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?

Police: Ambulance Support

Lord Hunt of Kings Heath Excerpts

Thursday 16th July 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the question of the London Ambulance Service’s performance, when does the Minister expect the LAS to perform according to the targets that it has been set?

[Lord Prior of Brampton]

The performance of the London Ambulance Service is improving, albeit too slowly. A new chief executive has just been appointed and the TDA is following the performance extremely carefully. We hope that improvements will continue to be made.

NHS: Reform

Lord Hunt of Kings Heath Excerpts

Thursday 16th July 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for his Statement. The Opposition support much of what he had to say. I will focus my remarks on the plan for seven-day working and then touch on a number of the other issues that he raised.

Ensuring our health services are there for everyone whenever they are needed, be it a weekday or a weekend, is essential to keeping people well and making the NHS sustainable. Of course the Opposition support the principle of what the Government are trying to achieve with seven-day working, and we will certainly work with them on making that possible. Where I urge some caution is in the manner in which the Government are attempting to achieve those changes.

The Minister will be aware that the NHS is in a rather fragile state at the moment. A&E performance has been very disappointing in the face of enormous pressures. He will know that primary care services are overwhelmed. We discussed in Oral Questions the failure of some ambulance services to meet their performance targets. We talked particularly about the London Ambulance Service. There is a shortage of staff and an overreliance on agency workers and undoubtedly patients are suffering as a result—on this Government’s watch. Staff are feeling pretty demoralised and rather unloved by the Government. It is important that the way the Government approach seven-day working does not make matters worse.

I am entirely unclear as to how seven-day working is to be achieved without significantly impacting the rest of the NHS. The real danger here, given the way the NHS will approach this kind of target, is that more staff will be produced at the weekend by cutting staff during the week. The Minister will be aware of the study published in Health Economics, which concluded:

“There is as yet no clear evidence that 7-day services will reduce weekend deaths or can be achieved without increasing weekday deaths”.

Clearly, it would be an absolute nonsense if we reduced weekend deaths but the price was an increase in weekday deaths.

The Government have produced no facts or evidence for the assertions they are making. If we are to take this seriously, we need to know a bit more about how the resources challenge and the current acute shortages in many staffing areas are going to be met—bearing in mind that the Government are cracking down on the use of agency workers; the ludicrous 2012 Immigration Rules, which mean that nursing staff who are not earning £35,000 a year after six years will be sent back to their country of origin; and the serious issue of staff morale.

The Minister mentioned the 2003 contract but will he confirm that the contract negotiated then was actually very largely based on the one negotiated by the previous Conservative Government in the 1990s? How does he think the Government intend to work in partnership with NHS staff to make those changes? The briefing from his department—phrases such as “declaring war on NHS staff”—does not seem to have got this policy off to the right start. The kind of provocative statements that are currently emanating from his department, no doubt under the authority of the Secretary of State, do nothing to create the conditions in which people in the NHS will actually want to work with the Government on developing these policies.

I also want to mention the impact of another five years of, in effect, real-terms pay cuts. What impact does the Minister think the Chancellor’s announcement on pay will have on future staff numbers and retention? I want to raise one issue with him, which is the subject of a statutory instrument in your Lordships’ House. If the pay of NHS staff is to be held down, how can he justify the 12% increase in fees by the HCPC, one of the key staff regulators for the healthcare profession? Will he withdraw this regulation? Does he not agree that it is absolutely disgraceful that staff are being asked to pay more money by what essentially is a government-owned quango when their own pay is being held down? It is utterly unacceptable.

Can the Minister tell me how this is going to be funded? Either the staff are going to be thinned out during the week or extra staff will have to be found. It is not just consultants and nursing staff; it has to be the whole infrastructure to make this work, including community services and primary services, and there will be a knock-on impact on social care costs. How is this going to be paid for? If he says that the Government are giving £8 billion to the health service overall, he knows that is dishonest. We know that that will probably be paid in 2021, according to the Treasury briefing. We also know that £30 billion per annum will be needed by then. Nobody I know in the health service thinks that it has any chance at all of closing that gap because the kind of efficiency saving required has never been achieved in this or any other health service. The excellent report on efficiencies by the noble Lord, Lord Carter, in itself will produce only £5 billion by 2017-18.

