Health: Global Health

Lord Prior of Brampton Excerpts

Monday 26th October 2015 Lords Chamber

[Lord Crisp]

To ask Her Majesty’s Government what is their assessment of the report The UK’s Contribution to Health Globally, published by the All-Party Parliamentary Group on Global Health in June.

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

My Lords, I congratulate the all-party parliamentary group on producing its report. The Government are determined to maintain Britain’s strong global role and welcome the report’s suggestions as to where we can continue to play a leading role in health globally. The United Nation’s sustainable development goals provide added incentive to look critically at where we can add maximum value in improving health systems overseas.

[Lord Crisp (CB)]

I thank the Minister for that very encouraging reply. The UK is a world leader in health. This report, produced by researchers from the London School of Hygiene & Tropical Medicine, shows that we have extraordinary strength in research, education, commerce, development, the NHS and the NGO sector. Given that, does the Minister agree that it is time for the UK to develop a new global health strategy to use that all-round strength to help to improve health globally—but, at the same time, to strengthen the UK’s health, science and technology base? More specifically, does the Minister agree that the UK’s medical, nursing and healthcare schools could be supported to play an even larger role in training health workers in low and middle-income countries?

[Lord Prior of Brampton]

My Lords, I agree with all the sentiments that the noble Lord mentioned—and, perhaps, one other, which is that in a number of other pioneering areas, such as genomics, dementia and antimicrobial resistance, the UK is very much at the forefront. The Government are following up the “Health is global” strategy that was initiated back in 2008 and will be reporting back in detail in 2016. I assure the noble Lord that we will take fully into account the findings of the all-party parliamentary group.

[Baroness Gardner of Parkes (Con)]

My Lords, does the Minister think it would be wise for us still to be learning from other countries, instead of learning only globally? For example, we have an appalling record on pancreatic cancer compared with many other countries. Is it not time for us to improve those things, and then we will be better able again to help others?

[Lord Prior of Brampton]

I agree with the noble Baroness that there is always plenty that we can learn from other countries. She cited one example, and I am sure there are many others. There is never any room for complacency. Other parts of the world are also making huge advances. One of the findings of the all-party parliamentary group’s report is that we face increasing competition not just from countries such as America, but from South Korea and Singapore, for example. The noble Baroness is right: we must always learn from others.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the report is abundantly clear that the UK gains enormously from its work in other countries but it is also clear that, taking the point of the noble Lord, Lord Crisp, many of our universities are very inhibited in recruiting the overseas talent that reinforces the UK as a global leader because of Home Office policies restricting entry to work in our universities and other institutions. One of the report’s recommendations is that the Home Office review immigration policy in this area. Can the Minister confirm that his department is urging the Home Office to get on with it?

[Lord Prior of Brampton]

I understand that the Home Office is in the middle of this review and is due to report back later this year or early in 2016. It is also worth noting that this important report said we are No. 2 in attracting overseas students to come to England to train as doctors. I think America is No. 1.

[Baroness Northover (LD)]

My Lords, the life sciences are indeed an area in which the United Kingdom leads, as we have just heard. Will this Government be continuing the previous Government’s work in underpinning that lead through long-term investment? In particular, can the Minister assure me that the Newton Fund, which links research scientists in the United Kingdom with those in developing countries, will not be scaled back?

[Lord Prior of Brampton]

I can assure the noble Baroness that this Government are fully committed to supporting our life sciences industry. I will look into her specific question on the Newton Fund and write to her directly.

[Lord Patel (CB)]

Following on from the Question from the noble Lord, Lord Crisp, does the Minister agree that, given the predicted growth of about 15% in the healthcare needs of countries such as India and China, we have a great opportunity not only to promote education but to develop health expertise? Does he agree that we need to have a stronger relationship with these countries in health?

[Lord Prior of Brampton]

I completely agree with the noble Lord. According to the report, health spending is likely to increase by 8% per annum in Asia for the foreseeable future and by some 5% in the rest of the world. This is a huge opportunity. The NHS is arguably the best-value healthcare system in the world, and the many lessons we have learnt since 1948 will be valuable when we go overseas.

[Lord Judd (Lab)]

Does the noble Lord agree that as part of carrying forward the excellent report to which the noble Lord, Lord Crisp, has referred, it is essential to take into account the lessons learnt from the Ebola episode in Sierra Leone, and to ensure that the World Health Organization has adequate resources to give muscle to its work, and to co-ordinate the work of other departments and aspects of government that are essential in preparing for such epidemics?

[Lord Prior of Brampton]

The Ebola crisis was indeed a wake-up call. There is no doubt that the leading role we play in the WHO is hugely important, so I agree fully with the noble Lord. The work we are doing on antimicrobial resistance is another example of the very important role the WHO can play, as does our Chief Medical Officer, Sally Davies.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chair of University College London Partners and an officer of the all-party group. This report identifies that our country is No. 1 among the G7 nations in terms of the impact of its medical research, as judged by citation impact. How do Her Majesty’s Government propose to ensure that the NHS continues to develop the foundation for that medical research impact?

[Lord Prior of Brampton]

The noble Lord raises an interesting point. Not only are there more citations of research conducted in Britain, but we co-operate with other countries far more than any other country. We also have in the BMJ, the Lancet and Nature the three leading medical and science magazines. The Government are determined to maintain Britain’s position as one of the leading medical research and life sciences nations in the world, and will carry on supporting that industry.

Access to Palliative Care Bill [HL]

Lord Prior of Brampton Excerpts

Friday 23rd October 2015 Lords Chamber

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

My Lords, first, I join with everybody else in thanking the noble Baroness, Lady Finlay, for raising this issue and bringing the Bill before us. She has a long history of passion, commitment and experience in this area, and we all recognise that. There seems to be violent agreement from all sides of the House on the substance of her Bill, and so I congratulate her on the support that she has garnered, which of course goes way beyond noble Lords in this House.

