National Health Service (Mandate Requirements) Regulations 2017

Lord O'Shaughnessy Excerpts

Wednesday 6th September 2017 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, we have a health service which is endeavouring to meet an ever-present and probably ever-growing demographic challenge. I was interested to hear the remarks of the noble Baroness, Lady Finlay, on the effect of the number of older people accessing the service, but there are many more people growing old and it is surely self-evident that there is bound to be an increase in waiting lists.

Perhaps I may leave your Lordships with two statistics. It is remarkable that last year the NHS carried out 11.6 million operations, some 1.9 million more than in 2009-10, and 61 million out-patients were seen, again 1.9 million more than in 2009-10. The health service is not perfect and there is certainly no room for complacency, but perhaps I may remind noble Lords that the 2016 GP patient survey showed that 84.6% of respondents rated their overall experience as good, while the 2016 British Social Attitudes survey showed a historical high level of satisfaction. This is a service which is endeavouring under very strict budgetary pressures to improve the lot of the nation.

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

My Lords, perhaps I may first thank all noble Lords for their contributions and indeed thank the noble Lord, Lord Hunt, for bringing about this debate and giving me a chance to defend the Government’s record on the NHS. We are very proud of our record on the NHS at a time when it is treating more people than ever before. We have protected and increased health funding, with real-terms increases every year since 2010, with more doctors, nurses, midwives and GPs working in the NHS, so people can get the care they need when they need it. This is the first Government to have got a grip on NHS spending and really prioritised those areas of the service in need of investment. We are investing in general practice, an issue that has been raised in the debate, allowing GPs to open for longer so that more people can access the services that they offer. Some 17 million patients have already benefited from evening and weekend appointments through our seven-day NHS, which is a considerable achievement. Investment in general practice will increase from £9.5 billion in 2015-16 to more than £12 billion in 2021, a 14% real -terms increase. By 2020 there will be an extra 5,000 doctors working in general practice, as well as 5,000 extra staff.

This is also a Government who have given parity of esteem to the treatment of mental health in the National Health Service. The Five Year Forward View for mental health sets out our ambitious programme for further system reform: more skilled staff, the first ever waiting time standards, and an ambitious plan for children and young people’s mental health provision is in development. We have increased mental health funding significantly since 2010 so that we can deliver the services that people deserve.

I am proud that the NHS has been found by the Commonwealth Fund for the second time in a row to be the best, safest and most affordable healthcare system of 11 countries including the US, Canada, Australia, France and Germany. This is a tremendous achievement and I join with all noble Lords in congratulating our dedicated NHS staff on the excellent service that they continue to provide for patients.

Spending is of course important. According to the OECD, in 2014, UK spending on the NHS was 9.9% of GDP, which is above the average for both the OECD and the 15 countries which were members of the EU prior to May 2004. I would also gently remind Members of the previous Labour Government that this is a higher level of spending than at any time during that Government. Of course, we are not complacent and we understand that the NHS needs to change, develop and improve in order to meet the needs of the future. The mandate to NHS England that the Secretary of State is required to publish and lay in Parliament for each financial year therefore sets out the steps that the Government expect NHS England to take to ensure that the NHS offers the safest, most compassionate and highest quality healthcare in the world. The mandate for 2017 sets ambitious objectives for the coming year with the aim of delivering real improvements in patient care and outcomes. They include improving outcomes for maternity and diabetes, reducing health inequalities, improving patient safety and quality, moving more care out of hospitals, and supporting people to live healthier lives—all while delivering a balanced budget.

In his Motion, the noble Lord, Lord Hunt, has questioned our commitment to ensuring timely access to elective NHS services by arguing that the National Health Service (Mandate Requirements) Regulations 2017 and the associated mandate to NHS England make no reference to NHS England’s obligation to deliver the 18-week standard. I do not accept that and I see no grounds for making such a claim. On the contrary, we remain committed to a waiting time standard for non-urgent referrals whereby NHS commissioners must make arrangements to ensure that not less than 92% of patients have been waiting to start treatment for fewer than 18 weeks. That standard, the standard we are discussing tonight, remains a patient right that is embedded in the NHS constitution and underpinned by legislation passed, as the noble Lord pointed out, by a Conservative and Liberal Democrat Government. We have no plans to change it. Alongside the other priorities that the Government have set out for the NHS, maintaining and improving performance against core standards continues to be a commitment.

I turn now to the legislation itself. The Health and Social Care Act 2012, which we have discussed tonight, introduced a requirement for the Secretary of State for Health to publish and lay before Parliament a mandate in each financial year. It sets out the Government’s objectives for NHS England and may specify requirements that the Government consider essential for the objectives to be met. Any requirements must also be set out in regulations. The mandate for 2017-18 has been published in full accordance with the Act, including with the requirement in the Act to consult both NHS England and Healthwatch England on it. There is no question as to its legality. The mandate for 2017-18 sets a clear expectation that NHS England will maintain and improve performance against core patient access standards, and the annual deliverable in the mandate reads as follows:

“With NHS Improvement, to meet agreed standards on A&E, ambulances, diagnostics and referral to treatment”.


I now turn to the key facts on NHS waiting times performance, as indeed the noble Baroness, Lady Walmsley, said I would. As noble Lords know, the NHS faces increasing demand for health services as a consequence of the ageing and growing population, together with the costs of new drugs and treatments. Let me give noble Lords some figures on how many more people are receiving care from the NHS. Some 23.4 million people went to A&E in 2016-17, 2.8 million more than in 2010. Some 1.87 million people were seen by a specialist for suspected cancer, 973,000 more than in 2010. My noble friends Lady Redfern and Lord Bridgeman have given other facts and I could go on, but I will not. However, the NHS is doing more and better for more people than ever before.

Despite the record numbers of people being seen by the NHS, the vast majority are being seen within the waiting time standards, whether for A&E, cancer treatment or non-urgent treatment. If we consider the 18-week standard, which is the subject of our debate today, the referral to treatment standard for non-urgent care is that at least 92% of people are seen by a consultant-led team within 18 weeks of referral, most commonly by a GP. I am very well aware that the NHS is not currently meeting the standard for 92% of patients to wait a maximum of 18 weeks from referral to treatment. The standard was last met in February 2016. The Secretary of State reflected this in his annual statement on NHS England for 2016-17. It has been laid before Parliament —we do not hide or resile from it. In the latest published monthly figures national performance was 90.3%, which is clearly lower than we would like.

--- Later in debate ---

[Lord Reid of Cardowan]

No.

[Lord O'Shaughnessy]

That is the truth.

Next year the NHS turns 70. As my noble friend Lady Redfern said, it has a unique place in our society. The mandate to NHS England for 2017-18 goes further than ever before to ensure that we not only continue to deliver the best care and support for today’s NHS patients but also deliver the reform and renewal needed to sustain the NHS for the future. We know there is more to do, which is why we have put our commitment to support NHS England and the NHS in delivering the five-year forward view at the heart of the mandate. We will continue to do so. I hope that I have persuaded all noble Lords, including the noble Lord opposite, that their fears are unfounded, and that the noble Lord now feels in a position to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, that is one of the most remarkable speeches I have heard in your Lordships’ House. I have to say that if the Government really think that the NHS is in the healthy position that the Minister says it is, I feel very sorry for them and sorry for NHS patients. Talk to anyone on the front line and they will tell you of the pressures, of the hopelessness of the changes the Government made and of the Brexit impact on staff. The NHS is facing a critical time and to have this litany, this list of so-called achievements, does no good at all to the health service or to the credibility of the Government.

I shall make only two points. The Minister said at the beginning that the Government are still committed to the 18-week target, but towards the end of his speech he quoted the same words as I quoted, which made it clear, as Simon Stevens has made clear and as is made clear in Next Steps on the Five Year Forward View, that actually the Government have given up on the 18-week target this year. They have said that,

“elective volumes are likely to expand at a slower rate than implied”

by the 92% target. That was an open admission that the target is no longer set in stone. Talk to any chair or chief exec in the NHS and ask them whether the 18-week target is a firm target in this financial year and they will say no. Of course the NHS faces pressures. In the days of my noble friend Lord Reid the demographic changes were taking place just as fiercely as they are now, but he made a dramatic impact in reducing waiting times.