On whistleblowing, I welcome the Freedom to Speak Up report, which contained a number of important recommendations to foster a more open culture. The Minister will know that in recent years there have been a number of other examples of appalling care in social care settings, including Orchard View, Oban House and, of course, Winterbourne View. Many of those scandals were exposed only once undercover reporters infiltrated the care home. Of course, we welcome the action the Government are taking, but does the Minister agree with the point I have made to him previously: that if the Government really want an open culture in which people can raise their concerns, that has to apply right up the line, meaning that the leaders of NHS organisations can speak openly about their own concerns about the direction of policy and the actions of Ministers? He will know that at the moment those people are slapped down if they make any criticism at all of the Government. You will not get an open culture until everyone in the system feels that they can be open. At the moment they cannot.

We support the steps in the Kirkup report to improve the regulation of midwives but if the Government are so concerned about modernising regulation, why have we not had the Law Commission Bill containing a comprehensive approach to the modernisation of health regulation for individual professionals? Why are we carrying on with this antiquated approach and these wretched Section 60 orders, which cause a lot more expense and delay in the Minister’s department? Why has the new speeded-up system of dealing with regulation, for regulators such as the Nursing and Midwifery Council, been held up for many months now? Of course, one of the reasons why it has had to increase its fees is that the Government will not agree to this legislation coming before Parliament to streamline its proposals.

It is pretty disgraceful that the Rose report, which was mentioned, was not published alongside the Statement. Why are we having to wait until after this Statement to look at it? The noble Lord knows that Ministers received it months ago. What is in the report that they do not want the public to see?

On the merger of Monitor and the NHS Trust Development Authority, I welcome the appointment of Mr Ed Smith, who is a high-calibre chair. He is also pro-chancellor of Birmingham University, which is a very strong recommendation. I also like the name “NHS Improvement”. But how many staff in Monitor and the NHS Trust Development Authority have any concept of improvement, given their current record of bullying, hectoring and intimidating the agencies they are responsible for? Can I assume that there is going to be a drastic change of personnel in that combined organisation? Will the Minister confirm that no one employed in that organisation will earn more money than the Prime Minister, given that the Government have chosen to attack NHS chief executives in relation to their salaries? Will he also confirm that they will not use agency staff? Does he not find it rather ironic that Monitor, in order to instruct NHS bodies not to use agency staff, has employed temporary staff? What is sauce for the goose is sauce for the gander.

There is a dangerous gap between the kind of fantasy land that Ministers talk about in the health service and the reality of life on the ground. On the ground, people are struggling every day to meet the pressures with limited money and no support from the Government. The health service is in real danger of falling over. The Government should stop blaming the NHS and take responsibility.

[Baroness Walmsley (LD)]

My Lords, I, too, thank the Minister for repeating the Statement. It reflected much of what I heard this morning from the Secretary of State at the King’s Fund. It is a brave and realistic approach but there are some yawning gaps in it compared to what I should have expected in a major statement about NHS reform. However, I welcome several points.

The focus on culture change and nurturing staff is absolutely right. The NHS is the best and most cost-effective service in the world only because of the skills and commitment of its staff, yet we are told that in some places staff morale is poor. This is very sad to hear. It was good to hear earlier this morning about the beneficial effect on morale in those hospitals that are responding positively to being put in special measures.

I welcome the new personnel, processes and training that are being put in place to ensure that staff can safely express concerns about the quality of care, so that each member of staff can take part meaningfully in the improvement pathway of his organisation. We could do with ditching for all time the expression “whistleblower” with all its negative connotations. I welcome what the Secretary of State called “intelligent transparency”, a no-blame focus on what went wrong and how to put it right. In common with the noble Lord, Lord Hunt of Kings Heath, I think that merging the TDA and Monitor could be a good thing, with this focus on no-blame improvement. That should help, but we still need more signposting for patients and service users about how and where to complain if they have poor care in what is a very complex system.

I of course welcome the focus on better data-gathering, especially in the field of mental health, where we are rather short of it. Managers cannot make good financial decisions without the facts about what everything costs. Businesses could not survive like that and neither can the NHS.

