Junior Doctors: Contract

Lord Hunt of Kings Heath Excerpts

Thursday 5th May 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I am not sure where that question ended up, to be honest. All I will say for today is that we have an opportunity over the next five days for the BMA and the Government to find a resolution to this issue. If we can, it will make the implementation of seven-day working across the NHS much easier.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Government’s approach has been cack-handed throughout the process. It would have been much better if, instead of initially rejecting this proposal and now setting out some new conditions, the Government had accepted it. Obviously, we hope the outcome will be successful and the situation will be resolved. At the end of this process, we are left with thousands of junior doctors disengaged from the service because of the circumstances of the dispute and the alarmist statements issued by the Secretary of State. Will part of the discussions look at how the junior doctors are to be brought back into the fold and given the support they so richly deserve?

[Lord Prior of Brampton]

My Lords, I think there is general recognition that many of the issues that lie behind the dispute over the contract are not actually involved in the contract itself. It is about how junior doctors are trained, valued and integrated into hospitals and the workforce. These are much broader issues than just the contract, and I assure the noble Lord that the Government are fully aware of that. Once this dispute has been settled, we can start to resolve those bigger, deeper and more fundamental issues.

Mental Health Services

Lord Hunt of Kings Heath Excerpts

Thursday 28th April 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, this year NHS England has chosen primary care, cancer and antibiotic prescribing to be the three key parts of the national quality scheme but, as the noble Baroness has said, 30% is determined locally, of which 17 indicators are related to mental health. NHS England proposes to include a mental health indicator in its national scheme in 2017-18. The point about the national schemes is to provide incentives and they will change from one year to another. If they are the same every year, they will cease to be incentives.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister will know that the general record on mental health has been very poor over the past few years. We are far away from parity of esteem; indeed the National Audit Office has commented on this. There is widespread concern within the circles involved in mental health services that, despite what Ministers say, the NHS itself and NHS England are not committed to parity of esteem. Leaving mental health out of the national priorities sends a signal to the NHS that, despite what Ministers say, in the end it is not important. I wonder whether the Government would reconsider this issue and give new instructions to NHS England on it.

[Lord Prior of Brampton]

My Lords, I find it hard to believe that anyone can think that mental health is not a key priority for this Government, given that we have promised to spend another £1.4 billion on children and young people’s mental health and a further £1 billion a year on adult mental health, along with accepting the findings of the Farmer report in full. I assure the House that mental health remains an absolute priority for the Government.

Health: Hepatitis C

Lord Hunt of Kings Heath Excerpts

Thursday 28th April 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, there is clearly a budgetary constraint. The noble Lord mentioned 220,000 people—I thought it was slightly less than that—and this drug costs many tens of thousands of pounds per treatment. Clearly, however much we would like to treat 220,000 people, it is just not feasible to do so. That is why we have NICE, which has produced its appraisals and said that, using its modelling, the number of people who need to be treated in the coming year is likely to be between 7,000 and 10,000, rising to 15,000 by 2021. However, I agree with the noble Lord that this interferon-free treatment is a massive improvement on previous treatments, with a very high cure rate.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this is a wonderful treatment, but what has happened is blatant rationing. The Minister says that it is down to money, but something has long puzzled me. The Government reached a five-year agreement with the pharmaceutical industry that any additional costs over a baseline plus inflation would be refunded by the industry and, every quarter, his department gets back millions of pounds from the drugs industry. So can he tell me why arbitrary limits are being placed at local level on the provision of new drugs? What is happening to that rebate money? Is it in fact going back to the Treasury and not the NHS? It is quite unnecessary for there to be this rationing.

[Lord Prior of Brampton]

I feel almost as if we are living on a different planet—of course there are going to be budgetary constraints. Some of these new drugs are hugely expensive. We have a good scheme—the PPRS scheme that the noble Lord referred to—which enables us to get rebates from big pharma, but some of these new drugs are extremely expensive. I cannot say what the exact cost is of this interferon-free treatment for hepatitis C, but I can tell the House that it is many tens of thousands of pounds for a treatment. There are 220,000 people who could benefit from this treatment, according to the noble Lord, Lord Patel—that means many billions of pounds. If we spend many billions on this particular drug, there are many billions that we will not be able to spend on mental health or in other parts of the NHS.

Health: Treatment Rationing

Lord Hunt of Kings Heath Excerpts

Tuesday 26th April 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what is their response to the Royal College of Surgeons report showing that Clinical Commissioning Groups are rationing treatments by the use of restrictions on routine surgery for patients who smoke or who are overweight or clinically obese.