My point is this: if the Government believe it is so difficult to manage the health service in such a challenging time, they should be open and honest and say that the target has been taken away; but they have not been honest, they have not been open and patients will suffer. My Lords, I beg to move.

End of Life Care

Lord O'Shaughnessy Excerpts

Tuesday 5th September 2017 Lords Chamber

[Baroness Walmsley]

To ask Her Majesty’s Government how they intend to implement the NICE guideline End of life care for infants, children and young people with life-limiting conditions: planning and management.

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

My Lords, responsibility for implementing the NICE guidelines lies with local NHS commissioners and providers. NHS England has commissioned the charity Together for Short Lives to assess whether local provision follows these guidelines. The results will be shared to help spread best practice and address common challenges. These actions form part of the Government’s commitment to ensure that everyone at or approaching the end of life has good-quality, compassionate and joined-up care in a setting of their choice.

[Baroness Walmsley (LD)]

I thank the Minister for his reply. The resource impact tool published with this guidance shows that by investing £12.7 million in implementing the guidance, savings of £34.7 million could be made by the NHS in England. What plans do the Government have to emphasise to local commissioners the cost effectiveness of implementing the guidance? Secondly, does the Minister think it is right that adult hospices in England receive 33% of their funding from statutory sources while children’s hospices receive only 22%?

[Lord O'Shaughnessy]

I thank the noble Baroness for raising this very important issue. On the tool and the cost effectiveness, we know how important it is to invest in these services. What we have now is not by any means a perfect service, but we do have the first national framework, NICE guidance and the CQC inspecting the quality of end-of-life care and showing up where there are still issues in provision. That is why we are working with Together for Short Lives and I think that the tool the noble Baroness has highlighted will help make the case to providers in order to do that.

There is significant funding going in from clinical commissioning groups and also what is called a care currency—a way of looking at that spending and making sure that it is being distributed to provide the care that is needed in a way that is predictable for the providers. In addition, another £11 million goes in from NHS England to support it. So there is always more to do but I think we are making good progress.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests, both as having established integrated paediatric palliative care services in Wales and as vice-president of Hospice UK. Does the evaluation that the Government have asked for from Together for Short Lives include evaluation of the experience of the family, including siblings, of the care? Are they able to access what they need when they need it, particularly on a 24/7 basis when the child is at home and crises may arise out of hours, to ensure that unnecessary and inappropriate emergency admissions are not happening because a family does not know what else to call for? Does the family feel supported—there is evidence of better long-term outcomes, both in the bereaved parents and in bereaved children?

[Lord O'Shaughnessy]

The noble Baroness is a true expert on this topic and we had a very good debate on the subject, which she initiated, in March this year. In terms of the experience of care, I will check exactly what the charity is looking at. I know that there is now a measure—a questionnaire—of maternity bereavement which is looking at the experience of care and trying to learn from that, and I will see whether that is more broadly the case in terms of siblings and others, and indeed for non-neonatal child deaths. On 24/7 provision, again, we know that it is not yet universal but a couple of pilots are taking place on 24/7 nursing community care, so we are making some progress on that. Indeed, one of the metrics by which we will measure our success is the number of admissions and the time spent in hospital in the final 30 days of life, which speaks to the point she was making in trying to keep those who are dying out of hospital if that is not where they want to be.

[Lord Howarth of Newport (Lab)]

My Lords, does the Minister accept that we live in a society animated by humane values, which is also one of the richest societies in the world, and that there can be no excuse for the extensive failure to provide appropriate palliative care for children who are terminally ill or bereavement support for their parents that has been reported by the Royal College of Paediatrics and Child Health and the charity Together for Short Lives? Will the Secretary of State, who is accountable for these matters, use the authority of his office to ensure that sufficient services are commissioned and sufficient qualified staff are available so that the NICE guidelines can be implemented fully and consistently across the country?

[Lord O'Shaughnessy]

I agree that there is more to do but progress has been made since the first national framework was published a couple of years ago, building on the work of successive Governments. Staffing is important. There are more early-life nurses than there were seven years ago. More than that, additional training is also going on. This is a really important part of this. Health Education England’s mandate now includes end-of-life care training within various care packages. Indeed, through the Nursing and Midwifery Council, midwives are starting to get systematic end-of-life care training. Given that, unfortunately, 40% of these child deaths happen in the neonatal and newborn setting, that is incredibly important. But I take the noble Lord’s point.

[The Lord Bishop of Southwark]

My Lords, as the Minister has already intimated, the key to delivery of end-of-life care to children and young people is the work of our children’s hospices. Given the 22% figure, will Her Majesty’s Government follow the lead of the Scottish Government and agree to work towards funding 50% of children’s hospices’ charitable costs, to the benefit of the patients concerned, rather than allow the proportion to decrease?

[Lord O'Shaughnessy]

I thank the right reverend Prelate for making that point. In Scotland there are different funding environments. I am aware of the 50% funding commitment from the Scottish Government. We are trying to make sure that CCGs in England not only have the funding they need by increasing NHS funding in real terms but that they understand how to spend it well for end-of-life care, and topping that up where necessary with central funds. So there is a big spending commitment there and with the new accountability framework we have a way of holding those CCGs to account for their performance.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister has talked about a new accountability framework but the fact is that the work that has been done so far shows that CCGs are simply not implementing the guidelines. What is the point of NICE guidelines if we cannot be assured that they are going to be implemented? I refer him to the NHS England mandate for 2017-18, which talks about developing a set of measures on end-of-life care against which CCGs will be judged. Can he assure me that the NICE guidelines will be fully part of those measures?

[Lord O'Shaughnessy]

It is important to point out that the NICE guidelines are not mandatory in and of themselves. What matters is that there is high-quality end-of-life care provided at the local level and indeed that CCGs are judged on that care. They can of course do things differently and that is the point of the system: to trust that clinical judgment. The noble Lord is quite right that end-of-life care is in the mandate—that in itself is a relatively new development. I will come back to him on the specifics that he asked for about the extent to which those metrics will be included in the mandate.

Health: Obstetrics and Gynaecology

Lord O'Shaughnessy Excerpts

Monday 17th July 2017 Lords Chamber

[Baroness Kennedy of Cradley]

To ask Her Majesty’s Government what action they are taking to address the issues raised by the Royal College of Obstetricians and Gynaecologists programme Each Baby Counts.

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

My Lords, the Government and NHS England are supporting NHS maternity and neonatal services to address the Each Baby Counts recommendations on clinical care, human factors and reviewing cases with poor outcomes. Key initiatives include the Saving Babies’ Lives care bundle, an £8 million maternity safety training fund, which includes multidisciplinary training on team working and communication, a maternal and neonatal health safety collaborative programme, and a national standardised perinatal mortality review tool.

[Baroness Kennedy of Cradley (Lab)]

I thank the noble Lord. This report by the royal college, which I believe is the first of its kind, creates a national measurement and a national picture, and shows that over 500 babies who died or suffered brain injuries during birth could have had different health outcomes if they had received different care—the human cost of a maternity service which is thousands of midwives short, underresourced and under increasing pressure and demand. How are the Government addressing the chronic shortage of midwives in the NHS, when new figures out last week, I believe, showed that more midwives are leaving the service and fewer midwives are joining it? Will he meet me and representatives of the royal college to discuss how training can match the implementation of the recommendations in the report and how best those recommendations can be continued in the work of midwives?

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight the appalling tragedies involved. As she said, over 500 families could have had different outcomes if the care they had received had been different. That is worth dwelling on because every one of these incidents is a human tragedy. She highlights midwives. There are over 2,000 more midwives in the National Health Service and 6,500 in training. There has been a big increase in the number of births in recent years, so the number has had to rise. Of course, I would be delighted to meet her to discuss the training and to make sure that it is the very best available so as to avoid and, as the Secretary of State has said, to reduce the number of maternity incidences in future years.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that it is good practice to involve parents in the reviews of what went wrong during their baby’s birth? Why were only 28% of parents involved in the reviews of what went wrong? Surely it is totally unacceptable that 25% of parents were not even told that a review was taking place.

