Access to Palliative Care Bill [HL]

Lord Hunt of Kings Heath Excerpts

Friday 23rd October 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Opposition warmly welcome the Bill. I hope that it can make progress and get to the other place in time to get on to the statute book this Session.

Clearly, we have much to be proud of in palliative care—in the hospice movement, in particular, but also in parts of the NHS. However, the ombudsman’s five key themes make salutary reading. Frankly, in many places people are not recognised as dying and therefore the service is not responding to their needs. There is poor symptom control and poor communication. There are also inadequate out-of-hours services, poor care planning and delays in diagnosis and referrals for treatment. As my noble friend Lord Turnberg said in yesterday’s palliative care debate, there is no shortage of guidelines. An enormous number of guidelines is available; the conundrum is that they are not being implemented consistently. The question that we want to put to the noble Lord, Lord Prior, is: what can be done to ensure much greater consistency? I know that NHS England has established palliative care networks across England which are meant to support improvements in palliative care and share good practice, but I hope that the noble Lord, Lord Prior, will be able to report on progress.

I also want to ask the Minister about staff training, which a number of noble Lords have mentioned. We often depend on many young doctors, nurses and care workers, but inevitably they may be ill prepared to deal with death. They certainly need support. I thought that the BMA’s submission to noble Lords on that was very interesting. It says:

“Caring for dying patients will always be difficult for doctors, regardless of their level of experience”.

It continues by saying that,

“doctors are not being equipped with the right tools to provide this care”,

and it refers to the review undertaken into the Liverpool care pathway, which,

“found that medical training in palliative care was inconsistent, and often inadequate, resulting in a large number of junior doctors feeling ill-prepared to care for dying patients at the beginning of their careers”.

That could also apply to nurses and other care workers. Again, I should like the noble Lord to say what the Government can do to get consistency in training.

My third point concerns leadership. The Health Select Committee in the other place recently said that evidence provided to the committee showed a clear lack of leadership at national level—at the centre of government —in relation to end-of-life care. It recommended that:

“The Department of Health and NHS England should ensure that end of life care is prioritised and embedded in future planning at all levels”.

Noble Lords have already mentioned the other recommendation concerning the identification of,

“named individuals who will be responsible for ensuring that the new approach to end of life care … is delivered nationally”.

Again, I ask the noble Lord whether the Government accept that recommendation.

The noble Lord, Lord Prior, in a very sympathetic response yesterday, put a lot of eggs into the CQC basket. Of course, we will have to wait to see the outcome of this work, but I was struck by the fact that he did not mention clinical commissioning groups. A number of comments have been made today about commissioning. Clearly, there is an inconsistency. We have to be honest and say that the capacity of CCGs to commission services is often very limited—they do not have the people with the expertise to do it. Does the noble Lord think that the situation might be better solved by having a national strategy in which a template as to what should be commissioned locally is required by CCGs? That would be entirely consistent with the terms of the noble Baroness’s Bill.

On funding—a point referred to by the noble Lord, Lord Howard, and the noble Viscount, Lord Bridgeman, in particular—there are two issues. One is the level of funding and the second is what I would call stability. The points on the level of funding have been well made, but my experience is that one of the problems—I speak as a supporter of Birmingham St Mary’s Hospice—is that hospices often do not know very much in advance how much they are going to get. Indeed, often they do not know until after the start of the financial year. I would have thought that one instruction that Ministers could give would be that hospices should be entitled to a three-year rolling contract so that they know exactly what they are going to get and can plan ahead. The figures given to them are, frankly, so low compared to the entire NHS budget that I do not believe it is unreasonable to ask clinical commissioning groups to do it. I think they often forget what it is like to be an organisation that is not certain of its funding. They get their funding—it might be tight but there is certainty of funding—but for hospices, there is no certainty of funding. At the very least, they ought to know and be able to plan ahead.

Time presses on, but I hope that the Minister will say that the Government are also going to accept the recommendations of the Health Select Committee on free social care, and I echo the point raised by my noble friend Lord Warner.

One thing I would ask the noble Baroness, Lady Finlay, is about the implications of the duty in the Bill compared to the general duties laid on the NHS in other Bills. If I were a Minister I would probably ask her what the hierarchy of importance is. I do not know whether we could explore this in Committee or whether the noble and learned Lord, Lord Mackay, and my noble and learned friend Lady Scotland might perhaps be able to help with an appropriate amendment in relation to that.