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

My Lords, we would not support CCGs imposing arbitrary restrictions on patients. However, there are often sound clinical reasons for encouraging patients to lose weight or stop smoking—for example, to get the best clinical benefit from joint replacement surgery. CCGs should support patients to reduce their tobacco usage or reduce their weight and signpost them to the appropriate services. It is for CCGs to ensure that their local commissioning priorities use resources in the best interests of their patients.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for that Answer because it is clear that these blanket bans are nothing more than crude rationing and cause great distress to patients. Will he issue instructions to CCGs that they are not to embark on these kinds of blanket bans? Does he agree that the programmes to support weight management and smoking cessation should be part of the treatment programme rather than be used as a barrier to treatment?

[Lord Prior of Brampton]

Yes, my Lords. The noble Lord has quoted almost verbatim from the recommendations of the Royal College of Surgeons report, which I have in front of me. I agree with him completely.

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, I am not able to answer that question, as I do not have the facts at my fingertips. However, I will investigate it and write to the noble Viscount.

[Lord Hunt of Kings Heath]

My Lords, the Minister said that the obesity strategy would be coming out soon. What is his interpretation of “soon”?

[Lord Prior of Brampton]

Before long, my Lords.

Junior Doctors: Industrial Action

Lord Hunt of Kings Heath Excerpts

Monday 25th April 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

First, my Lords, I thank the noble Lord for repeating the Statement made in the other place. No one could be in any doubt that tomorrow’s strike will be a very sad day indeed for the NHS and the country. What is so frustrating is that it could, I am convinced, have been prevented. Yesterday the Health Secretary was presented with a genuine and constructive cross-party proposal to pilot the contract and potentially avert this week’s strike. A responsible Health Secretary would have grasped the opportunity immediately or would at least have considered and discussed it. However, all we had was a tweet yesterday morning from the Health Secretary saying, “Labour ‘plan’ is opportunism”. That was a deeply disappointing response.

The proposal was not a Labour plan. It was co-signed by two respected former Ministers, the Conservative Member for Central Suffolk and North Ipswich, and the Liberal Democrat Member for North Norfolk, as well as the SNP’s health spokesperson, the honourable lady the Member for Central Ayrshire. It not only had the support of a number of medical royal colleges, including the Royal College of Surgeons, but, crucially, the BMA had indicated that it was prepared to meet with the Government and discuss calling off Tuesday’s and Wednesday’s action.

The Health Secretary has claimed that a “phased imposition” is the same as a pilot, but can the Minister explain how imposition on a predetermined timescale, with no opportunity to make changes to the proposed contract and no independent evaluation of the impact on patient care, can be the same as a pilot? Surely the Health Secretary should have welcomed independent evaluation. Surely he wants to know how changing this contract contributes in practice to his aspirations for more consistent emergency care across seven days of the week. And surely there was always a strong case for road testing the contract, thus enabling junior hospital doctors and managers in those hospitals to bring about changes in patient care and the outcomes that the Government want to see. The Government claim that any further delay will mean that it will take longer to eliminate the so-called “weekend effect”, but he has failed so far to produce any convincing evidence to show how changing the junior doctors’ contract by itself will deliver that aim.

On safety, NHS England’s update today says that the NHS is pulling out all the stops to minimise the risks to the quality and safety of care. We know that in many cases senior clinical staff will be stepping in to provide cover and ensure the provision of essential services. But there is no escaping the fact that this is a time of unprecedented risk, as regards what happens not just in the next two days but in the months and years ahead.

So can the Minister say how it will be safe to impose a contract when no one knows what the impact will be on recruitment and retention and when everyone in the service fears the worst? How can it be safe when we are running the risk of losing hundreds of women doctors, given the contract’s disproportionate impact on women—which, as the Minister knows, was disclosed by the belated publication of the equality assessment? How can it be safe to impose a contract that risks destroying the morale of junior doctors and to introduce a contract where there is no guarantee that effective and robust safeguards will be in place to control hours worked and shift patterns?

I noted that the Statement made some rather eloquent or exaggerated claims about the amount of money going into the NHS. I do not want to distract our focus from the essential point in question, but I point out to the Minister that we are on the longest period when the amount of real-terms growth going into the NHS has been less than 1% per annum, against an average increase since 1948 of 4% per annum. Our share of GDP spent on health is going back down to the days in the mid-1990s when we were spending about 6% of GDP. When you compare that to the demands being placed on the health service and the workforce demands that the new contract entails, it is very difficult to see how you can square the ambitions of the Secretary of State on the one hand and the practical reality of what resource has been made available.

