is given on a weekly basis, for example—but the proportion is only 1%. The Defence Committee set out several recommendations, one of which was that there should be face-to-face risk assessments before prescribing. That figure is now up to 89% of the total; for the remaining 11%, the problem may be about recording rather than their not happening. The rate is much higher than it has been historically.

NHS: Winter Staffing Levels

Lord Hunt of Kings Heath Excerpts

Thursday 26th October 2017 Lords Chamber

[Lord O’Shaughnessy]

We recently debated community pharmacies. Reforms have ensured that most people—more than 80%—are within a 20-minute walk of a community pharmacy. As a consequence of these reforms, there has been no decrease in the number of community pharmacies in England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the case raised by my noble friend relating to Essex goes to the heart of the problem of discharging patients from NHS hospitals because of the lack of support in the community from social care and the reduction in nursing home places during the last four years. Is the Minister as surprised as I am that, despite this, up and down the country the NHS, through its sustainability and transformation plans, is putting forward proposals to cut out community hospitals and community hospital beds? Will Ministers issue an instruction to the NHS so that this will not be allowed to happen?

[Lord O’Shaughnessy]

We have discussed the issue of nursing home beds. We also know that there has been an increase in the provision of domiciliary care packages which reflects people’s changing care needs. Figures published yesterday show that social care spending has risen by £500 million during 2016-17. I am sure this will be warmly welcomed across the House. On community beds, noble Lords should know that, in addition to the usual four tests for reconfigurations, last year Simon Stevens, the head of NHS England, said that there is now a fifth test—the bed test. There must be robust evidence that any proposed reduction in beds is because of a reduction in demand and not the other way round.