I welcome the long-awaited publication of the Rose report and the acceptance of its recommendations. I look forward to seeing what they are. We need a new focus on the quality of NHS management. If we are to rise to the challenge of the £22 billion of efficiency savings, we need excellent managers and finance directors as well as excellent doctors and nurses. I welcome the fact that the noble Lord, Lord Rose, extended his remit to CCGs.

I also welcome the new requirement for hospitals and groups of doctors to provide a seven-day service but I share some of the concerns of the noble Lord, Lord Hunt, about how it will be delivered. People do not get sick to order just on weekdays, so that is important. I should, however, like assurance that this does not necessarily mean putting any further burden on individual hard-working doctors, nurses and laboratory staff. Good planning is needed to avoid further burdens. However, this will certainly mean the recruitment of more trained staff. We need assurance that they are in the pipeline. Can the Minister say, for example, what the Government are doing to stem the flow of staff, trained by the NHS at a cost to the taxpayer, who leave the country as soon as they qualify?

What was missing from the Statement and the speech this morning was context and understanding that filling the £30 billion black hole in the NHS requires a whole-Government response. If patients are to be in charge, they need good health education so that they know what a healthy lifestyle means. They need access to sports and leisure facilities and nutritious food, and they need warm, dry homes. Integration needs to be a lot broader than just integration between health and social care. Unless social care is properly funded, the NHS will not be able to find its expected £22 billion of efficiency savings while making the improvements outlined in the Statement because of the knock-on effect on acute hospital beds. Yet while there has been more money for the health service, there has been nothing but cuts in social care.

The thrust of the Statement was about getting it right first time and, if not getting it right the first time, then certainly the second and subsequent times. This has to be right for patient safety and confidence but also for cost-effectiveness. If we are to rise to the increasing demand on the health service, we must get it right as near as possible every time and we must support the staff in doing so.

National Institute for Health and Care Excellence

Lord Hunt of Kings Heath Excerpts

Monday 13th July 2015 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government why the National Institute for Health and Care Excellence was asked to suspend its work on safe staffing guidelines regarding nurses.

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

The Government are committed to supporting NHS trusts to put in place sustained safe staffing by using their resources as effectively as possible for patients. The existing National Institute for Health and Care Excellence guidance on maternity settings and acute in-patient wards will continue to be used by NHS trusts. NHS England, working with NICE and other national organisations, will continue with this work in other areas of care and other healthcare professional groups.

[Lord Hunt of Kings Heath (Lab)]

I am grateful to the noble Lord, but that does not explain why NHS England put pressure on NICE to stop working on guidelines on safe staffing levels, despite the recommendation of Sir Robert Francis following the Mid Staffordshire inquiry. Was it because NHS England was no longer prepared to fund the implications of such work? Given that NICE has now decided to continue with work on A&E guidelines, will the Minister assure me that the Government will insist that the NHS implements those guidelines?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Lord raises a good point. We need to train as many of our own nurses as possible. There will be times when we get those calculations wrong and it will be necessary to bring in nurses from overseas. That is not a desirable outcome for many reasons, which there is not time to go into today. We need to train more ourselves.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister have another go at the Question? I still fail to understand why an independent body, NICE, was instructed by NHS England to discontinue work on safe staffing guidelines. What on earth caused NHS England to do that?

[Lord Prior of Brampton]

NICE has not been instructed to cease its work on safe staffing standards; on the contrary, it has been asked by NHS England to provide it with appropriate guidance.

Health Funding

Lord Hunt of Kings Heath Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness will know that decisions on these matters are left to local authorities, and we wish to give them as much discretion as we can.

[Lord Hunt of Kings Heath (Lab)]

My Lords, there is not much discretion if the Treasury decides to take away £200 million in-year on public health programmes from local authorities. If the intention is to squeeze the public health budget, will the Government therefore take action at national level to compensate for this by legislating to reduce the amount of fat, salt and sugar in food and drinks that are aimed mainly at children and young people?

[Lord Prior of Brampton]

My Lords, prevention is very important to the Government and a very important part of the NHS Five Year Forward View. The reduction of £200 million in the grant to local authorities should be seen in the context of a total grant of £3.2 billion; it is a 6% reduction. Public Health England has a campaign to raise awareness of the damage that sugar and salt, as well as smoking and alcohol, can do to people’s lives.