Even at this late hour—and it is later than when the other place debated this Statement—I hope that sense will be seen and that the Government will recognise that there is a need to come back to the table to discuss not just the contract but the wider issues of the disengagement of the junior doctors, their concerns about the current approach to training, the fear that the imposition of this contract will lead to less well-trained doctors in the future, and indeed the issues around workforce and women doctors which have now been identified but on which I have yet to hear a convincing response from the Government. Even now, the case for getting round the table with the junior doctors is persuasive.

[Baroness Walmsley (LD)]

My Lords, instead of reeling off the litany of justifications and figures that we have just heard, is it not really time for the Secretary of State to put aside his pride, stop being pig-headed and listen to people in the national interest? He is clearly not listening to the junior doctors but will he not now listen to the sensible compromise proposal from other parties, including my own, which, I point out, does not undermine the Government’s objectives in the long term?

There are two big differences between the euphemistic “gradual introduction” that he is proposing and the pilot projects proposed by other parties. The first is that of course a pilot scheme can be independently evaluated. If the Secretary of State is so confident that this scheme will not damage patients or doctors, why is he afraid of proper evaluation? The proper and safe implementation of the new contract is surely worth a very small delay. Secondly, a pilot would mean that all junior doctors evaluated in a hospital would be on the same contract, whereas piecemeal introduction, which he is proposing, could mean that two doctors working side by side in the same department were on totally different contracts. Does the Minister not agree that this would be deeply divisive, as well as very difficult practically?

I am also very concerned about the idea of consultants manning A&E departments this week. While I am grateful to them for being willing to step forward in the interests of patient safety, I am concerned that it might work in the opposite direction in their own departments. Who will take the difficult decisions in, for example, cardiology or vascular medicine when urgent cases come up and the consultant is setting somebody’s broken finger in A&E? Has the Minister thought about that?

Should not the Secretary of State consider his position? Is he really the right person to solve this dispute? Patient safety, not the future of his own job, should be his prime consideration. This week, that will be at risk—website or no website.

Wheelchair Users

Lord Hunt of Kings Heath Excerpts

Thursday 21st April 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they will introduce uniform standards and a national tariff payment in order to achieve high-quality outcomes for wheelchair users.

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

My Lords, NHS England is developing a national dataset to ensure transparency about the quality of services in order to drive improvement. NHS England and NHS Improvement are actively working with the sector to define the currencies and reference costs that will enable national tariffs to be set.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord will know that the wheelchair alliance, chaired by the noble Baroness, Lady Grey-Thompson, has shown that we have, essentially, a set of dysfunctional local wheelchair services with variations in access, standards and waiting times. The noble Lord has referred to a national specification but the reality is that, unless he can ensure that it is mandated at local level we will not get high-quality, consistent services. Will Ministers be prepared to meet the wheelchair alliance to discuss how we can get uniform, high-quality standards at local level?

[Lord Prior of Brampton]

The noble Lord is right: the variation in wheelchair standards around the country is wholly unacceptable. The truth is that we do not know the level of this variation because we have never collected the data before. The data are now collected and, of course, I can answer yes to his question. In fact, my honourable friend in the other place is making an announcement on 18 May, I think, about the support we are going to provide to local CCGs over wheelchair provision. I am sure that I can speak for him and say that he will be delighted to meet the wheelchair alliance.

NHS: New Junior Doctor Contract

Lord Hunt of Kings Heath Excerpts

Monday 18th April 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for repeating the Answer given in the other place, which I have listened very carefully to. It now seems abundantly clear that the Secretary of State does not have the power in law to impose a new contract on junior doctors. The problem is that the Secretary of State’s various Statements over the last few months could not be interpreted in any way other than that he thought he had the power and he was going to impose a contract. The significance of this is that the junior doctors took him at his word. The importance of that is that the Junior Doctors Committee of the BMA took the unprecedented decision to escalate industrial action on the back of his apparent decision to impose the new contract when talks collapsed.

The noble Lord, Lord Prior, knows that I have absolutely no argument with the development of fully comprehensive seven-day services in the NHS. However, the tragedy is that the very group of staff on whom so much is now dependent for clinical out-of-hours care—the junior doctors—has become utterly disenchanted with the way this has been handled. We have reached a very serious situation, and I very much fear for the future of the NHS and what is happening. I just say to the noble Lord that surely, even now, the Government need to find a way through. Interestingly, in the response, which has come from Ministers in the other place, there is a recognition of the benefit of collective bargaining. Is it not time to give collective bargaining another go?