[Lord O'Shaughnessy]

I agree that parents should be involved in such reviews—as those who are ultimately most affected by these tragedies, they absolutely should be involved. It is fair to reflect that issues around maternity deaths, brain injuries and so on have been going on for a very long time, and in certain trusts there have been acute instances of tragedy. That is why, as I said, the Secretary of State is determined to halve the number of deaths and incidents. We have had a number of reports, not only the one we are discussing today but also that of my noble friend Lady Cumberlege, Better Births, in an attempt to improve the way that services are delivered.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I want to follow on from the question about reviews. The royal college that looked at the way in which the local reviews were undertaken found wide inconsistencies between different hospitals. Not only did a majority of reviews not involve parents at all, but my understanding is that, in its initial report, it found that only 9% of the reviews involved external experts. I know that the Government are very reluctant to intervene, but surely it would be possible to issue very straight guidance to the NHS to say how reviews should be undertaken and that in all circumstances both parents and external reviewers should be involved. Will the Minister give that some consideration?

[Lord O'Shaughnessy]

I shall certainly give that consideration. There may be specific reasons why, in particular instances, that might not be possible or even desirable, but I shall certainly look into it. Take one of the instances: the tragedies at Morecambe Bay. It was found that there was a lack of objectivity in investigations and that that—along with other problems such as a lack of good data—led to the kinds of tragedies we saw, not happening once but over and over again. I completely take the noble Lord’s point, and I will look into it.

[The Earl of Listowel (CB)]

Is the Minister aware of the excellent work of the charity Best Beginnings, of which I am a patron, which provides perinatal support to families? The charity has, for instance, created videos to support families with very premature children, helping them to bond with their children. With the Royal College of Gynaecologists and Obstetricians, it has developed the Baby Buddy app, which gives parents exactly the information they need during and after pregnancy, so that they can have the safest pregnancy possible.

--- Later in debate ---

[Lord O'Shaughnessy]

I thank the noble Lord for his question. I was not aware of that and will certainly look at it. I know that foetal monitoring is one of the key recommendations of the Saving Babies’ Lives care bundle that I mentioned, making sure that movement of the baby in the womb is continuing and monitoring the heart rate. That is critical to avoiding some of these tragedies.

Mental Health Services: Children and Adolescents

Lord O'Shaughnessy Excerpts

Monday 17th July 2017 Lords Chamber

[Baroness Lawrence of Clarendon]

To ask Her Majesty’s Government when they intend to bring forward proposals to reform Child and Adolescent Mental Health Services as outlined in their 2017 manifesto.

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

My Lords, the Government are committed to delivering their manifesto pledge to reform child and adolescent mental health services so that children and young people with serious conditions are seen in a timely manner and no child has to leave their local area and family to receive normal treatment. We will set out proposals in the Green Paper for children and young people’s mental health later this year.

[Baroness Lawrence of Clarendon (Lab)]

My Lords, I thank the Minister for his Answer. In a report published on 5 November 2014, the Health Select Committee came up with a series of deep-rooted complications in the provision of child and adolescent mental health services. With 75% of mental health problems starting before the age of 18 but only 8% of mental health funding currently spent on children and adolescents, questions must again be raised. Will the Minister consider ring-fencing funding for young people with mental health problems and ensure that it reaches front-line services, so they do not have to wait for another report to be published?

[Lord O'Shaughnessy]

I thank the noble Baroness for highlighting this very important issue. She will know that ring-fencing funding for mental health comes up a lot. There has been increased funding for mental health, but there is more than one reason why ring-fencing is not used for clinical commissioning groups, including honouring the principle of clinical autonomy, and we do not ring-fence around particular disease areas. I should point out that CCGs are being monitored now to ensure that they are increasing spending on mental health, year on year, in line with the increases in funding they are receiving, which is £1.4 billion over the coming years. The noble Baroness is of course quite right in what she said about the specific issue of children under the age of 18. That is why, among other things, we have committed to introducing mental health first aid in all secondary schools.

[Baroness Meacher (CB)]

The Minister will be aware that the threshold for children and adolescents who have severe mental health problems is extraordinarily high and that they may have to wait months before getting any treatment, whereas children with similar levels of physical ill health will be treated within perhaps a day or days. Does he accept that we are still an incredibly long way from equality between mental and physical healthcare, and what does he plan to do about it?

[Lord O'Shaughnessy]

I accept the point that the noble Baroness makes. Unfortunately, we are starting from a low base, over many years, in mental health provision, and that is what we are trying to rectify. She will know that the Prime Minister is deeply committed to this agenda. Let me point to a couple of issues. First, there is the introduction of the first waiting time standards—and indeed there are positive early data on meeting those stretching standards—as well as an increase in the number of beds available for those suffering from the most severe episodes of mental illness.

[Lord Deben (Con)]

My Lords, this is an area which has been not only underfunded but not cared about for a long time, and we have got to get it right. Someone has to stand up for these people because in their own home circumstances they do not have the kinds of opportunities and support that many others do. Will the Minister commit himself personally to make this worth fighting for? This issue is perhaps in the front-line of human rights in Britain.

[Lord O'Shaughnessy]

I completely agree with my noble friend and I commit myself personally to this issue. He may know that I have opened up primary free schools which focus on improving mental health and well-being, so I feel this personally. He mentioned children coming from chaotic homes, which is true in some instances. However, it is not always true. Mental illness can strike anyone, and all families and schools need to be prepared for it. Another commitment in the manifesto, about which there will be more detail in the Green Paper, is the introduction of a single point of contact in schools so that there is a champion, if you like, for any child who needs to access mental health services that go beyond the school gate.

[The Lord Bishop of Newcastle]

My Lords, I declare an interest as a member of the Children’s Commissioner’s advisory board for Growing up North. Recently, the Church in Newcastle and Durham brought together delegates from more than 100 schools in the north-east to share their serious concerns for the mental health of children in our schools. Will the Minister say what is being done to support schools in dealing with this increasingly difficult problem and what plans there are for in-school counselling?

[Lord O'Shaughnessy]

I thank the right reverend Prelate for raising this issue. I have mentioned mental health training and single point of contact. There are also curriculum changes. There will certainly be a number of policies within the Green Paper that will address the points she has raised.

[Lord Rennard (LD)]

The Government in Scotland are considering providing mental health counsellors in every secondary school. Does the Minister accept that all schools should have dedicated members of staff able to do more than just provide mental health first aid, and that there should be a trained mental health and well-being lead in every school, college and university?

[Lord O'Shaughnessy]

That is what we are moving towards with the mental health first aid training for teachers in all schools. The noble Lord will recognise that schools come in all different shapes and sizes and that it is easier to do that initially in secondary schools, which are bigger than, for example, rural primary schools which might only have a staff of 10. It is critical to make sure that there is at least one member of staff who is highly trained in spotting and dealing with the initial signs of mental health problems and signposting them to the relevant authority—local health authority or whatever it is—for further care.

[Baroness Wheeler (Lab)]

My Lords, the recent survey by the Children and Young People’s Mental Health Coalition has shown that the problems young people are now presenting with have become even more severe. Can the Minister reassure the House that funding earmarked for local CAMHS transformation plans will reach local services this year? How are the Government making sure that this happens and preventing funds from being diverted to other desperately stretched services?

[Lord O'Shaughnessy]

The transition from CAMHS is now one of the mandatory national indicators in what is called the Commissioning for Quality and Innovation scheme which provides incentives for performance, so I can reassure the noble Baroness on that. She is also quite right to highlight the issue of severity. That is why, under the plans that we have set out for CAMHS, by 2021 the service will be able to see 70,000 additional children per year for evidence-based treatment.

[The Countess of Mar (CB)]

My Lords, I declare my interest as the chairman of Forward-ME and a patron of the Young ME Sufferers Trust. Many young people with ME are believed to have a mental illness, and despite what the noble Lord said two weeks ago and what other Ministers have said—that ME is not a mental condition—how do we persuade professionals that these children would probably be much better off if they were left to allow their bodies to heal themselves rather than having cognitive behaviour therapy and graded exercise imposed upon them?

[Lord O'Shaughnessy]

I know that the noble Countess feels passionately about this issue, but she will know that it is only right for me to say that we need to be guided by evidence that is collected in clinical reviews. A review is being carried out by NICE at the moment and we shall wait to see the results of that before deciding what needs to happen as a consequence in terms of the kinds of treatments that are appropriate for those suffering from ME.

[Lord Foulkes of Cumnock (Lab)]

My Lords, the Minister has answered both this Question and indeed the previous one in his usual effective manner. However, I wonder if he could tell us on behalf of which half of the Cabinet he is speaking.