Before I address the Bill directly, I want to draw out three themes that have emerged out of the debate today. The first is that, despite the report from the ombudsman and some very upsetting individual stories, the UK does pretty well in this area. My noble friend Lord Howard referred to the report in the Economist. For the second time—the first being five years ago—out of all 80 countries surveyed, the UK came top, and that includes all the richer nations. We come significantly higher than most other European countries. In part, that is because the hospice movement in the UK has been extraordinarily successful. My noble friend Lord Howard referred to the CQC report. It is quite extraordinary that 90% of all hospices inspected have been “good” or “outstanding”.

However, in praising the hospice movement and the care that it delivers at home, let us reflect for a minute on how difficult it is to provide good-quality palliative care in a very busy acute hospital. It is true that they probably do not do it as well as it is provided in hospices, but, given the circumstances, they often do a remarkable job. My noble friend referred to the bowl of porridge that was provided in a hospice. I refer him to the Wrightington Hospital, where a lady coming near to the end of her life said that her one last wish was to see her horse. They brought the horse to the hospital and wheeled her down to see it. We do see these extraordinary acts of kindness and compassion in NHS hospitals as well. That is the first point that I would like to make: the UK does this pretty well.

Secondly, the most important point to come out of today’s debate is the patchiness of how we do it. Variation, I am afraid, is a problem that runs right through the NHS. The noble Lord, Lord Davies, went right back to 1946. Whether it is in end-of-life care, orthopaedics, stroke care or cancer care, there has been this level of variation since the inception of the NHS in 1946. The way that this Government have decided to try to confront this level of variation is through transparency.

It is a fact that, outside healthcare, the only way to drive out variation is through a market—we all know that. If you have choice and competition, they will drive out variation. It is much more difficult in an area such as healthcare, where there is such imperfect information and such imperfect choice. Our approach is to try to confront this issue of variation through transparency. It is not just through CQC reports but through having a much more open culture within the NHS. I say to the noble Lord, Lord Warner, that choice is also a key factor in that, where it is possible.

The third key theme to emerge from this debate is the importance of out-of-hospital care. Where we can deliver good-quality, safe care outside hospital, it tends also to be at lower cost. If it is at lower cost, we have more resources to spend elsewhere in the system. I say in response to my noble friend Lord Howard that I know that Hospice UK is in discussions with NHS England about whether it can help us deliver more care outside hospital. Other noble Lords referred to the huge importance of district and community nurses. Delivering out-of-hospital care to people who are at the end of their lives requires considerable expertise; you need district and community nurses on hand to administer pain relief and the like. In the case of my own mother, who died very recently in an NHS hospital, it was essential to have people there all the time who could adjust the level of pain relief, oxygen and the like.

Those were the three general points that I wished to make. I am afraid, however, that the Government cannot support the Bill and I will set out the reasons why. The most important reason is not that we disagree at all with the underlying intention of the Bill—we are in full agreement with it—but that we do not feel that primary legislation is the right way of tackling the issues raised because it could lead to unintended consequences. Most importantly, we feel that it attempts to deal with issues that, in the main, are best tackled by clinicians, ideally together with patients, carers and loved ones, based on a combination of the patient’s individual condition, preferences and the clinician’s professional expertise.

There is no other part of the healthcare system, be it cancer, stroke, maternity—the beginning of life as well as the end of life—where we have the mandated system that is proposed in the Bill. I will withdraw the following analogy if it is not fair. When the Liverpool care pathway was introduced—I was a huge supporter of it—there many parts of the country and many hospitals where it was implemented sensitively and where it contributed greatly at the end of many people’s lives. Yet, because in some parts of the system it became a tick-box solution where people were ticking the box and missing the point, I sometimes feel that a top-down, central directive, be it through legislation or from another source, can interfere with best-practice decision-making. That is the primary reason why we oppose the Bill.

However, there is a second reason—it is probably less strong, but it is strong nevertheless. It is that we feel that the Bill goes against the whole concept and principle of local autonomy that was established in primary legislation through the Health and Social Care Act 2012. I accept that clinical commissioning groups are still in their infancy—they have only been there for just over two years—but they are bound by a duty to commission health services based on the assessed needs of their local population, and palliative care is included in that stipulation. There is also concern that legislation on this issue as set out in the proposed Bill could stifle local innovation by NHS bodies, including commissioners, as they seek to improve the quality of care and provision.

As well as the responsibilities given to the local commissioning bodies, the 2012 Act also enshrines specific responsibilities for health education and training on Health Education England. This Bill would supersede those provisions, thus undermining the role and responsibilities of Health Education England, which works in partnership with local training and education boards to commission and deliver appropriate training and education.

I could go on and talk about what the Government are doing in this area, but that is the fundamental point and I should probably leave it there. We have huge sympathy for the underlying intent of the Bill.

[Lord Elton]

My noble friend has put local autonomy at the centre of his argument. If local autonomy results in unacceptable variations between localities, will the Government be on the look-out for this? It has only been running recently, as my noble friend says, but will he keep it at the forefront of his watch? If it increases or does not diminish, then something will have to be done about local inequalities.

[Lord Prior of Brampton]

My noble friend makes a good point. There is tension in the health service between local autonomy, local accountability and the National Health Service. There has always been this tension. We believe that in driving up standards it is best to have the local autonomy. However we must also have transparency so that we know who is falling behind and who is forging ahead. As to transparency at a clinical level, I was talking to a former president of the Royal College of General Practitioners recently—she comes from a different political background from myself—and she said that within the DNA of all doctors is a huge sense of competition: they want to deliver better care than the next-door doctor. That is true of surgeons probably more than anyone, but also true of GPs, physicians and hospitals, and increasingly it will be true of CCGs as well. My response to my noble friend is that we are embedding a much higher degree of transparency into the system and it is through that transparency that we will drive improvement by highlighting the best and the worst.