[Lord Prior of Brampton]

My Lords, the noble Lord has raised two substantial points. The first is the difference between introduction and imposition. The fact is that, in the context of the NHS, where there is really only one offer, the difference between introduction and imposition is very small. Technically, it is true that individual employers are responsible for its imposition, but in reality, as the noble Lord will know from all his years in the Department of Health, the Secretary of State has considerable powers in this matter. I do not think the noble Lord would want all trusts to cut their own deals locally—there has to be an actual contract. It is true that when the legislation for foundation trusts was brought forward by the noble Lord’s Government a few years ago, they were given the power to negotiate their terms and conditions locally but, with the exceptions of, I think, Southend and possibly Guy’s and St Thomas’, they have chosen to stick with the national contract.

On the noble Lord’s last point about a way through, there are no winners from this dispute. The patients are very clear losers, and it is tragic that we have got to the situation that we have. The threshold for withdrawing emergency cover from hospitals needs to be a lot higher than the one the junior doctors are adopting on this occasion.

Health: Neural Tube Defects

Lord Hunt of Kings Heath Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Prior of Brampton]

I will certainly draw that point to the attention of the SACN. It would be surprising if it was not already aware of that fact, but as I said I am addressing not really the science but whether it is right or proportionate to fortify bread for everybody to reach such a small number of people.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord made it clear that this is a political decision, for which we should be grateful. He also made it clear that the Government have decided that it is not going to happen. But does he accept that a 30% improvement is actually a large, positive outcome? The fact is that the voluntary approach that this Government have been wedded to is simply not working. If the answer is no, and if the voluntary approach is not working, what, then, will the Government do?

[Lord Prior of Brampton]

My Lords, the evidence given by the SACN is that it affects between 15% and 30%. My honourable friend in the other House, Jane Ellison, is bringing together a round table of all stakeholders interested in preconception health to discuss this matter.

NHS: 111 Service

Lord Hunt of Kings Heath Excerpts

Monday 21st March 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the safety and reliability of the National Health Service 111 service.

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

My Lords, NHS 111 is a vital service helping people to get medical advice quickly and easily. It has received more calls this year than in the same period in 2014-15 but continues to perform well overall. The Care Quality Commission has announced that it will inspect all NHS 111 providers by September 2016. The CQC will assess whether the services are safe, caring, effective, responsive to people’s needs and well led.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is not the problem that when the excellent NHS Direct service was replaced, very many experienced nurses ceased to work for the new 111 service and were replaced by call handlers with a few weeks’ training who have to follow instructions on a computer rigidly? The evidence is that there have consequently been misdiagnoses. One ambulance trust fiddled the response time for 999 calls routed through 111 to meet the targets. There have been a number of personal tragedies as a result. Therefore, in addition to the CQC’s inspection, will the noble Lord institute a review of the safety of 111 and return to having qualified nurses handling the calls?

[Lord Prior of Brampton]

My Lords, the decision to stop NHS Direct was, of course, taken in 2008, when I think the noble Lord was in post. He shakes his head, so perhaps he was not, but the decision was taken in 2008, before this Government were in charge, if you like. The new system uses the NHS Pathways algorithms developed by the Royal College of GPs, on which the BMA and the Royal College of Paediatrics and Child Health sit, so we have considerable confidence in the algorithms used. We will also increase the number of clinicians. I accept the noble Lord’s point that we need to have more clinicians answering these calls rather than call handlers, as he puts it. It is our intention progressively to increase the number of clinicians in these 111 hubs.

General Practitioners: Appointments

Lord Hunt of Kings Heath Excerpts

Thursday 17th March 2016 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the noble Earl, Lord Attlee, for allowing us to debate this very important question and congratulate him on the quality and range of his contribution, which was extremely interesting. I echo his initial comments about the value of the National Health Service. However, he also referred to the considerable challenges we face, not least the amount of money that is being made available. I note the comments that the noble Lord, Lord Rennard, made and I will be most interested in the Minister’s response to his suggestion that we need to move to hypothecated taxation. Interestingly, we have a recommendation from the Liaison Committee—of which I am a member—which I hope will come to the House next week to establish a special Select Committee in the next Session looking at the long-term sustainability of the NHS. I think that that will be a very interesting discussion, not least because it is clear, as the noble Earl said, that alongside A&E and ambulance services, general practice is facing considerable pressure.