--- Later in debate ---

[Lord O'Shaughnessy]

Both halves.

[Lord Ramsbotham (CB)]

My Lords, can I press the Minister on the Green Paper? It is apparent that something must be produced as a matter of urgency. The much-respected Centre for Mental Health has for a long time been reporting on the inconsistency of the delivery of children’s services across the country. What is more, too many CAMHS are offputtingly clinical, formal and remote and do not relate well to children. This is something that we really must get on with, so the Green Paper is required as soon as possible.

[Lord O'Shaughnessy]

I agree completely with the noble Lord. As I have said, the Green Paper will be ready later this year. I am afraid that I cannot give him any more detail than that at this point.

Brexit: Risks to NHS Sustainability

Lord O'Shaughnessy Excerpts

Wednesday 12th July 2017 Lords Chamber

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

My Lords, I thank the noble Lord, Lord Warner, for obtaining this debate, and I assure him and your Lordships’ House that this Government are committed to making leaving the EU a success for the health and social care sector as well as for the UK as a whole. I thank all noble Lords who have contributed to the debate.

I have to say, as noble Lords probably expect, that I do not share the gloomy prospectus that has been set out for the NHS in the years ahead or for Brexit. My noble friend Lord Cormack asked for a bit of optimism and hope. He might be interested to know that my youngest daughter is called “Hope”, so I am a great optimist. I will explain why I am an optimist about how the years ahead will pan out for this country and for the NHS.

The sustainability of the NHS is, of course, a timely issue, not least because of the excellent report The Long-term Sustainability of the NHS and Adult Social Care, which the noble Lord, Lord Warner, produced earlier this year. I pay tribute to how well that was marshalled by the noble Lord, Lord Patel, who was in his place earlier. I reassure noble Lords that the response to that report is being drafted, so work is in progress and the response will be coming shortly.

As noble Lords will know, the organisation and delivery of healthcare is a member state competence, and this means that the vast majority of the work to implement the NHS five-year forward view will remain relatively unchanged and will continue to have the full support of this Government. While I am on the subject of policy, the noble Lord, Lord Hunt, asked what happened to Dilnot and social care. As he will know, and as I have said before on the Floor of the House, we intend to consult on both a cap and a floor within the social care funding sector, which is in essence what is at the heart of Dilnot. We will be coming forward with proposals that build on that later this year.

The ongoing work of the department and of the entire health sector is to transform how the NHS delivers care to ensure that it is properly configured for the future and that it remains both sustainable and fit for purpose after we exit the EU, and for many years after that. I completely concur with the statement made by the noble Lord, Lord Clark, that not only is it the most efficient healthcare system in the world but that it delivers wonderful care. Despite the ageing and growing population, it has had a number of successes in recent years: real-terms increases in funding, a greater share of public spending, more people being seen in A&E and seeing specialists for cancer, more doctors and nurses, and rising life expectancy. Public perception as measured in a ComRes poll at the start of the year shows support of the statement that the NHS provides a high standard of care to patients was up 13 points to 71% compared to 2014.

The noble Lord, Lord Clark, who speaks with experience on this, is quite right to point out the issue with sources of information. I can reassure him that I have plenty of friends who are either doctors or nurses, so I do hear from the coalface, if you like, and I know that it is not an entirely rosy picture at times. I pay absolute tribute to the work that our NHS staff and staff in social care do, often in very challenging circumstances. I reassure him that I try to expose myself to the realities of life in the NHS as much as I can.

As noble Lords know, following the publication of its Next Steps on the Five Year Forward View, NHS England is working with local areas to develop them into sustainability and transformation partnerships—moving beyond plans to develop tangible delivery organisations with clear partnerships between local organisations, fairly appointed leaders and clear governance structures. I welcome the support of the right reverend Prelate the Bishop of St Albans for this process, which has been backed by Treasury capital funding announced in the Budget. This is enabling the most advanced STPs, as they are known, to evolve into accountable care systems, which will provide joined-up, better care, breaking down the barriers between GPs and hospitals, physical and mental healthcare, and social care and the NHS.

The noble Lord, Lord Hunt, asked what the legislative framework for this is. I am sure that in the long run, the creation of ACSs, or ACOs as they are sometimes known, may require legislative change, but it is not currently necessary, and we can move ahead with the kind of integration that we all want to see. We are serious about improving care for local communities, and these steps towards integration and collaboration provide a mechanism to do just that.

By redesigning services to make it easier for patients to access health and social care at the right time, in the right place, we can make real progress in improving care for local communities. We can begin to move beyond sterile debates about reorganisation, while making sure—in response to the question asked by the noble Lord, Lord Hunt—that the five principles of when reorganisations should happen stay in place. Of course that became five recently with the addition of patient safety, which I think was a point raised by the right reverend Prelate and others.

As this debate has helped highlight, our work will need to be supported by a strong outcome from the Brexit negotiations. Since the result of the referendum, the Department of Health has worked hard to identify areas of the NHS that will be affected and to put in place plans to mitigate any risks and seize any opportunities. I completely agree with my noble friend Lord Cormack on the importance of working together. The Prime Minister has said just that, and it was rather disappointing to hear the leader of the Labour Party be so scornful of such an approach—I am sure that noble Lords on the Opposition Benches would not share their leader’s dismissal of the idea of working together.

The noble Lord, Lord Warner, described in his speech what could be rightly called the doomsday scenario. I think he is perhaps allowing his own beliefs and views of the referendum to cloud the reality. There is a strong desire to have a positive new relationship, and that is shared by the UK and the European Union. That is one that respects the nature of the European Union. That is precisely why the Lancaster House speech set out the position on the ECJ, the single market and the customs union: to respect the nature of the European Union, rather than to have our cake and eat it. It is important to note that more than 80% of votes in the most recent general election were cast for parties that support the process of leaving the European Union.

One of the main areas that noble Lords have highlighted is the ability to maintain our superb NHS workforce. I reassure noble Lords that we are doing our best to provide as much certainty as possible to the 3 million EU citizens in the UK, including the many who dedicate themselves to the work of the NHS and the wider social care system. It is simply not true that we do not value them; we do, and I never miss an opportunity to say so at this Dispatch Box.

Noble Lords will have seen that the Prime Minister has put forward a fair and serious offer on the rights of EU nationals already residing in the UK, and we expect it to be reciprocated by member states for UK nationals in the EU. There are approximately 150,000 staff from the EU doing a vital job for patients, and we expect and are confident that we will be able to negotiate for them to continue to do so post Brexit.

My noble friend Lord Cormack and the noble Baroness, Lady Ludford, asked about the impact of Brexit on recruitment from EU countries. As we have discussed in this House before, the introduction of the language test has been a much more significant factor affecting the flow of EU nationals into the health service. It is important to note that there are more EU nationals than ever working within the NHS.

In the same vein, we intend to protect the current healthcare arrangements for EU citizens who are ordinarily resident in the UK, an issue highlighted by the noble Baroness, Lady Ludford. We are confident that we can reach an agreement on this important issue early in negotiations. Indeed, there is already much common ground between the UK and EU positions. That is in respect of both the EHIC programme and pensioner benefits. The aim here is to achieve reciprocity, as my right honourable friend the Brexit Secretary, David Davis, has set out.

More broadly on immigration, we will continue to welcome the contribution that EU migrants make to our economy and society. We are considering options for a future immigration system very carefully. New UK immigration rules will be decided taking into consideration the prevailing social and economic circumstances, aiming to recruit the brightest and the best for our life sciences industry and to fill any skills gaps. It is important to state—and I state it to the noble Lord, Lord Hunt, and others—that the purpose of leaving the European Union is not to end immigration; it is to get control of immigration and to build public trust in the immigration system. Any immigration system will clearly need to take account of the economic and social needs of the country.

Turning to medicines, the UK is committed—through the FT article by my right honourable friends Jeremy Hunt and Greg Clark, as many noble Lords have noted—to continue a close working relationship with the EU on matters such as public health and medicines regulation. Indeed, we are planning an ambitious life sciences industrial strategy to make sure that we are one of the three global hubs for medical innovation. Our aim is to ensure that patients in the UK and across the EU continue to be able to access the best and most innovative medicines and to be assured that their safety is protected through the strongest regulatory framework. I point out to noble Lords the three principles set out in that letter: that patients should not be disadvantaged; that innovators should be able to get their products into the UK market as quickly and simply as possible; and that we continue to play a leading role in promoting public health. Whatever happens, as I said, we have set out our desire for a strong and positive relationship with the EU. Those will be our guiding principles.