[Lord Davies of Stamford]

On the matter of transparency, does the Minister agree with my point that it is important that the commission should be transparent vis-à-vis the patient and that there should be a policy of full disclosure to the patient of the diagnosis, prognosis and any implications involved or deriving from changes in treatment or changes of venue from, for example, hospital to hospice or otherwise?

[Lord Prior of Brampton]

I accept and agree with that. One should not underestimate that even sophisticated, well-informed people put huge trust in their clinicians. How many of us, confronted with a difficult diagnosis, say, “What would you do?”. That is the question that most people put to their doctors. Of course individual choice is extremely important, but the role of the clinicians and the trust that we as patients put into them should not be underestimated.

In conclusion, let me reiterate how much we support the underlying intent of the Bill but that we do not believe that legislation is the right way to address the problems that the noble Baroness has outlined.

Lyme Disease

Lord Prior of Brampton Excerpts

Thursday 22nd October 2015 Grand Committee

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

My Lords, I echo other noble Lords in thanking the noble Lord, Lord Greaves, for raising this important issue. I, too, have read a lot in the media over the past two or three weeks; that has been good in raising awareness of the whole issue, and I hope that this debate today will also do so. A big theme in the contributions from noble Lords has been the need to raise awareness, not just with the public but with GPs and clinicians.

I seem to be almost the only person in this room who has not had—if I may put it this way—a head-to-head relationship with a tick, but I can imagine that it was not a happy occasion for the noble Lord, Lord Greaves, or for others.

The briefing by the Lyme Disease Action group was excellent. It was measured, well-informed and very constructive, so I thank the group. Secondly, I know that Dr Tim Brooks, the head of the Rare and Imported Pathogens Laboratory at PHE at Porton Down, is very happy to meet with noble Lords or others who are interested outside the Chamber to discuss this in more detail.

I would like to deal with two issues before I talk more generally about the importance of awareness, treatment and research. First, the noble Lord, Lord Greaves, raised the issue of a national inquiry. I do not think that we will go down that route at this stage. Secondly, on the point raised by the noble Lord, Lord Patel, about the NICE guidelines on how early we should start treatment with antibiotics, I will take that up separately with NICE.

We recognise that Lyme disease is overwhelmingly the most important tick-borne infection in the UK, and we are aware that its incidence has risen severalfold over the past couple of decades. Even so, the UK has a much lower incidence of tick-borne diseases than the rest of Europe or North America—indeed, I believe it was in Lyme in New England where it was originally discovered. Many of the more deadly diseases do not occur here at all. However, as noble Lords have mentioned, Lyme disease can be acquired almost across the country now—in Richmond Park or in North Yorkshire. Therefore, it is important that doctors across the country can recognise the features of these diseases even if the patient lives in an area not hitherto associated with Lyme disease.

I will talk first about public awareness, an issue that all noble Lords have raised, particularly the noble Baroness, Lady Parminter; she described her daughter going off on a Duke of Edinburgh’s Award trip, which is a good illustration of the need for public awareness. To raise awareness among the public, the first line of attack should be on the tick. Public Health England is working with Liverpool University and others to survey tick populations and the organisms they host to determine risk areas across the UK. PHE, the charity Lyme Disease Action and various local councils and national park authorities produce public information leaflets on how people can protect themselves against tick bites and on what to do after a tick bite. Noble Lords might like to look on NHS Choices, for example, where they can see what a tick bite looks like, and if anyone would like any materials on this horrible disease, I would be very happy to distribute them later.

Early diagnosis and treatment of Lyme disease is the best way of limiting complications once a patient has been infected. GPs are, of course, at the front line of this. NICE and Lyme Disease Action produce guidance and training modules for GPs, and PHE has a helpline for doctors, as well as running GP training days. Specialist doctors have access to the literature on Lyme disease and are trained in the recognition and management of the disease within their higher professional training and continuous professional development. There is clearly much more that we can and should do in raising awareness. Of course, one of the difficulties is that many GPs never—or very rarely—come across a case of Lyme disease. Nevertheless, we can and must do more to raise awareness. That is possibly the most important thing that we should be doing.

Public Health England has a long and distinguished history of diagnosing infectious disease and developing tests for this purpose. A key principle is that the test should be able to recognise true cases of the disease and distinguish it from other conditions that might cause the same symptoms.

In Lyme disease, current tests rely on finding the organism, which is rarely present in the blood and so it would be looked for in tissue samples taken by a biopsy. This is impractical in general practice and, of course, not popular with patients. Rather than finding the organism, looking for the antibody response is the most productive diagnosis. The body produces the antibodies as it tries to clear the infection. If a patient is treated early, there will be insufficient antibodies in the blood so the test will also be negative. Tests taken early in infection, before enough antibodies have been made, also will be negative. Therefore, doctors should be aware that if symptoms persist a second sample should be taken at a later date when the antibodies have developed.

There is a routine test used by PHE of a commercial product used by many other national laboratories across Europe. Through an international, external, quality assurance scheme, the performance of these tests is compared regularly against more than 70 other state laboratories in Europe and meets the current high standard. Tests used by private laboratories may not be subjected to the same rigorous quality control and I think this is an important issue that has been obscured in some of the reporting by the media. There is no requirement for these labs to demonstrate the evidence base for their test and some tests inevitably will give a very high rate of false positive results. This is why some GPs and infectious disease specialists frequently will not accept test results from independent laboratories because they wish to avoid unnecessary or inappropriate treatment. Of course, I can totally understand how frustrating and upsetting that is for individual patients. PHE recognises limitations in the present tests, especially in early disease and in the subset of complicated cases, and is working with national and international partners to develop and evaluate new testing methods. It is a complex disease, it is a difficult disease and I do not think we will be doing ourselves any favours if we try to oversimplify it.