Like my noble friend Lord Turnberg I am very lucky to enjoy an exceptional GP practice, which is a small branch of a large inner-city practice. It is clear from the comments of noble Lords and from the regular GP patient survey that people’s experiences are very mixed. The noble Earl focused on economically active members of society, but his comments could have applied to all patients. Noble Lords are often fond of quoting the Commonwealth Fund’s international comparators, which do not always compare with the OECD research covering the same ground. I was interested in its latest report on public perception of primary care in the UK and the fact that there has been a dramatic drop in the positive view of how primary care works, with the percentage of those expressing satisfaction going down from nearly 50% in 2009 and 2012 to just over 20% in 2015. So there has no doubt been an appreciable change in attitude by the public in relation to GP services. The GP patient survey shows, for instance, that only 70.4% of patients find it easy to get through to someone at their GP surgery on the phone. This is down from previous figures. It also showed that 6.5% book their appointments online, up from 3.2% in December 2012. It is really disappointing that such a low number of people actually take advantage of online booking or, indeed, that such a low number of practices promote online booking. Obviously, it would make life so much easier if it were easier for people to do that, and it would deal with the problem that the noble Earl, Lord Attlee, described, about the differentiation between an urgent appointment and one that is important but does not have to take place within 48 hours. Many GP practices seem quite unable to devise a system to cope with those circumstances.

It is also interesting that the GP patient survey showed that 23.1% see their preferred GP a lot of the time. We need to think through the implications of that, particularly with seven-day working, because I suggest that with the move into larger federations, which I support, the seven-day working concept inevitably means that people will have less opportunity to see their preferred GP—particularly, as we know, when many GPs do not want to work full time any more. That seems to me to depend on information, particularly electronic information, being available, so that a patient does not have continually to tell different GPs in a practice about their conditions, because they actually have systems where that is noted down.

I also note that in the survey 57.7% were happy with the amount of time that they had to wait for an appointment. Again, that is down—it is not a great figure. The overall satisfaction with GP opening hours, at 74.8%, is down and again not very satisfactory.

The noble Lord, Lord Rennard, referred to the PAC report on access to general practice, which came out only a couple of weeks ago. I thought that it was a very interesting report and, no doubt, the Government will respond in due course. But it showed that we have problems with retention and recruitment, that good access to GP care is too dependent on where patients live, and there is an unacceptable variation in patients’ practices and in the appointments system. Tellingly, it said that the Department of Health and NHS England do not have enough information—that is a point that the noble Lord made—on demand, activity or capacity, which one would have thought might have been of interest to NHS England. I think that it is clear that both the department and NHS England has really failed to ensure that staffing in general practice has kept pace with growing demand. I think that they have been complacent about general practitioners’ ability and, indeed, willingness to cope with the increase in demand caused by rising public expectations and the needs of an ageing population.

No doubt the Minister will tell us about recent initiatives, which are welcome in themselves, but a lot of changes will come about because GPs themselves will make them happen. I am really impressed by the large federations that have been established. There is one very large one in west Birmingham and the Black Country, which has had some incredibly impressive results in relation to access. It is through having a large enough federation that you can meet the work patterns of individual GPs, and it is through the simple use of phone and email to have much more flexible appointments. I do not know whether the noble Lord has read a report from David Pannell, the chief executive of Suffolk GP Federation, which complains that the department is not really giving support to the development of provider networks and federations and that the only initiative promoting working at scale was the Prime Minister’s GP access fund, which was doing little to diverge from the traditional model of contracting with individual practices.

The point being made here is that every single contract which is part of the PM’s access fund has been a traditional primary medical services or general medical services one with an individual practice. Would the Minister be prepared to have a look at this and to talk to the National Association of Provider Organisations? Its chair has commented:

“Whereas NHS England supported the vanguards programme, there has been virtually no support for the leadership of federations which are not part of a vanguard”.

I have quoted from a story in the Heath Service Journal and I have also looked at comments which have been made on it. One comment, which was anonymous—I do not know why—said:

“Brighton and Hove CCG have been developing a really innovative and ambitious contract with GPs working at scale which the LMC have supported”.

It may well be worth looking at that to see whether more can be encouraged.

Finally, I wonder if the development of federations means that the Government need to look at CCG governance. If you have a large-scale federation covering an area roughly the same size as a CCG, I can see a potential conflict of interest. The federation could dominate the election of members to the CCG board. The contracts should be at that level, not held by NHS England, so I wonder if we need to go back to the issue of CCG governance and have a majority of lay people on CCG boards. That would enable the Government to be much more proactive in supporting these federations. I am convinced that they are the only way we can deal with the problems raised by the noble Earl.