Of course, that must be backed up by excellent research. As a nation, we have a proud history of leading and supporting cutting-edge research. Indeed, many of the innovations that take place in health systems around the world come from research that took place in the UK. I reassure noble Lords that the Treasury is honouring all Horizon 2020 and other EU-based research funding beyond the time horizon of leaving the European Union.

Finally, I turn to the issue of Euratom, which was raised by several noble Lords—the noble Lords, Lord Warner, Lord Clark and Lord Hunt. I understand that this evokes strong feelings, but it is simply wrong to say that cancer patients will be at a disadvantage after we leave Euratom, because it places no restriction on the export of medical isotopes to countries outside the EU. I acknowledge, in particular, the wisdom and experience of the noble Lord, Lord Clark, in this area, and I would be delighted to discuss it with him in person if he were able to make the time.

I now want to return to the beginning of the theme and talk about optimism. Uniquely, possibly, in the history of the negotiation of free trade agreements, we start from the position of regulatory equivalence. So we can do harm only by deciding to go our separate ways. I do not believe that there is any desire on behalf of the UK and the EU to do that. There are, of course, lots of questions to be resolved, and they have been highlighted in the debate today. I think they can be resolved if we take a positive view of what can be achieved as we go about honouring the decision of the British people to leave the European Union.

I can assure noble Lords that the Department of Health is working hard with a large range of stakeholders, and indeed with Members of this House, to work through the upcoming changes. We remain committed to ensuring that we have a sustainable NHS, free at the point of use, which continues to deliver high-quality care now and after Brexit.

House adjourned at 6.51 pm.

Older Persons: Care and Human Rights

Lord O'Shaughnessy Excerpts

Tuesday 11th July 2017 Lords Chamber

[Lord Foulkes of Cumnock (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I refer noble Lords to my entry in the register of interests.

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

My Lords, first, I congratulate the noble Lord on leading the production of this report. The Government are pleased to note its publication and look forward to contributing to the response. This Government’s ambition is to make the UK a good place for everyone to grow old, and we have put in place a programme of reforms across health, care, housing and other services to support older people to live independent and fulfilling lives.

[Lord Foulkes of Cumnock]

My Lords, I have no doubt at all about the Minister’s sincerity on this, but he will know that in the last few weeks Age UK, the Care Quality Commission, the King’s Fund and the Local Government Association have all produced reports showing problems and failings in the provision of services for older people in the United Kingdom. Will Her Majesty’s Government now discuss with civil society the implementation of the recommendations contained in the report?

[Lord O'Shaughnessy]

I certainly pay tribute, as the noble Lord does in the foreword of the report, to the growing trend towards strengthening the protection of older persons’ human rights. He is also right to highlight today and in the report that there are still widespread negative stereotypes. The Government are proud to lead the world in tackling age discrimination, and we published in February a strategy called Fuller Working Lives on that purpose. We are taking many actions to fulfil the requests in his report; one particular one that I would focus on from a health perspective is the fact that, by 2020, all medical curricula will include training for geriatrics, so there will be that additional support throughout the entire NHS.

[Lord Clark of Windermere (Lab)]

My Lords, I, too, congratulate my noble friend on producing such a brilliant report. One theme running right through the report is that ageism, like sexism and racism, is simply wrong. Does the Minister agree with that? In his response to the report, will he make it clear that the Government will not support ageism in general legislation or in any rules affecting this House?

[Lord O'Shaughnessy]

Rules affecting this House will, of course, be decided by its Members, who are probably the least likely group in the entire country to be ageist. The noble Lord is quite right to highlight this incredibly serious point. Any form of negative stereotyping or discrimination is, of course, wrong. I mentioned a couple of things that the Government are already doing and a lot is going on to counter any kind of discrimination. This Government have got more older workers into employment and are tackling the discrimination in the workplace that, unfortunately, still takes place.

[Baroness Barker (LD)]

My Lords, given the salutary experience of the general election, does the Minister now agree that the previous Conservative Government were wrong to kick the Dilnot commission recommendations into touch and that now would be the time to get that report back off the shelf, dust it down and hold proper discussions about the funding of long-term care?

[Lord O'Shaughnessy]

The noble Baroness is quite right that this is a nut we have to crack. The Government are going to begin consulting widely on proposals at the end of the year and this consultation will be on specific proposals rather than being open ended. As we have discussed in this House before, it is important that we do that in a spirit of consensus, because I do believe that there is a way forward which all parties can support.

[Lord Spicer (Con)]

My Lords, I declare an interest in the old and decrepit—I am one of them. Will the Minister confirm that much of what the noble Lord, Lord Foulkes, is saying is already standard practice in this country? Does that not bode well for the Brexit legislation when it comes forward?

[Lord O'Shaughnessy]

I do not know if we can relate this to Brexit, but we can always try. The UK has a good record in this area. There are 14 specific recommendations in the report authored by the noble Lord. We are doing good things on personal budgets and on encouraging volunteering for the over-50s—so there is a lot of work going on in this country that we can be proud of.

[Baroness Howe of Idlicote (CB)]

My Lords, given that in future we will be looking at older people being very old indeed—up to about 150—what are we doing to think about their lives and about care for them beyond that age?

[Lord O'Shaughnessy]

There is a prospect to look forward to. If we will be living to 150, there are a lot of middle-aged people in this Chamber. The noble Baroness is right. There is a particular issue around frailty as people move into old age. That is why the GP contract introduces responsibility to look out for frailty, as well as making sure that there are named GPs for the over-75s and, if necessary, annual health checks, to make sure that there is both health and social care provision for older people.

[Baroness Wheeler (Lab)]

My Lords, my noble friend is to be congratulated on his excellent report, bringing together key issues that would enable older people to maintain their independence, dignity and quality of life and to receive the care that they need. The report underlines the importance of countries having an enabling legal framework for the provision of integrated health and social care. What action will the Government therefore take in the light of the conclusions of last week’s IPPR report, which calls for our existing national legislation to be amended to enable pooled budgets and integration, and also says that if everybody has to carry on working round the 2012 Act, as at present, STPs and accountable care systems could both be blocked?

[Lord O'Shaughnessy]

I will read the report that the noble Baroness mentioned. She is quite right that integration of health and care budgets is the way forward, particularly as the burden of disease changes away from infectious diseases towards lifestyle and complex diseases of old age. The better care fund is beginning to start the kind of integration she is talking about, but of course we need STPs and accountable care systems, as set out in the five-year forward view. We feel there is, at the moment, the legislative freedom we need to move ahead with that.

[Lord Laming (CB)]

My Lords, the Minister will recall that last week there was a question about the number of residential homes for older people that were failing to provide adequate care. The temptation in some circles is simply to say that these homes should be closed down. The human rights of these very vulnerable people are bad enough when they are getting inadequate care; it is even worse when they are threatened with homelessness at this advanced stage in their lives. Will the Minister and his department give some thought to how failing homes could be tackled more effectively without creating homelessness for very vulnerable residents?

[Lord O'Shaughnessy]

The noble Lord makes an excellent point—and with great authority, as ever. The CQC report published last week indicated an improving picture, but clearly too much care is not up to scratch. One of its more heartening findings was that 80% of settings that had been deemed inadequate had improved by the time of the next inspection. It is clearly not right just to go in and start closing these homes: they need support to improve. As we are talking about care, it is worth bearing in mind also that the CQC report indicated that 98% of settings were deemed good or outstanding on caring. That goes to the heart of the fact that the people working in the care sector really do care and have been found to do so.

Adult Social Care Services

Lord O'Shaughnessy Excerpts

Thursday 6th July 2017 Lords Chamber

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

My Lords, with permission, I shall repeat as a Statement the Answer given by my honourable friend the Parliamentary Under-Secretary of State in response to an Urgent Question in the other place. The Statement is as follows:

“Mr Speaker, there are few things more important to any one of us than the way in which the eldest and most vulnerable are cared for in our society. First, let me pay tribute to the 1.4 million people who work in this country’s social care sector. They support many of the most vulnerable people in our communities in the most difficult of circumstances.