Turning to treatment, oral antibiotics are the mainstay of treatment for Lyme disease and are successful in the majority of cases. Of course, the earlier that the bite or disease is treated, by and large, the better. However, it is becoming increasingly apparent that in complicated disease, especially where there are significant neurological symptoms, more than one course of antibiotics may be needed and a course of intravenous antibiotics may sometimes be indicated. PHE has published a referral pathway for GPs to follow to ensure that problem cases are seen by appropriate NHS specialists.

Some patients suffer debilitating illness with symptoms that persist after treatment for several months or longer. What therapy is appropriate for these patients depends on whether symptoms are a function of persisting pathogen or a legacy of damage that the pathogen has left behind. More research is needed to identify the basis of these persistent symptoms and define effective treatments. As the symptoms may be non-specific, a key part of management is a careful investigation to ensure that other serious conditions are limited. I am reminded by a question this week in the House of Lords about post-polio syndrome. It seemed to raise very similar issues.

Patients need to have access to physicians with an interest in Lyme disease. Since the disease can be present in many different ways and can be confused with other more life-threatening conditions, in future this could be best done by establishing a network of interested NHS practitioners across the country with multidisciplinary experience. This issue was raised by a number of noble Lords and clearly is important.

On research, PHE has a long track record in infectious disease research both through its laboratories at Porton Down and in partnership with universities and international groups. This provides PHE with deep background knowledge and specific expertise and techniques. With the University of Liverpool, PHE is looking at new markers of Lyme disease infection and this is supplemented by work in the Czech Republic to evaluate potential test methods at different stages of disease by accessing a large clinic with a high throughput of Lyme patients. PHE is also exploring new concepts for both diagnosis and treatment through its relationships in the United States. Having a network of interested professionals across the country will enable further clinical studies to be undertaken if funding can be secured. Funding is clearly going to be extremely tight within the NHS. If we could secure funding from private sources as well, that would be a very sensible way forward.

This has been a very good debate. Just having the debate itself helps raise public awareness. A lot is being done but clearly there is a lot more that needs to be done. I reiterate the offer from PHE that if noble Lords would like a more detailed discussion with it, perhaps along the same lines as the discussion the noble Countess, Lady Mar, had at Porton Down with members of Lyme Disease Action, we are very happy to organise that.

[Lord Greaves]

Before the Minister sits down, will he comment on the suggestion that the pressure on the small charity LDA to provide help and advice in individual cases might be lessened by some sort of regional organisation: clinics, groups of GPs or whatever?

[Lord Prior of Brampton]

I think I mentioned that the intention is to have people with specialist knowledge of Lyme disease around the country. We feel that that would be a better approach than having a single centre.

Palliative Care

Lord Prior of Brampton Excerpts

Thursday 22nd October 2015 Grand Committee

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

My Lords, first, I congratulate my noble friend Lord Farmer for raising this debate. As my noble friend Lady Perry of Southwark said, the way we die is as important as the way we live. Nothing can be more important. Dying Without Dignity, which was produced by the Parliamentary and Health Service Ombudsman, shed light on a number of cases which were unacceptable and quite shocking, but we should take some comfort from the fact that we have a high degree of transparency. We are prepared to reveal things when they go wrong, and only by doing so can we learn from them and do better.

There are 350,000 expected deaths in England each year. Of this group, many people will require high-quality generalist end-of-life care, and 170,000 will require specialist palliative care. Many of these people receive good care at the end of their life. The fact that there are 12 unacceptable instances in the PHSO’s report should not lead us to believe that that is normal for most people. The most recent National Survey of Bereaved People (VOICES) report showed that three out of four people—75%—rated the overall quality of end-of-life care for their relative as outstanding, excellent or good. I accept that that 75% figure means that 25% of people did not have a good end of life.

Research by the Economist Intelligence Unit, which noble Lords have referred to in this debate, showed that the UK came out top of all 80 countries that were surveyed. Sometimes I feel that those of us who work closely with the NHS tend to beat ourselves up a bit more than we should. However, the fact is that end-of-life care is incredibly difficult. It is very difficult to manage; each case is very different. Therefore, that we come top in that world ranking is very important. One interesting part of that report is that,

“The biggest problem that persists is that our healthcare systems are designed to provide acute care when what we need is chronic care. That’s still the case almost everywhere in the world”.

The CQC has recently begun inspecting hospices. The chief inspector for the CQC said:

“I know from what my inspectors are finding”,

that,

“hospices provide amazing care and support for people at the end of their lives”.

More than 90% of hospices that it has inspected have been rated as good or outstanding.

It is quite easy to think that all deaths in hospital are bad and that somehow all deaths in hospital should be moved to a hospice or to people’s homes. It may be true that that is where most people want to go. However, I can give my experience of my mother, who died quite recently after 14 days in hospital. I can hardly imagine how someone in her state could have been treated at home. She needed constant changes of her oxygen levels, she had to be switched from dry to wet, and her pain relief—diamorphine—had to be changed constantly. You could have that care at home, but it would require 24/7 care at home from trained nurses with a doctor on call. My noble friend Lord Ribeiro referred to seven-day care, and there was seven-day care. In many of our hospitals we provide seven-day care. She had seven-day care with a senior consultant present throughout her stay, including over the two weekends she was there.

Last year, we introduced the five priorities for the care of the dying person to embed these principles in all end-of-life care settings, and we have seen widespread engagement from clinicians across the system to make those priorities a reality. This new approach replaced the use of the Liverpool care pathway, which was comprehensively phased out in July 2014. I echo the words of the noble Baroness, Lady Hollins, who said that many nurses and doctors implemented the spirit as well as the letter of the Liverpool care pathway. Of course, she is right that protocols and tick-boxes can sometimes drive the spirit out of what was originally intended. However, I know from experience that many nurses—Macmillan nurses and palliative care nurses—used the Liverpool care pathway in the way that it was originally intended to be used. On the other point that the noble Baroness raised about inequalities—she referred to people with learning difficulties—the CQC will undertake a thematic inspection that will report next year to look at inequalities and variations in the way that end-of-life care is administered, so she may wish to speak to the CQC and contribute to that.