National Health Service: Sustainability

Lord Hunt of Kings Heath Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, as we are touching on procurement, I declare an interest as president of GS1 and the Health Care Supply Association. I, too, warmly welcome the debate of the noble Lord, Lord Patel, and the excellent way that he put forward his arguments. Of course, the issue of sustainability has been asked almost every year since the NHS’s formation in 1948. Right from the start, voices said that public expectations were too high and called for explicit rationing of services. We know that almost as soon as the NHS was established, our friends in the Treasury were keen to see the introduction of charges. Indeed, in the early 1950s, charges for spectacles, dentures and then prescription charges were introduced. This was followed by the 1953 Gillebaud commission. At the time, it was thought that NHS costs were spiralling out of control and Gillebaud was asked how we could reassert control over NHS spending. In fact, he came to the conclusion that there was a popular misconception about a vast increase in costs and ended up recommending a big increase in capital expenditure.

Through the years, we have had many other reports. Harold Wilson in opposition did not think much of royal commissions. He famously said that they took minutes and wasted years. But he was very fond of them in government and set up a royal commission on the NHS. Interestingly, its brief included the possibility of a greater reliance on other means of funding the NHS. But it was not convinced of that, and said that the claimed advantages of insurance, finance or substantial increases in charges—or co-payments, as we now call them—would outweigh the disadvantages in terms of equity and administrative cost. Mrs Thatcher had another go. Patrick Jenkin set up an internal review to look at the sustainability of the NHS, with potential restrictions of coverage, but it never published the results and no change took place. Now again, we are debating the sustainability of the NHS and the suggestion that a royal commission should be established.

I do not doubt that the challenges put forward today are formidable, but I agree with my noble friend Lord Turnberg that the NHS is still sustainable. For all the problems that we face, the US Commonwealth Fund’s analysis of the NHS two years ago, on comparative terms, as the number one health system in the world at least gives us some confidence that we have something that is worth preserving—albeit one that needs developing as we try to deal with some of the issues that noble Lords have raised.

That does not underestimate the financial gap and the productivity challenge facing the noble Lord, Lord Prior, in his new responsibilities. We talked about the £30 billion gap by 2020. We have heard the forecast from NHS England that if we achieve a 2% to 3% per annum rise in productivity, we could reduce that to £8 billion. The Government have promised that £8 billion, but I doubt that it will be seen until the 2020-21 financial year, judging by the documents published alongside the Budget yesterday. We know that historically the NHS has achieved a 0.8% productivity gain, so that would make the gap £21 billion and not £8 billion. More recently, in the last Parliament, there was a 1.5% productivity gain, but that dipped in the last two years because of the post-Francis impact of increased staffing and, because there had been cuts in training commissions, agency costs spiralled out of control.

Then we had the report of the noble Lord, Lord Carter. My noble friend Lord Reid is quite right: clearly, in relation to procurement, there is money to be got. But even if we implemented the whole of the Carter report, which includes some brave decisions about the employment of staff midweek on wards, it would produce only £5 billion. Put all that together and clearly there is a big gap. Last year provided deficits of £822 million: this year they are projected to be £1 billion.

Alongside that, the Government are actually increasing demand rather than discouraging it. Understandably, more people want access—but 24/7 access? The NHS Choices website is always encouraging people to use the service more and more. It was right for my noble friend Lord Desai to ask the noble Lord about the tension between this desire to give greater accessibility and the issue of demand management. We are reaching a difficult point where the two are not deliverable.

I hope that the Minister will say how he thinks productivity will be improved, but another issue that is vitally important is the quality of management and leadership in the NHS. The challenge is daunting: the productivity gap, the move to seven-day working without the use of agency staff—let alone health and social care integration. At the same time, we know that at the moment performance is deteriorating. Clearly, we need the best possible managers and leaders. I am sure that the Minister has read the Health Service Journal report on leadership, chaired by Robert Naylor, which came out last month. It said that a third of trusts have either vacancies at board level for key leaders or were employing highly expensive interns. There is a 20% vacancy rate for financial directors and chief operating officers. One in six trusts has no substantive chief executive. One in 10 has retained the same CEO for more than a decade, but the median time in post for a trust CEO is a mere two and a half years. One in five CEOs has been in post for less than a year.