We wish this Bill well. I hope that we will have time for a proper Committee stage, as there are clearly a number of issues to be discussed. However, we wish to send this Bill on, with progress, to the other place.

Health: Post-polio Syndrome

Lord Hunt of Kings Heath Excerpts

Tuesday 20th October 2015 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they will develop a strategy for post-polio syndrome.

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

My Lords, the NHS Five Year Forward View sets out a number of high-level objectives that will support better care for people living with long-term conditions, including post-polio syndrome. Our overall approach is to enable person-centred care so that health services can work in partnership with people to manage their symptoms and improve their quality of life. The Government wish the British Polio Fellowship every success with its post-polio syndrome awareness day this Thursday.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that the Minister’s response on that latter point will be very welcome. He will be aware that an estimated 120,000 people are affected by post-polio syndrome. This will often occur years after they contracted polio and it brings pain and tiredness. The problem is that the NHS is largely unaware of the condition. There are very few specialist consultants, GPs do not usually recognise it, and the orthotic services are not geared up to provide some of the appliances that are necessary to ease the pain. Is the Minister prepared to look at this again to see whether some kind of national strategy or care pathway could be produced which would lead to a much greater consistency of provision in the health service?

[Lord Prior of Brampton]

The noble Lord is right that there is no specific pathway for people suffering from post-polio syndrome. NHS England will approach this on the basis of all long-term conditions rather than segmenting them by individual disease categories. I will be very happy to meet with him outside the House to discuss this.

Primary Care: Targets

Lord Hunt of Kings Heath Excerpts

Tuesday 13th October 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Lord makes an interesting point. I do not have an answer to give him today, but perhaps I may reflect on that and come back to him.

[Lord Hunt of Kings Heath (Lab)]

My Lords, clearly the role of community pharmacists could be enormous in the future, but in the end we still need more GPs. I have yet to be convinced that the Government really do have a programme that will effectively make sure that current GPs stay in the profession and that new GPs enter it. Can the Minister confirm that a number of the seven-day working pilots involving primary care have had to be cut back because of a shortage of GPs?

[Lord Prior of Brampton]

I cannot confirm that a number of the pilots have been cut back because of a shortage of GPs. I assure the noble Lord that we are committed to having an additional 5,000 doctors and a further 5,000 professionals working in general practice by 2020. That is a key priority for the Government.

NHS: Mental Health Patient Assessment Needs

Lord Hunt of Kings Heath Excerpts

Monday 12th October 2015 Lords Chamber

[Lord Prior of Brampton]

In picking up the general point that the noble Baroness made, the Government have committed a great deal of extra resource to the mental health needs of young people. For example, I cite the NHS mandate and the Health and Social Care Act 2012, in which there is a duty to establish parity of esteem between mental health and physical health. It is also true that one can never do enough, and when one hears about a tragic case such as that described by my noble friend earlier, one has to look very carefully in the mirror and ask whether one could do more. That is why I have offered to meet my noble friend outside this House to discuss the matter in more detail.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on parity of esteem, is it not a fact that, in their allocations, clinical commissioning groups have reduced the proportion of resource going into mental health services? Will the Minister tell the House what he is going to do about that? He mentioned the mandate. He will know that, in 2012, the mandate said:

“By March 2015, we expect measurable progress towards achieving true parity of esteem”.

Can the Minister tell me that that progress has now been achieved?

[Lord Prior of Brampton]

I cannot tell the House that we have achieved parity of esteem. Demonstrably, across the country, we have not yet achieved parity of esteem, but we are on a journey to doing so. On the figures that the noble Lord raised, we spent £300 million more last year than the year before on mental health, and every CCG is spending more on mental health this year than the overall increase in their allocation. At the end of October, we will have the figures for the first six months, and perhaps then I can come back to the House and give him those figures in more detail.

Child Health: Play

Lord Hunt of Kings Heath Excerpts

Monday 12th October 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, when I am asked a question like that in such an engaging way, the answer has to be yes—and I look forward to it. I congratulate the noble Baroness and her team on the work that they have done with the all-party group on the fit and healthy child—I believe that the report is due to be published later this week. It almost goes without argument, and you do not need a lot of academic literature or UN conventions to know, that play is hugely important in the development of a child. On that, we are absolutely agreed, and I look forward to discussing with her ways in which we can help more in that regard later in the week or next week.