I am proud that we have done more than any Government before to improve the quality of social care: introducing a tough system of CQC ratings; new qualifications for care workers; and new standards to ensure that everyone receives the highest-quality support. I am heartened that today’s CQC report, in a time of fiscal pressure, shows that 79% of providers were rated good or excellent.

The announcement that my right honourable friend the Health Secretary made on Monday set out a clear package of measures to reduce the variation highlighted by the CQC today. It is impossible to ignore the pressures that our ageing population and advances in medicine are putting on the social care system. We have seen the numbers of over-65s increase by nearly 1.2 million, or around 14%, over the last five years, and today’s CQC report shows that in some areas it is completely unacceptable that standards in some settings are below those rightly expected by care users and their families.

This Government view social care as a priority, which is why the spring 2017 Budget announced an additional £2 billion to councils in England over the next three years to spend on adult social care services. This means that in total councils will have access to £9.25 billion more dedicated funding for social care over the next three years, enough to increase social care spending in real terms. We have also been clear that later this year we will be consulting widely on the future of social care in this country, to put it on a stable footing for the future and address issues related to the quality of care and variation in practice.

My right honourable friend the Health Secretary updated the House on Monday about action we are taking to address delayed discharges from hospitals in advance of this winter. Last year, there were 2.25 million delayed discharges, up 24.5% from 1.81 million in the previous year. This Government are clear that no one should stay in a hospital bed longer than is necessary: it removes people’s dignity, reduces their quality of life, leads to poorer health and care outcomes for people, and is ultimately more expensive for the taxpayer.

Since February, there have been significant improvements within the health and care system, with a record decrease in month-on-month delayed discharges in April 2017. However, we must make much faster and more significant progress well in advance of next winter to help free up hospital beds for the sickest patients and reduce pressures on A&E, which is why we have introduced a package of measures to support both the NHS and local government to reduce delays. This package includes guidance, a performance dashboard, plans for local government and the NHS to deliver an equal share of the expectation to free up 2,500 hospital beds, and CQC reviews. We have also been clear that we will consider a review, in November, of 2018-19 allocations of the social care funding provided at spring Budget 2017 for areas that are poorly performing. We have been clear that the Budget funding will all remain with local government to be used for adult social care”.

[Baroness Wheeler (Lab)]

My Lords, I am grateful to the Minister for repeating the Answer, but once again the Government seem to be in complete denial about the reality of the situation facing us in social care. A year ago, the Care Quality Commission first warned that social care could be approaching a tipping point. Today, Andrea Sutcliffe, Chief Inspector of Adult Social Care, has said that,

“the danger of adult social care approaching its tipping point has not disappeared. If it tips, it will mean even more poor care, less choice and more unmet need for people”.

Why have the Government neglected to tackle the issues facing our social care sector and failed to give it the money it needs? This report highlights safety concerns in one in four care homes. Age UK described choosing a care home as Russian roulette. Does the Minister believe that it is acceptable to force people to take these kinds of risks with their loved ones?

According to the Care Quality Commission report, 4,000 fewer nursing-home beds are now open than in March 2015. Is the Minister concerned about this drop, and what actions is he taking to ensure that there are enough nursing-home beds for those who need them and enough nurses to staff them?

This week marked the sixth anniversary of the Dilnot commission report into social care. The Government accepted the commission’s recommendations; they legislated for them; and they announced that the cap on personal funding would be £72,000, after which the state would intervene. Why did the Government abandon all that in favour of their ill-fated dementia tax? Why are this Government no closer to finding a solution for funding social care? Can the Minister tell the House why his Government have wasted seven years and failed to take any action to solve the social care crisis?

[Lord O'Shaughnessy]

I shall respond to the several questions that the noble Baroness asked. She is right that the CQC made that warning last year, and that is precisely why the Government have chosen to put in additional money—£2 billion extra was announced in the spring Budget—to support the social care system and provide real-term increases in funding.

It is worth pointing out that today’s report shows that 79% of care settings received a good or outstanding rating, compared with 72% last year. There are obviously differences in the kinds of settings that were inspected; nevertheless, it shows an increase in the number of good or outstanding settings.

I completely agree with the noble Baroness’s point about patient safety. I think that the phrase “the Mum test” is both accurate and evocative. Clearly, nobody wants to choose care settings that do not pass that, and any care that is inadequate is unacceptable. However, the reason we have that information about unacceptable care settings is that this Government, in coalition with the Liberal Democrats, introduced a very tough inspection regime in 2014. I believe that today’s report shows that four out of five settings that were judged inadequate on the first inspection had improved on reinspection, so the inspection regime is itself a critical part of dealing with the issue that she rightly points to.

The noble Baroness highlighted the number of beds and staffing. Around 165,000 more staff are working in the care sector, but of course care is moving more from residential homes to domiciliary settings, so the nature of care is changing there. However, more staff are going into the service and they are now being paid the national living wage.

Finally, it is fair to say that no Government have a completely unblemished record in getting to grips with the problem of funding care. The Labour Government had Green Papers, royal commissions, the Wanless review and so on; we have had other investigations. However, to go back to the beginning, the point is that we cannot wait any longer—we need to get on with this—and that is why I set out in the Queen’s Speech debate last week that the consultation that we will publish at the end of this year will look not just at an open question but at very specific proposals around floors and caps, and I hope that we will be able to build a consensus on the need to move forward.

[Baroness Walmsley (LD)]

My Lords, quality improvement is really urgent given that, as the noble Baroness, Lady Wheeler, said, one in four settings was found by the CQC either to be unsafe or to require improvements in safety. Safety is fundamental when you are looking for a setting for one of your loved ones. Given that, according to the CQC, the rate of improvement is slowing down in some settings and in others has deteriorated, does the Minister agree that a shortage of well-trained staff is at the root of this problem?

While we wait for the Green Paper, will the Government respond to the CQC’s second warning that social care is at a tipping point and inject some urgent cash into it? Many authorities, which really understand these issues, told us last autumn, when the extra money was announced, that it was really only half of what social care required to keep it at the same level, let alone improve, so some extra cash is urgently needed.

[Lord O'Shaughnessy]

I reiterate the point I made to the noble Baroness, Lady Wheeler. I completely agree that safety is paramount: it is the beginning of any good care setting. As I said, the new regime highlights issues of safety where they exist so that operators and commissioners, whether that is local authorities or whoever, can demand turnaround in those services. As I said, the response to that has been demonstrated.

I mentioned that more staff are, of course, getting the national living wage, which will continue to attract people to the sector. The noble Baroness is quite right about skills, which is why we have the skills for care programme.

It is also worth pointing out that one thing the CQC report did show, as indeed you would hope it would, is that 79% of settings provided either good or outstanding care. There is no doubting the motivations of the people who work in this sector, and we all pay tribute to them. It is about making sure that there are enough of them and that they are properly skilled. That is precisely why we have put additional money into social funding, to enable real-term increases over the next three years to address the fact that we have an ageing and growing population.

[Lord Warner (CB)]

My Lords, I declare my interest as a member of the Dilnot commission. I am sure we all welcome the idea of a longer-term set of proposals for consideration later. However, does the Minister not realise that the money the Government have said they are putting in over the next three years, including the current year, merely puts back a lot of the money that was taken out before, and certainly does not meet the proposal for immediate funding made by your Lordships’ Select Committee on the sustainability of the NHS and by the King’s Fund? This year, the Government are about £1.5 billion to £2 billion short to meet the needs. Does the Minister understand that this is not just about quality but about quantity? People working in publically funded care are leaving in droves. Is this on the Department of Health’s risk register? What are the Government going to do if the tipping point is reached on providers not providing publically funded social care?

[Lord O'Shaughnessy]

First, I congratulate the noble Lord on the work he did on the Dilnot commission in setting out the challenges we face and the kinds of solutions that we need to put the sector on a long-term footing. I merely reiterate the point that extra funding is going in, at a time when we are still addressing the £150 billion deficit that the Government inherited in 2010. That is enabling real-terms increases. Of course we need to keep going with that, because there are more older people and their care is increasingly complex.

I want to come back to the changes we are making on delayed transfers of care. Making sure that the interface between the NHS and social care is as quick, smooth and suitable for patients as possible is critical. That is why there is renewed emphasis to make sure that the money going in is addressing one of the major problems that is preventing the quality of care that we want.