I know that spiritual concerns, as raised by my noble friend Lord Farmer and other noble Lords, are particularly important to people at this time in their life, and the priorities reflect that importance. They rightly emphasise that care planning at the end of life must take account of the dying person’s spiritual and religious needs as well as their physical, emotional and psychological needs. If we are honest, we do not do dying well, but that is because it is extremely difficult to do well. It raises all kinds of emotions, such as guilt, as well as the sadness that is inevitable around a person’s death.

The right reverend Prelate the Bishop of Carlisle raised the incredibly important work that chaplains do in hospitals, and I agree with him wholeheartedly. Not just chaplains but the whole mass of volunteers who work with them give comfort and support not only to relatives and those who are dying, but also to the staff in hospitals who have to work closely in very distressing circumstances.

I would also like to highlight the work being done by the Dying Matters campaign, which focuses on raising awareness of issues around death and dying and encourages people to plan earlier and think about what is important to them at the end of life. I wonder how many people in this Room have realised only when someone close to them has died that there were things they wanted to say, but never said, and by then, of course, it is too late. I suspect it is part of the human condition.

We know high-quality care relies on good care co-ordination and planning tailored to individual needs and preferences. Electronic palliative care records, “e-packs”, which the noble Baroness, Lady Walmsley, referred to are a very important part of that, so that when someone has expressed a wish it is recorded and does not have to be repeated umpteen times to paramedics, A&E doctors, geriatric doctors and the like. I would like to come back to this in more detail if I can, but I am told that some 70% of CCGs have now got this programme under way.

I am also encouraged by CQC’s new approach to inspection and its welcome focus on end-of-life care. All CQC inspections of hospitals include looking at end-of-life care. Already a number of care providers have been inspected, including hospitals, hospices, care homes and GP practices. Not only has this identified areas for improvement, but it also allows CQC to highlight and celebrate excellent care where it exists. I reiterate that transparency is a very important part of the approach of this Government to all aspects of healthcare.

My noble friend also raised the important issue of guaranteeing access to a level of social care that ensures that the end of life is valued. We recognise the vital role that social care support plays for many people approaching the end of life and their families and carers. Timely access to a high-quality and responsive social care system is critical in supporting people to die in their setting of choice at the end of their life. It also helps to avoid traumatic and unnecessary admissions to hospital. Interestingly, the Economist Intelligence Unit report says,

“People have woken up to the fact that we may be able to save money overall to society by investing in dying better”.

We should perhaps not be talking about saving money. Nevertheless, it is often not only better for the individual, but can be cheaper if we provide better care outside acute hospitals. That is true, of course, in the treatment of many chronic conditions as well.

We want to give people more control over the health and care services they receive, including end-of-life care. We have been promoting greater personalisation in how services can be accessed. This means building support around individuals and providing them with more choice, control and flexibility in the way they access and receive care and support.

Once again, as I conclude, I thank my noble friend for highlighting this vital issue. I think there is a huge measure of cross-party agreement in this area and I look forward to discussing it further in the debate tomorrow with the noble Baroness, Lady Finlay, who is in the Room today. I end by saying that the Government are fully committed to improving standards across palliative and end-of-life care services.

Health: Parity of Esteem

Lord Prior of Brampton Excerpts

Tuesday 20th October 2015 Lords Chamber

[Lord Stone of Blackheath]

To ask Her Majesty’s Government what progress has been made in establishing parity of esteem between mental and physical well-being.

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

My Lords, we are committed to improving mental health services, putting them on a par with physical health services. We have already expanded our world-leading psychological therapy services. This approach is now being emulated internationally. For example, Sweden is now running a pilot project in Stockholm based on IAPT principles. We have also introduced the first ever access and waiting times for mental health and changed people’s attitudes towards mental health.

[Lord Stone of Blackheath (Lab)]

Thank you. Will the Minister study the Mindful Nation UK report, published today by the Mindfulness Initiative and the All-Party Group on Mindfulness? It shows that mindfulness-based cognitive therapy—MBCT—recommended by NICE 10 years ago for recurrent depression, can provide cost-effective interventions for a range of mental and physical health conditions. In fact, almost four in five GPs want to recommend MBCT, but only one in five has courses available in their area. Expanding mindfulness provision in the NHS could save £15 for every £1 spent. Also, I ask the Minister, mindfully, to look at the evidence in the report suggesting that mindfulness-based interventions could provide powerful support and engender compassion to help those thousands of health workers who are fraught by some of the stresses of working in the National Health Service today.

--- Later in debate ---

[Lord Prior of Brampton]

I look forward to reading the report; perhaps the noble Lord would like to send me a copy. I cannot comment specifically on mindfulness, but there is no doubt that talking therapies are having a big impact. The evidence shows that some 45%, perhaps up to 50%, of people who have been introduced to IAPT talking therapies—CBT, psychotherapy and the like—have experienced considerable improvements.

[Lord Patel of Bradford (Lab)]

My Lords, my understanding was that, in an effort to ensure parity of esteem between physical and mental health, clinical commissioning groups were directed to increase spending on mental health in line with the increase in their 2015-16 budgets. What evidence and assurances can the Minister give that that has taken place?

[Lord Prior of Brampton]

NHS England is committed to ensuring that every CCG in the land increases its spending on mental health. The general allocation to CCGs was 3.7%, and the CCGs’ commitment to spending 4.6% of their allocation on mental health will hold NHS England to account for achieving that.