[Lord Hunt of Kings Heath (Lab)]

My Lords, perhaps I could come, too; it sounds a jolly interesting meeting. Does the Minister agree that while fitness is very important for young people, so, too, is diet? Would he like to comment on the story on the front page of the Daily Telegraph this morning which suggests that his boss has prevented Public Health England publishing a report which shows the direct link between too much sugar and obesity? Will he confirm that the Secretary of State has prevented PHE publishing the report and can he tell me what action the Government propose to take to reduce the amount of sugar in foods that children take?

[Lord Prior of Brampton]

I regret that I have not seen the report in the Daily Telegraph, so I cannot confirm or deny what was written in it. What I can say is that the Secretary of State regards the fact that one in five primary school-age children is now obese as being, in his words, a “great scandal”. The report on childhood obesity is due to be produced, I think, before the end of the year, and certainly within the next few months. I imagine that it will say that the problems are a combination of lack of exercise, lack of play and nutrition—but we will have to wait and see.

NHS: Financial Performance

Lord Hunt of Kings Heath Excerpts

Monday 12th October 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister is certainly having a busy day. I thank him for repeating the Statement. Obviously, these figures are very worrying. They relate to quarter 1. We are now well into quarter 3. What is the Minister’s latest assessment of hospital finances and his updated estimate of the year-end position? Clearly, there is not enough money in the budget to cover the existing costs of growing pressures, so how on earth is the service to fund seven-day services?

I noted the Minister’s comments about consultancy spend and agency staff. However, does he recognise that the reason so much money has been spent on agency staff, apart from through the actions of agencies themselves, is the fact that his Government cut the number of nurse training places in 2010? Does he also recognise that his Secretary of State’s attitude towards doctors is driving many of them away from this country? We should not be surprised if desperate NHS bodies, beset by criticism from the CQC about the numbers of doctors and nurses they need on the wards, resort to the use of agencies. As far as consultancy spend is concerned, does he accept that the Government’s own agencies—Monitor and the NHS Trust Development Authority—encourage NHS bodies to use consultancies? Will he ask them to try to reverse some of their actions themselves?

I quoted the Daily Telegraph to the Minister earlier. However, I want to say something about a story in the Mail yesterday concerning Sir Thomas Hughes-Hallett, chairman of Chelsea and Westminster Hospital in London. He has said that the NHS is in crisis and has referred to:

“A ‘worsening financial crisis’ leading to a ‘crisis in care provision’; An ‘environment of negativism’ triggered by endlessly critical missives from Ministers and officials; ‘Highly burdensome regulation’ leading to ‘abject confusion, fatigue and short-sightedness’; A ‘climate of fear’ ruling wards … ‘Continued emigration’ of doctors … The risk that these problems will cause an ‘inevitable reduction in quality and patient care’”.

You do not have to believe everything that Sir Thomas said without knowing that most people in the NHS share that view about tackling impossible pressures with limited resources. What are the Government going to do about it?

Health: Detection Dogs

Lord Hunt of Kings Heath Excerpts

Thursday 17th September 2015 Lords Chamber

[Lord Prior of Brampton]

It is interesting that the cost of training a dog is some £11,200—considerably less than the cost of training a doctor, I might add. Unquestionably there is considerable evidence to suggest that dogs can make a real contribution as regards people suffering from diabetes and low-sugar problems, whom the noble Baroness mentioned. Decisions in this area are for local CCGs to make, but it is something that we will certainly encourage.

[Lord Hunt of Kings Heath (Lab)]

My Lords, that is a clear hint of the Government’s new approach to the workforce shortage in doctors. We will see the outcome of the Milton Keynes trial, but does he agree that the organisation Pets as Therapy needs to be praised? I do not know about dogs detecting illnesses but they have certainly been shown to provide great companionship to patients, particularly long-stay patients in hospitals and care homes. This organisation does a fantastic job.

[Lord Prior of Brampton]

I agree with the noble Lord. Dogs—indeed, all pets—can provide companionship to many people who are lonely, particularly elderly people who have lost many of their relations. I congratulate Pets as Therapy.