[Baroness Browning (Con)]

My Lords, will my noble friend consult the CQC on a rather intimate but difficult problem? Elderly people admitted to busy trauma wards with fractures that result in them not being able to weight-bear very often find that, when they press the bell for the loo, they are not able to access a commode and there is no time for a bedpan. They end up being consigned to using adult nappies for an unnecessary long time. That has a knock-on effect on both their ability to rehabilitate and if they subsequently go into nursing or residential care. This is an outrage. Tackling this would save money and give more dignity to elderly people, but it is not something that one hears talked about very much. I have witnessed this happen with my elderly relatives and ask the Minister to take a look at it

[Lord O'Shaughnessy]

I am sorry to hear that my noble friend’s loved ones have experienced that. She is quite right: not only would that inhibit rehab but there is also the question of the dignity of the patient. I shall certainly look at the issue and write to her.

[Baroness Pitkeathley (Lab)]

My Lords, the Minister has reminded us just how many consultations there have already been on this subject, most of them not moving us very far forward, sadly. It is welcome news, therefore, that the consultation will focus on solutions, not just problems. Does the Minister agree that if we are doing this for the long term—and it essential that we are—a whole-population solution and, dare I say it, a cross-party solution is required?

[Lord O'Shaughnessy]

The noble Baroness is quite right. We need to move forward on the basis of consensus, which is one thing that has been lacking in the past. There is no doubting the point we have reached: we cannot wait any longer and we need to move ahead. That is why we will do so, on the basis of consensus.

National Stroke Strategy

Lord O'Shaughnessy Excerpts

Wednesday 5th July 2017 Lords Chamber

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

My Lords, decisions about the development of disease-specific strategies are made by NHS England. Its current view is that, rather than focusing on specific diseases, it is better to promote plans and policies that cut across several disease areas. So, while there is not going to be a new strategy, stroke is high on the list of NHS England’s priorities in terms of both prevention and treatment.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Stroke is the largest cause of all adult disability in this country and costs billions of pounds in health and social care, disabilities and work and related costs. However, all the evidence from STPs is that they are not prioritising stroke care. They are focused mainly on acute hospital care rather than on commissioning the whole stroke care pathway, which provides the rehabilitation and community support that stroke survivors need. They are also very short on specifics on how preventive services for stroke or any other key services will be delivered or funded. With such overwhelming evidence from STPs that improvements to stroke services will stall or come to a complete halt, will the Government now put pressure on NHS England to review its decision not to renew the national strategy?

[Lord O’Shaughnessy]

I know that the noble Baroness has a deep commitment to ensuring the best possible stroke care. She is quite right to highlight the economic and personal costs of stroke. There is a good picture in this country in so much as mortality from stroke and the incidence of stroke have halved over recent years—so the picture is improving. The stroke strategy the noble Baroness mentioned was superseded in 2013 by a cardiovascular disease outcome strategy that is obviously broader but includes stroke. That builds on the work that has already happened. I am realistic about the fact that there is obviously more to do, but we now have a number of hyperacute centres that are rolling out new treatments, such as thrombectomy, which will help treat stroke and make sure that we bring mortality down even further.

[Lord McColl of Dulwich (Con)]

My Lords, is the Minister aware that the incidence of stroke in the Scotland is 40% greater than in England? That is surprising in view of the fact that Scotland spends 25% more on its health service. Could this have something to do with the obesity epidemic?

[Lord O’Shaughnessy]

Well, in order not to fall out with Scottish noble Lords, I shall not comment on that. Under successive Governments there have been improvements in stroke outcomes, which have come about through the centralisation and specialisation of care. That is not always popular because of what it does with reorganisations, but it is definitely paying dividends in England.

[Lord Rennard (LD)]

My Lords, there is very strong evidence that the number of strokes could be reduced nationally if there was better detection and appropriate treatment of atrial fibrillation. Will the Minister commit to a proper national screening programme to detect this condition and ensure that there is appropriate follow-up treatment for those diagnosed as suffering from atrial fibrillation?

[Lord O’Shaughnessy]

The noble Lord is quite right to highlight that issue. There is increased screening for atrial fibrillation as part of the community-based efforts to prevent the incidence of stroke, and that has been one of the factors that have reduced the incidence of stroke over the past few years.

[Baroness Oppenheim-Barnes (Con)]

My Lords, does my noble friend not agree that one of the most important issues is informing people about what is likely to cause a stroke if special care is not taken?

[Lord O’Shaughnessy]

I thank my noble friend for that question. She is quite right. That is why public health campaigns around both obesity and smoking—a cause I know the noble Lord, Lord Rennard, is also passionate about—are so important. That is why we are continuing to invest in those public health programmes that have led to the improving stroke outcomes that I have described.

[Lord Lansley (Con)]

My Lords, as a former chair of the All-Party Parliamentary Group on Stroke, I agree with the Minister that we have done tremendous things over the past decade and a half in improving acute care of stroke in this country—although there is more to do, such as getting all stroke patients into a specialist stroke unit. However, too often stroke patients find that there is something of a cliff edge when it comes to leaving acute care and going into the community. Will my noble friend look at the ability of NHS England and local government together to deploy the better care fund specifically to support rehabilitation and recovery in the community for a period after discharge from hospital?

[Lord O’Shaughnessy]

My noble friend is quite right to highlight that issue. I must congratulate him on the progress made in stroke treatment during his time as Secretary of State for Health. I shall certainly look at whether the better care fund can be used in the way that he has described.

[Baroness Masham of Ilton (CB)]

My Lords, does the Minister agree that there is fragmentation across the country and that care differs in some areas? Did the strategy not pull it together and pass on good practice to those less experienced?

[Lord O'Shaughnessy]

The noble Baroness is of course right that the strategy had that galvanising effect. As I said, it has been superseded by a broader cardiovascular strategy, which is leading to some of the improvements that I have discussed. The other thing to focus on is the fact that stroke is now being included in the new urgent and emergency care standards that are being introduced, which will ensure, and indeed require, that all stroke patients are seen within 14 hours by consultants who are stroke specialists. That is precisely about ironing out some of the discrepancies in actual practice that happen across the country.

[Lord Foulkes of Cumnock (Lab)]

My Lords, although I would hesitate to disagree with the noble Lord, Lord McColl, and his very helpful obesity advice, I fear that he is completely wrong in relation to public expenditure on the NHS in Scotland. If he had read today’s Scottish edition of the Times, he would know that it is being slashed in Scotland and that Scotland is facing problems in the health service even greater than those in the rest of the United Kingdom. Could the Minister apportion the blame? Is it the United Kingdom Government not giving enough money to Scotland, or is it the Scottish Government getting their priorities wrong—or maybe both?

[Lord O'Shaughnessy]

Can I first say how slim the noble Lord is looking? I do not think that it is a case of apportioning blame. All health systems, not just in the UK but around the world, are facing pressure from an ageing and growing population and from the incidence of lifestyle diseases. We are all trying to deal with them as best we can.

NHS: Working Conditions

Lord O'Shaughnessy Excerpts

Wednesday 5th July 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what proposals they have to improve working conditions for NHS staff.

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

My Lords, the Government are improving working conditions for NHS staff by recruiting record numbers of doctors and nurses over recent months. Furthermore, we are helping trusts to become employers of choice through more flexible working, improving staff health and well-being, and tackling bullying of and violence against NHS staff.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply, but it indicates to me that the Government are still in a state of denial. He talks about recruiting extra nurses. Has he seen the report last week that showed that for the first time ever there were more nurses leaving the profession than joining it? How does that stack up with his assertion that they are recruiting more nurses? Does he not accept that it is only on account of the dedication and commitment of all NHS staff, including doctors, nurses and ancillary staff, who on occasion work in appalling conditions, that the service is as good as it is? Why do the Government, as a first step, as a gesture, lift the pay cap so that the nurses and the doctors can have a salary that they deserve?

--- Later in debate ---

[Lord O'Shaughnessy]

I join the noble Lord in paying tribute to the commitment and selflessness of NHS staff. I am of course aware of the report that he talked about. That is why we need to increase the numbers of both nurses and doctors in training, which has happened. On pay, I think we all know that everybody has had to make sacrifices as we get the public finances in order. That is well understood. My right honourable friend the Secretary of State is shortly meeting the leaders of the Royal College of Nursing, for example, but of course any decisions on pay will be made as a consequence of the reports from the independent pay review bodies.