[The Lord Bishop of St Albans]

My Lords, the NSPCC report on achieving emotional well-being among young people in care found that 45% of them experience mental health problems, many of which continue to remain undiagnosed. It recommends that those young people should have not only an automatic physical health assessment but an automatic mental health assessment. Will Her Majesty’s Government consider introducing legislation to give that right to all young people as they enter care?

[Lord Prior of Brampton]

I am not sure that legislation is necessarily the right way forward, but perhaps we can pick up that issue with NHS England to ensure that it is written into the NHS mandate for next year. It is certainly something I will explore with them. It is worth noting that we are spending £94 million a year on IAPT for children, and we have increased spending on tackling eating disorders in young people by £150 million over the course of this Parliament. We are beginning to rectify what has historically been an area of huge underfunding of mental health for young people.

[Baroness Browning (Con)]

My Lords, I support the plea from the noble Lord, Lord Stone, to my noble friend on mindfulness. We have a very active mindfulness group in this Parliament and I hope that my noble friend will encourage all colleagues to sample it for themselves.

When people present at a GP surgery with mental health problems, there are still far too many GPs who reach for the prescription pad. If we really are to get parity of esteem, GPs need more training in mental health and need to be able to access referrals close to their surgery for talking therapies and other such solutions, rather than just reaching for the prescription pad.

[Lord Prior of Brampton]

My noble friend makes a very good point: reaching for medication is often not the right way forward. I am not sure how much time in the undergraduate syllabus is reserved for mental health training. However, I know that a considerable amount of time is set aside for it, so that people who decide to become GPs will have had some training in mental health before they qualify. Only last week, I was talking to Clare Gerada, who was the president of the Royal College of General Practitioners. She said that she thought the best combination of all was for a GP to have studied psychiatry as well.

[Baroness Brinton (LD)]

My Lords, it is encouraging to hear the new Government continue the priority that the coalition Government gave to improving mental health access for everyone, and specifically for children. I am also encouraged to hear the Minister talk about waiting time targets. However, surely true parity of esteem will be reached when we have targets for CCGs and, if they miss them due to lack of funding and the appointment targets are missed, that is publicised in the same way as missed A&E targets.

[Lord Prior of Brampton]

That is a very interesting point. We have three principal targets for mental health: two relate to IAPT and the other to access for those who have their first psychotic episode. Clearly, we do not yet have the range of targets for mental health that we have for physical health, although the introduction of those three targets this year is a big step forward. It is important that the targets should be based around outcomes rather than funding.

[Lord Bradley (Lab)]

My Lords, the five-year investment in child and adolescent mental health services is welcome, but the scale of the problem of achieving parity of esteem is huge, as a recent NSPCC report clearly showed. It stated that out of over 186,000 cases referred by doctors from 35 mental health trusts, nearly 40,000 children received no help at all. The investment equates to barely over £1 million per clinical commissioning group each year. Does the Minister believe this is sufficient not only to tackle the chronic bed shortage and the distribution of such beds across the country, but to develop comprehensive prevention and early intervention programmes?

[Lord Prior of Brampton]

The noble Lord makes a good point. I may get these figures wrong, but I think the total spend on mental health across the country is about £11 billion a year, and spending on children and young adolescents is under £1 billion—around £700 million. Therefore, under 10% of the total spend goes on young people. On the face of it, that looks to me to be far too low. That is why the last Government committed to increase that spending by £1.25 billion over the course of this Government and put another £150 million into tackling eating disorders.

Health: Post-polio Syndrome

Lord Prior of Brampton Excerpts

Tuesday 20th October 2015 Lords Chamber

[Lord Hunt of Kings Heath]

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

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

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Prior of Brampton]

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

[Lord Walton of Detchant (CB)]

My Lords, is the Minister aware that the poliomyelitis virus attacks the nerve cells in the brain stem and spinal cord which give origin to the nerves that control the movement of the muscles, and, hence, that if these cells are killed, the result is paralysis of the relevant muscles? Several authorities believe that in an acute attack of poliomyelitis, certain nerve cells are damaged but recover, only to die prematurely some years later, thus causing the post-polio syndrome of progressive muscular weakness. Would not one important strategy be to have a graded exercise programme to try to increase the power of those muscles that retain a viable nerve supply?

[Lord Prior of Brampton]

The noble Lord is much better informed about this than I am, and of course I agree with him 110%. However, there are other aspects to treating this pernicious illness; clearly pain relief is important. It raises the issue that GP practices having a multidisciplinary team—physios and people who are experts in mobility, orthotics, pain relief and exercise—is very important.

[Baroness Walmsley (LD)]

My Lords, people with post-polio syndrome often require the care of a wide range of different specialists, which makes the linking up of their care and treatment particularly crucial. What are the Government doing to ensure that these can be linked up? Could the Minister say whether any of the vanguard sites are working on partnerships that will enable this to happen?

[Lord Prior of Brampton]

NHS England’s approach to most people who are suffering from long-term conditions is best summed up through its House of Care programme, which is very much based around the individual and their carers and so is personalised. Of course, personal health budgets can have a big role to play for people with long-term, complex, chronic conditions.

[Lord Brooke of Alverthorpe (Lab)]

Is the Minister entirely content with the change that has taken place whereby we do not develop single-disease strategies? I speak as a patron of the British Liver Trust. We have long argued that there should be a strategy on liver disease, but this has been resisted. We find an increasing number of people dying from liver cancers, yet no strategy exists because of the decision that the Minister explained to us.

[Lord Prior of Brampton]

I agreed that I would meet with the noble Lord opposite to talk about post-polio syndrome, but perhaps this raises wider issues, including about liver disease and other disease categories, which we can cover at the same time.

Mental Health Services

Lord Prior of Brampton Excerpts

Monday 19th October 2015 Lords Chamber

[Lord Patel of Bradford]

To ask Her Majesty’s Government how they will improve mental health services, as outlined during Prime Minister’s Questions on 16 September (HC Deb, col 1039).