Nigel Edwards of the Nuffield Trust has said that high executive turnover,

“has a chilling effect on the willingness of chief executive officers to take bold initiatives and encourages a passive and responsive culture”.

In other words, the fact that chief executives are in fear of losing their jobs encourages the kind of culture that will make sure that we cannot deliver the productivity challenge. I agree with my noble friend Lord Warner that there is no chance whatever that the Government will get to 2020 with a 3% to 4% productivity gain with the current culture—a blame culture with incessant interference by the regulatory bodies and supervising bodies into the work of NHS trust chief executives.

I know that the Minister has huge experience—apart from CQC, he chaired a highly successful trust in Norwich, Norfolk—and I know that he understands this. At heart, Ministers set the tone and culture. I appeal to him to start to change the culture. He will have to put much more trust in people in the field to achieve this change. Of course we have to intervene, as my noble friend Lord Warner said, when an organisation is clearly failing, but if we carry on the way we are doing at the moment we will simply not achieve what we need to achieve, and I believe that the health and social care system will fall over.

I know why noble Lords wish to see a royal commission established—on the face of it, it is very attractive. But I sound a note of warning. My experience of the NHS is that the moment you set up a committee of inquiry, it is always used as an excuse to put off difficult decisions. In a sense, we have in the Five Year Forward View a challenging and agreed programme—agreed by almost everybody—for the way forward. If a commission were established, it would have to be clear that its remit accepted the five-year forward plan as the way to go. I fear the killing effect of a royal commission that took two years and then a Government taking another two years to make up their mind about challenging funding issues such as co-charges. We have already had the Barker commission, set up by the King’s Fund, which went into most of the issues that noble Lords raised.

At the end of the day, I agree with my noble friend Lord Reid that the political process will always come to the fore. The sustainability of the NHS ultimately depends on political will. In the end, it is down to Governments to make sure that the NHS provides what the public want. Do the public want the NHS to be sustained? Yes, they do.

--- Later in debate ---

[Lord Patel]

I thank the Minister for his response, and I am encouraged by his last comments. A 10% gain is still a gain—I would not have expected him to agree. By the way, I did not use the words, “royal commission”. I asked for an independent commission. I understand why political parties may not like the idea of a royal commission, but I am encouraged by what the Minister said.

I am grateful to all noble Lords who have taken part. It has been an excellent debate and the stature of those who have spoken indicates the interest in the subject. I do not think that the matter will be left today, just for another debate. I have to say to the noble Lord, Lord Hunt, that I get the feeling that political parties want to keep the health service in some trouble all the time, so they can use that for the next election.

[Lord Hunt of Kings Heath]

My Lords, the noble Lord is far too cynical.

[Lord Patel]

I wonder what makes me cynical.

Health: Children and Young People

Lord Hunt of Kings Heath Excerpts

Tuesday 7th July 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, we have had a very good debate, and I am pleased that the noble Baroness, Lady Hollins, has enabled us to do it. Rather like the noble Baroness, Lady Walmsley, I want to start by focusing on physical health issues. As she said, the frightening obesity rates among young people are associated to a certain extent with lack of exercise, but I agree with her on what she said about food, eating and poverty.

We have heard the noble Lord, Lord Prior, speak at a number of seminars recently. He has stressed the Five Year Forward View, which the Government have endorsed. One of the encouraging things about that report is that I see—I think for the first time—some passion coming from NHS management about the need to deal with public health issues. That document points out the issue of obesity among young people and the problems that it is going to store up for the future. It also recognises the role of government in terms of legislation. Does the Minister accept the need for legislation when it comes to basic issues of the amount of salt, sugar and fat in foodstuffs, particularly those marketed at young people? He will know that in this country young people drink more of those super-sugary drinks than in any other country within Europe. Of course there is always a balance to be struck between the emphasis on individuals, the parental role and schools, but in the end legislation is sometimes required. I urge the noble Lord that his department ought to be battling in Whitehall to get some legislation around the protection of young people.