[Baroness Walmsley (LD)]

My Lords, in the 2016 NHS staff survey, 47% of staff who responded said that staffing levels were insufficient for them to be able to do their job properly. One in five GP training places were unfilled, mental health and community nurse numbers fell by 13%, and district nurse numbers fell by 42%. Given that workload is the major reason given for staff leaving the service, how do the Government plan to increase the number of patients treated in primary care and in the community as opposed to in acute settings in hospital, as recommended by a number of authoritative reports, including that of the Select Committee of your Lordships’ House?

[Lord O'Shaughnessy]

I can only reiterate that I recognise the pressures on the workforce. That is why we are recruiting more GPs and nurses. There are more than 50,000 in training, and we are aiming to get 5,000 more GPs into the NHS over the next few years. On the noble Baroness’s point about moving treatment out of hospitals and into the community, that is one of the core drivers of the STP process, which is about reorganising care so that it happens sooner and, ideally, in a preventive way rather than after the fact.

[Baroness Meacher (CB)]

My Lords, I think the Minister will be aware that GPs are routinely required to see, diagnose and treat 80-plus patients in a day. What plans do the Government have to ease that situation when it is still getting worse month by month and it is proving impossible to recruit GPs? In the meantime, until things improve, will the Minister have discussions with the CQC and the ombudsman about how best they should undertake their jobs, taking account of the horrendous pressures on NHS staff and on GPs in particular?

[Lord O'Shaughnessy]

The noble Baroness is quite right to talk about the importance of having more general practitioners. I have talked about the increases in recent years—there have been net increases of 5,000 over the last 10 years—and the fact that we are recruiting another 5,000 over the next few years. I do not pretend that it is easy to recruit them, but the numbers are increasing. One of the keys to solving this problem is through the new models of care. In its General Practice Forward View, which was published last year, NHS England demonstrated a renewed emphasis on general practice and reforming it. That is one way of ensuring that GPs can cope with what is of course an increasing workload.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I just do not understand the Government’s response to this very pressing question. Already, recruitment from other EU countries has ground to a halt because of the anti-EU rhetoric of the party opposite. In this country we now have a net loss in the number of nurses coming into the NHS. Is the Government’s policy to recruit nurses from overseas countries other than the EU, as we have for generations? If it is, and I hear that the NHS is recruiting hugely in those countries, does that not make a mockery of the Prime Minister’s ludicrous target to reduce immigration?

[Lord O'Shaughnessy]

As the noble Lord knows, we have talked about one of the reasons for the drop-off in nurses coming from the European Union; it is because of the stricter language testing. Stricter language testing was brought in for reasons of patient safety and was supported by the noble Lord when the regulations went through in 2015. Indeed, I think there was cross-party support for that. As for anti-EU rhetoric, I do not recognise that in anything that we have said. We absolutely value the contribution of anyone who is living and working here in the UK, and indeed have made a very generous offer to solve this problem as part of the talks for leaving the European Union. As for recruitment, of course we want to recruit as widely as possible. We want the brightest and the best to be here, and that is an absolutely core part of any immigration strategy.

[Lord Dobbs (Con)]

My Lords, are we not in danger of missing an important point in this discussion? Simon Stevens, the head of the NHS in England, recently talked about the abuse of the system by those who selfishly and drunkenly turn up at A&E on a Friday evening expecting the NHS to bail them out. There is the abuse of health tourism, and indeed abuse by those who simply fail to turn up their appointment. Is there not an abuse here that is costing hundreds of millions, if not billions, of pounds to the NHS, disrupting the service for those who really need it? Should we not be doing more to crack down on this abuse?

[Lord O'Shaughnessy]

I completely agree with my noble friend. That is one reason why we are taking steps to deal with health tourism and to ensure that people who not only abuse the system but actually abuse NHS staff, which unfortunately is far too prevalent, are properly prosecuted.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister explain how the STPs will be achieved without further investment in continuing professional development so that people such as paramedics and nurses can work effectively in the community?

[Lord O'Shaughnessy]

I can tell the noble Baroness that investment is going into STPs not just in recurrent spending for the purposes she described but, as was announced in the Budget, in capital spending to achieve the transformations that we all want to see.

Health: Medically Unexplained Symptoms

Lord O'Shaughnessy Excerpts

Tuesday 4th July 2017 Lords Chamber

[The Countess of Mar]

To ask Her Majesty’s Government who is responsible for ensuring the implementation by Clinical Commissioning Groups and hospital providers of the Guidance for commissioners of services for people with medically unexplained symptoms, published by the Joint Commissioning Panel for Mental Health.

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

My Lords, the Joint Commissioning Panel for Mental Health is not a government body and implementation of the guidance that it published is not mandatory. Regarding the classification of chronic fatigue syndrome and myalgic encephalomyelitis, or CFS/ME, the Government accept the World Health Organization’s classification of the illness as a neurological condition of unknown origin.

[The Countess of Mar (CB)]

My Lords, I am grateful to the Minister, although I am disappointed that we cannot pin anyone’s foot to the floor on this. There is no definition of medically unexplained illnesses in the paper mentioned in my Question, but in interpreting it, hospitals and other providers have somehow made CFS/ME a medically unexplained symptom and have recommended graded exercise and cognitive behavioural therapy as treatments. Graded exercise in many cases is known to make people sicker and to damage them, the scientific reasons for which are also known. Cognitive behavioural therapy has been shown to work for only about six months. The PACE trial which recommended cognitive behavioural therapy and graded exercise is now discredited, and NICE is reviewing its guidelines on it. Who is responsible for worsening the condition of patients who are advised or coerced into taking cognitive behavioural therapy and graded exercise?

[Lord O'Shaughnessy]

I congratulate the noble Countess on the important work that she does through Forward-ME on behalf of the illness’s sufferers. On who takes responsibility for the care of those suffering from CFS/ME, it is of course clinicians. They work to evidence of best practice, which is guided by NICE. She alluded to the fact that the NICE guidelines are being reviewed to make sure that we have the best possible understanding of what is effective in the treatment of the illness, but I reiterate to her the point that the Government’s acceptance of the WHO classification of it as a neurological disease has not changed.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the approach taken by the NHS and child protection services to CFS/ME and other unexplained symptoms has had a sorry history. Some clinical commissioning groups state with great authority that graded exercise and CBT are the appropriate response. The point made by the noble Countess is that in many cases they are not, and can cause damage. Unfortunately, where children are involved, patients who resist such therapies often find themselves in problems with child protection agencies—there was an excellent programme about this on Radio 4 over the weekend. Prior to the NICE guidance coming out, will the Minister look with his officials at whether CCGs might be given some rather more authoritative advice, because it is clear that some CCGs have got this wrong?

[Lord O'Shaughnessy]

I am certainly happy to investigate CCG practice and commit to write to the joint panel to make sure it understands both the nature of the classification of the illness and the fact of the NICE guidelines. Of course, those are guidelines for clinicians; they are not mandatory in themselves.

[Baroness Jolly (LD)]

My Lords, the commissioning of mental health services has a chequered past at best, particularly when involving many agencies such as in this case. However, good commissioning practice exists. What training is available for commissioners of such complex services and what opportunities are there for sharing innovative practice?

[Lord O'Shaughnessy]

Of course, a suite of training is available for those treating illnesses such as this one, which affects about 220,000 people in England. It is not a rare disease; unfortunately, it is far too common. That treatment is there and also a number of networks exist, such as the Academic Health Science Networks, to spread innovation and best practice for treatments around the NHS.

[The Lord Bishop of St Albans]

My Lords, many of us are glad to have this report published by the Joint Commissioning Panel for Mental Health on services for people with medically unexplained symptoms. There is a welcome stress in it on trying to get integrated care—a both physical and mental approach. Would the Minister comment on the need to have an integrated approach to the spiritual dimension of this as an essential aspect of addressing these medically unexplained symptoms?

[Lord O'Shaughnessy]

Of course, the difficulty for sufferers of these illnesses is precisely the unknown origins of them. There are obviously physical aspects—that is the whole point of this being a neurological condition—as well as mental health aspects in terms of dealing with it. No doubt, spiritual guidance and uplift can help those dealing with these awful conditions.