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

My Lords, the Government are committed to putting mental health on a par with physical health. We invested more than £120 million to introduce the first waiting times standards for mental health services from April 2015. We have expanded access to psychological therapies. Our crisis care concordat has ensured that we have halved the number of cases of people going through a mental health crisis being held in police cells.

[Lord Patel of Bradford (Lab)]

The Minister gave three significant areas of development. First, on the investment to introduce the first waiting times standards for mental health services from April 2015, will the Minister say what the results of the waiting times standards have been in the first quarter, from April to June? Secondly, he mentioned the expansion of IAPT services, but as I understand it there is no ring-fencing for IAPT services. What evidence and assurance can the Minister provide that these services are being provided across the country, especially for children and young people?

Finally, the Minister mentioned the excellent crisis care concordat, which says that we have halved the number of people in crisis being held in a police station. He will be aware that just this June the CQC report said that people in mental health crises, even those who are suicidal, are not getting the care that they need in emergency situations. What assurances and steps are the Government taking to deliver care to those people in an emergency situation?

[Lord Prior of Brampton]

My Lords, very briefly on those three points, we will have the waiting time results for IAPT tomorrow. I will publish them in the Library and write to the noble Lord. On the ring-fencing point, the IAPT part of the £150 million extra spending on CAMHS is not ring-fenced, but the £150 million is in total. We will wait to see the results on how effective the IAPT spending is before we come to a final decision on how much should be spent on IAPT and on other parts of the care budget. On the noble Lord’s third point, the CQC published its report, Right Here, Right Now, some six months ago. It found that things were getting better, but there was still far too much variation. By using that report and encouraging local crisis care concordat teams, we hope to address that variation.

[Baroness Tyler of Enfield (LD)]

My Lords, given the current paucity of mental health services in meeting rising demand, will the Minister say what steps the Government are taking to ensure that money earmarked for mental health services is spent on mental health by clinical commissioning groups?

[Lord Prior of Brampton]

It is too early. I cannot give the noble Baroness specific figures for last year’s spending, but we believe that they will show an increase of some £300 million over the year before. We have made it very clear to NHS England in the mandate that we expect spending on mental health services to increase this year and that every CCG in the country will see a real-terms increase in mental health spending compared with the previous year.

[Lord Winston (Lab)]

My Lords, we are very grateful that money is being spent on waiting times, but will the Minister be kind enough to comment on a particular situation that occurred just a few weeks ago? The husband of a colleague of mine had a severe manic episode and was in a hospital casualty department for the best part of the day and the whole night, most of the time not being seen. He waited for two days before a bed could be found, not at that hospital, nor at his local mental hospital. Eventually, a bed was found some distance away. Does the Minister feel that that is satisfactory?

[Lord Prior of Brampton]

The noble Lord makes a very good point. It is totally unsatisfactory that beds are not available for people suffering a severe mental health crisis. However, looking at the research done by the noble Lord, Lord Crisp, it is not the number of beds that is a problem, but the use of the beds we currently have. Far too many people still in in-patient beds could be treated outside. The answer is not more beds, but using the beds we have more effectively. I completely agree with the noble Lord. What he described I have seen myself. It is totally unsatisfactory.

[Baroness Fookes (Con)]

My Lords, will my noble friend look very closely at mental health provision in prisons, where a disproportionate number of people have mental health problems? This is a matter of many years’ standing.

[Lord Prior of Brampton]

The noble Baroness makes a very strong point that people with mental health problems who are in prison should be entitled to exactly the same care as people who are not in prison, and the extent to which that is not the case should be addressed. It is an issue that I will certainly take up outside the House.

[The Earl of Sandwich (CB)]

My Lords, I am sure the Minister knows about the ill effects of many very common prescribed drugs, which can contribute to mental illness. I have experience of that in my own family. However, is he also aware that there are no significant government services for those mental health patients? Will he follow the lead of the BMA, which is preparing a document right now on that subject?

[Lord Prior of Brampton]

I am not aware of the report being prepared by the BMA but I will certainly be very interested in seeing it, reading it and discussing it with it.

[Lord Bradley (Lab)]

My Lords, I declare my health interests. Although I welcome the ban on the use of police cells as places of safety for children under Section 136 of the Mental Health Act by July 2016, barely nine months away, does the Minister believe that the £50 million investment in health-based places of safety will be sufficient to achieve a similar ban on the use of police cells for adults and significantly reduce the thousands of adults who end up in accident and emergency departments each year under Section 136 at a time of severe mental crisis?

[Lord Prior of Brampton]

The noble Lord makes a very good point. Treating people in the right place is fundamental to any notion that we have of parity of esteem. He recognises the successful work that has been done with children, which we are hoping to replicate with adults. As part of the increased spending on mental health, we are also investing £30 million in liaison services in A&E departments, which is very important. A&E departments are not an appropriate place for people with a severe mental health crisis. Certainly, the evidence from Right Here, Right Now, by the CQC, indicates that people with such a condition are often treated extremely badly in A&E departments.

Social Care and Support: Funding

Lord Prior of Brampton Excerpts

Monday 19th October 2015 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they propose to take to address the concerns about the availability of social care and support funding expressed in the joint statement Spending Review 2015: a representation from across the care and support sector.

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

My Lords, social care is a priority for this Government, which is why we have established the better care fund to join up health and social care. We recognise that there are pressures on the system and we welcome the joint spending review representations from the care and support sector in helping us to understand these fully. The representations from the sector will help inform spending review decisions. The review will be announced on 25 November.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. I emphasise that this very stark submission to government represents the collective view on the deepening social care crisis from care providers, commissioners and national organisations from across the private, public and voluntary sectors. While understanding that the Minister will not pre-empt the spending review, will he at least reassure the House that, in making the very welcome decision to introduce the national living wage from April next year, the Chancellor fully recognises the estimated additional £2.3 billion cost of this for the social care sector? Does he honestly expect councils to be able to meet this cost if the scale of cuts made over the last five years continues into the future and the Government fail to provide any substantial extra funds?