NHS: Clinical Commissioning Groups

Lord Hunt of Kings Heath Excerpts

Wednesday 16th September 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness is right that there is considerable variation in the performance of CCGs and, indeed, commissioning support groups. In an effort to address that variation, we are in discussions with the King’s Fund to publish in a very transparent and open way the performance of individual CCGs.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister will be aware that the Global Burden of Diseases, Injuries, and Risk Factors Study was published in the Lancet yesterday. It showed that if the south-east of England were a country, it would come top of the 22 most industrialised countries in terms of health outcomes, whereas the north-west would be in the bottom range of countries. Does he accept that in the end this is a ministerial responsibility, and can he explain why allocations to CCGs, last year and this year, put much more money into the south-east of England than into the north-west?

[Lord Prior of Brampton]

The method of allocation is based around population, demographics and deprivation. The formula has developed over many years. The current formula was developed by the Nuffield Trust. There is no intention in the formula to skew the allocation from one part of the country to another. It is based in an independent and transparent way around population and deprivation.

Health: Children

Lord Hunt of Kings Heath Excerpts

Thursday 10th September 2015 Lords Chamber

[Lord Prior of Brampton]

I have indeed read the report by the NCB, although it came out only on Monday so I have not fully digested its conclusions. I think that it very much echoes the work done by Michael Marmot four or five years ago. He said that the first two years, and certainly the first five years, of a child’s life are crucial in determining their subsequent standard of living and health. The variation that the NCB’s report has identified is extremely important. It is a variation not just between rich areas and poor areas but within deprived areas. That level of variation is best tackled at local level by local authorities. The decision to push the commissioning process down to local authorities is probably the right one, but they will be heavily supported by Public Health England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, all the evidence suggests that there is a direct link between poverty and poor health outcomes. In view of that—and I accept that the Minister’s department has noble aims—what is his response to the work of the Child Poverty Action Group, which estimated very recently that by 2020, 4.7 million children will live in poverty? What representations has his department made to the DWP about its disastrous welfare policies?

[Lord Prior of Brampton]

My Lords, the causes of childhood poverty are profound. They are to do with employment, family relationships and education. The work that the DWP is doing with its troubled families programme and the work that the Department for Education is doing in improving educational standards will have a much greater impact on childhood poverty than, for example, focusing solely on things such as tax credits.

Health: Lymphoedema

Lord Hunt of Kings Heath Excerpts

Wednesday 9th September 2015 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they will publish a national strategy for the treatment of lymphoedema in the NHS.

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to put the case to the House for the development of a national strategy for lymphoedema services. I thank all noble Lords who have put their names down to speak in today’s debate and the noble Lord, Lord Prior, for responding on behalf of the Government. I pay tribute to the British Lymphology Society and the Lymphoedema Support Network for the tremendous work they do and the excellent briefings they have given me.

Lymphoedema affects more than 200,000 people. It causes swelling of the limbs or body and an increased risk of infection. Although it is a long-term condition that cannot be cured, its main symptoms can, with appropriate treatment, be controlled and often significantly improved. However, it remains an underestimated health problem and many healthcare professionals know little or nothing about how to treat it appropriately. As a result, it has a significant long-term impact on patients’ quality of life and the current disparate and unco-ordinated approach costs the NHS more money in the longer term.

Primary lymphoedema usually develops as a result of a genetic fault within the lymphatic system. With underdevelopment or weakness of the lymph vessels, swelling can appear at or around birth or, more often, later in life. It can affect infants, children and men or women of any age and often runs in families.

Secondary lymphoedema develops when the lymphatic system is damaged. This may happen following treatment for cancer—surgery or radiotherapy—but may also occur as a result of infection, severe injury, burns or any other trauma. Research has shown that for every cancer-related patient, there are three non-cancer-related patients, but a point I stress to the Minister is that non-cancer-related patients often struggle to get treatment.

Chronic lymphoedema has been shown to have a significant impact on sufferers, affecting the quality of their lives and causing loss of time from work. There is also a significant cost to the health service for the treatment of the most common complication, cellulitis. This is supported by statements which have been sourced from patients living with the condition by the Lymphoedema Support Network, Breast Cancer Care and Dr Todd. They showed that of the patients surveyed, 80% had had to take time off work for treatment, 8% had had to stop working completely because of their lymphoedema, 50% of patients with lymphoedema had experienced recurrent episodes of cellulitis, 27% of the people with cellulitis required hospital admission for intravenous antibiotics—and I understand that the mean hospital in-patient stay for treatment of cellulitis is 12 days—36% had received no treatment for their condition, and 50% of patients suffered from uncontrolled pain. That statistic is symptomatic of a wider problem of a lack of availability of pain relief in the health service. Here, I pay tribute to the work of the Chronic Pain Policy Coalition.