I hope that the noble Lord will respond to the point made by the noble Baroness, Lady Walmsley, about academy schools and their ability to go outwith much of what is sensible in relation to the teaching of young people in this area. Also, alongside the issues of food and healthy eating, there is a real concern about where exercise for young people has gone within our schools.

Frankly, we have now reached a point of hysterical obsession with testing young people, and that is crowding out the agenda and the focus. When I talk to year 6 teachers about the SATS testing that now has to be undertaken, I realise that in many schools they are doing nothing else but preparing for the tests for six months, mostly all the wretched testing around maths and English to the exclusion of almost anything else. We are reducing children’s education to a miserable exercise, one in which teachers do not believe, but they are being forced to do it. This is the Government’s obsession, and of course Ofsted has lost any notion of independence in terms of its own role.

The noble Lord may ask what all this has to do with him. It has plenty to do with the health department now that it is no longer concerned with NHS performance—or at least we are being told that, because the 2012 legislation promised it. The department has the space in which to argue in Whitehall for some of the measures that now need to be taken.

I agree with the noble Earl, Lord Listowel, about the whole issue of access to leisure facilities and the impact of local government reductions on many of them. Many local authorities have decimated their leisure service provision, which has a devastating impact on the ability—particularly of those who do not have access to resources—to use such facilities. This will become a very serious problem for the future.

I do not want to spoil the noble Baroness’s Question for Oral Answer on Thursday, and she might have mentioned it, but the Government and certainly the Chancellor have rather undermined NHS England when he swiped £200 million from the public health budget of local authorities in-year. There is a sense in which the Government are saying that of course prevention is important, but their first action after the election was to reduce the amount of money available to local authorities to act in this area. The noble Baroness, Lady Stedman-Scott, made some important points about families, which I hope the noble Lord will respond to.

We have debated the issue of mental health some four times, I think, over the past few weeks. That is important because it is an important subject, but we know from the Royal College of Psychiatrists, which is one source of information for this debate, that one in 10 children and young people suffers from a diagnosable mental health disorder. Half of all diagnosable mental health conditions start before the age of 14, and 75% by 21. We also know that the figures are even more worrying for young people from BME backgrounds. The Health Select Committee report published in November 2014 talked about,

“serious and deeply ingrained problems with the commissioning and provision of children’s and adolescents’ mental health services”.

I know that the Government are going to talk about the task force, and that is welcome, but perhaps I may put four questions to the Minister. First, why is the funding for children’s mental health services still so low in view of all the problems that have been identified? Secondly, I understand that, of the joint strategic needs assessments that are written by each public health director for their local authority, very few mention children’s mental health services. I also suspect that even fewer pick up the point made by the noble Earl, Lord Listowel, about the health concerns around looked-after children. Why is that? Does the Minister believe that directors of public health need to have their attention drawn in their annual report to the importance on the state of the health of their local authority, and that this is an important area for them to be concerned about?

Finally, I want to ask about the introduction of waiting time standards for mental health services. The Minister will know that this was introduced in April 2015 and people are guaranteed talking therapy treatment within six weeks, with a maximum wait of 18 weeks. For individuals experiencing a first episode of psychosis, access to early intervention services will be available within two weeks. I recognise that it is early days; we are only four months away from the start of these new standards, but I wonder whether the Minister can say something about how he thinks the service is progressing.

NHS: Whistleblowing

Lord Hunt of Kings Heath Excerpts

Tuesday 30th June 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord rightly expects a fundamental change of culture among NHS bodies, but does he agree that one way in which that could be helped would be if Ministers welcomed criticism from chief executives and leaders of those bodies of unrealistic expectation on the part of Ministers and of there being too few resources? Does he agree that such leaders are stamped on for making their views known, which is simply not conducive to encouraging openness in their own organisations?

[Lord Prior of Brampton]

The noble Lord makes a good point. If one looks back at the history of Mid-Staffordshire, one sees clear evidence that the priorities of that organisation were too skewed towards hitting financial targets and meeting other extraneous objectives such as becoming a foundation trust. The message to all NHS organisations should be that patient safety and quality of care come first.