Professor Peter Mortimer, consultant dermatologist at the Royal Marsden and St George’s Hospitals, London, and the UK’s leading lymphoedema authority, is clear that patients with chronic swelling should all expect to receive, first, an explanation about the most likely cause of their chronic swelling; secondly, prompt referral to a lymphoedema practitioner; thirdly, a treatment programme incorporating the four cornerstones of lymphoedema treatment as appropriate; fourthly, ongoing care according to accepted standards; and, fifthly, the option of additional treatment at intervals as needed. Unfortunately, this is not the experience of most patients and we need to see a step change in approach by the NHS.

Reducing the risk of developing lymphoedema is an essential element of any national strategy. Many groups of potential lymphoedema sufferers can be identified; for example, breast cancer patients and those with several episodes of skin infection. We know that early intervention is the most effective way of dealing with lymphoedema. Good-quality advice and support can help reduce complexity and assist patients to self-manage. Improved access to the correct information, treatment and self-management support could significantly reduce hospital admissions. The extent of treatment needed should be assessed and managed by a qualified lymphoedema practitioner. Long-term monitoring and treatment are subsequently required, with the emphasis on strategies to control swelling and prevent infection.

It is pretty clear that education of both healthcare professionals and potential patients is required to increase awareness and to ensure an early diagnosis and timely referral if required. But the problem is that lymphoedema is not currently included in most undergraduate nursing and medical curricula. Nor does the United Kingdom have regulated education standards for those working in lymphoedema practices. An education strategy is needed to formalise training and to ensure that practitioners are trained appropriately and continue to update their learning and practice. This is particularly important in relation to non-cancer patients. Cancer patients are likely—not always, but likely—to be picked up within cancer services by practitioners who have some knowledge and understanding of the issues, but there is a particular problem in relation to non-cancer patients.

The National Cancer Action Team was asked in autumn 2012 to put together a case of need to inform the development of a lymphoedema strategy for England. A group of clinical experts and representatives of support groups and voluntary sector organisations were invited on to the lymphoedema reference group to undertake the work. This led to the publication in March 2013 by the National Cancer Action Team of an excellent paper which argued the case for a national strategy. It pointed out that existing service provision is not related to the level of patient need, lacks uniformity in approach and ignores the fact that high-quality lymphoedema services can improve outcomes in all domains of the NHS outcomes framework. It described the service as a Cinderella service struggling for recognition. Services are generally small, 36% of them being delivered by single-handed practitioners. As I have already mentioned, there are no key performance indicators or minimum education standards.

The work done for the National Cancer Action team also said that obtaining an accurate diagnosis is difficult, especially for non-cancer related, late onset and children. It warned that lack of early, accurate diagnosis leads to increased complexity and increased costs, some of which could be avoided. It warned also that increases in cancer and obesity will show a corresponding increase in the incidence and prevalence of lymphoedema.

Following the National Cancer Action Team report, the NHS England board was asked to consider developing a national lymphoedema strategy for England, but this has not happened. The National Cancer Action Team has been disbanded and it is my understanding that no formal response has been received from NHS England. Those people who devoted their time and effort to serve on the reference group for the National Cancer Action Team have not even had the courtesy of a letter from NHS England to say what action will be taken. At the very least, someone in NHS England should apologise for that gross lack of courtesy and tell the members of the reference group what is happening. I hope that the chairman of NHS England will take on that personal responsibility.

Since then, very little progress has been made. I know that the Minister is sympathetic to these kinds of issues, which fall between a number of stools. I hope that he will agree to a sympathetic look at my request to take forward a strategy. At the very least, lymphoedema ought to be on the list of prescribed nationalised services and be commissioned at a national level. If the Minister’s response to is to say that it should be left to clinical commissioning groups, it is quite clear that nothing at all will happen. I have said this before: clinical commissioning groups simply do not have the capacity or the wherewithal to deal with a service of this sort. There has to be some kind of national framework or direction.

I hope that the Minister will also agree to look at minimum standards for the training of health professionals and the development of key performance indicators and commissioning guides. If his response is that CCGs will be handed this responsibility, they must have some guidance about what kind of service they should be commissioning.

Finally, will the Minister agree to meet representatives of the British Lymphology Society and the Lymphoedema Support Network, who do so much to raise these issues of concern?