[Lord Prior of Brampton]

As regards the position of the social care sector, “fragile” is putting it kindly. It is very difficult; there is no point making any bones about that. The increase in the living wage, which is long overdue and very welcome, will add to pressures on the sector. It was made very clear in the Five Year Forward View that the future of the healthcare system is very much tied up with the future of the social care sector. The noble Baroness can be assured that we have brought that to the attention of the Treasury and we are waiting for a favourable result in November.

[Baroness Brinton (LD)]

My Lords, the social care sector is in a perfect storm, with councils having faced a 30% cut in their social care budgets as well as the increase in the national living wage which—much as it is welcomed—it is estimated will cost an extra £1 billion. I ask the Minister once again: will the Government commit to spending the extra £6 billion that they are saving by not implementing Dilnot and ring-fence that money to support the social care sector through this very difficult time?

--- Later in debate ---

[Lord Prior of Brampton]

I thank the noble Baroness for those comments. I do not recognise the size of the cut to which she alluded. The figures that I have seen indicate that in cash terms it has been broadly neutral over the last four years, representing a real-terms cut of probably more like 10%. However, I think we are cavilling over numbers here because I agree with her broader comments about the state of the social care sector. We have, indeed, noted the savings gained from the delay in implementing the Dilnot proposals, which have been brought to the attention of the Treasury.

[Baroness Pitkeathley (Lab)]

My Lords, while I recognise the Minister’s concern about the spending review, does he accept that the lack of proper provision of social care has a very profound effect on the rest of the economy? I offer as evidence a family carer to whom I spoke last week. She is a single mother. She looks after her mother, who has Alzheimer’s, and a son with severe learning difficulties. She has been doing so for many years. She has been receiving two afternoons a week of respite care for the son and gets one day of daycare for the mother. This rather minimal provision has just about enabled her to cope. Both those services have now been withdrawn. I fear that she will have a breakdown because she is so distressed and under pressure. If she does, all three of those people will be a charge on the state. Will the Minister explain how that makes any kind of economic sense?

[Lord Prior of Brampton]

There is no doubt that what the noble Baroness says is true: the impact on other parts of the economy will be significant. It is also true that the impact on the healthcare system of reduced resources in social care will have an effect, which is why we are developing the better care fund and why we believe that more of the health and social care budgets should be pooled and used as one. Again, that is an integral part of the Five Year Forward View. At the risk of being boring, I am afraid that I will repeat myself: we will have to wait until the end of November before we know what the financial settlement is.

[Lord Wills (Lab)]

My Lords, in view of the undoubted stringency of the forthcoming spending review, and all the pressures on social budgets we have just heard about, what words of comfort can the Minister give that care leavers, who are already an extremely disadvantaged group, will not be further disadvantaged as a result of all these financial pressures?

[Lord Prior of Brampton]

I think that the only word of comfort I can give is that in the long run we will have a well-funded social care sector and a well-funded NHS only if we have a successful and productive economy, and we will have a successful and productive economy only if we can get government borrowing back to where it needs to be and so can begin to eliminate the government deficit.

[Lord Foulkes of Cumnock (Lab)]

My Lords, does the Minister not realise that he is not just a disinterested observer in this matter? He has admitted a 10% reduction, he has said that the sector is “fragile”, and then he says that we have to wait until the settlement in November. What are he and his colleagues doing about saying to the Treasury, “This is a fragile sector. This is a sector that needs more money. This is a sector that is alarming many, many Members of the House of Lords”, and getting those messages over to the Government?

[Lord Prior of Brampton]

What we are saying is that we have to fundamentally transform the health and social care sector so that it is fit for the kinds of patients living in today’s society, not those living in, frankly, 1948.

[Baroness Howarth of Breckland (CB)]

My Lords, it seems an extraordinarily unreal situation—the present circumstances that people find themselves in. Day after day, as the noble Baroness, Lady Pitkeathley, pointed out, we hear about people having their hours cut, people finding that they no longer have carers and local authorities having huge cuts in their budgets. What is the Government’s plan if we do not get the settlement that we need from the spending review?

[Lord Prior of Brampton]

I am afraid that I can only repeat what I said earlier: our plan is for health and social care to become more integrated and for more budgets to be pooled, and that by doing so we can transform the care we deliver to the very vulnerable people in our society.

Social Care

Lord Prior of Brampton Excerpts

Thursday 15th October 2015 Lords Chamber

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

My Lords, the Government have made the Care Quality Commission’s regulation and inspection regime much tougher to ensure that people receive safe, high-quality and compassionate care. The CQC’s report, The State of Health and Adult Social Care in England, published today, details how well adult social care is performing overall in respect of quality. The new care certificate is equipping staff to deliver high-quality services, while the national living wage will ensure that they are properly paid.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I am grateful to the Minister for that Answer. I declare my interest as a trustee of Crossroads Care in the Forest of Dean and Herefordshire. The Minister mentioned the new national living wage, which is coming in in April. At the same time, local councils up and down the country will have more and more cuts to their budgets. Notwithstanding what the Minister says, I believe that the sector is in crisis, and the sums simply do not add up. Some care organisations are already pulling out, especially in rural areas, where they do not wish to pay travel times. What are the Government going to do to ensure that there is quality care in isolated areas as well as in other parts of the country? Will the Minister agree to have a meeting with me to discuss this specific issue, which is a matter of deep concern?

[Lord Prior of Brampton]

First, I would be delighted to meet the noble Baroness any time—

[Noble Lords]

Oh!

[Lord Prior of Brampton]

—any place! I look forward to that. We will be accompanied by officials. There is no doubt that the local authority-funded care sector is under considerable pressure at the moment and that the increase in the national living wage will add to that pressure. Those pressures are well recognised by the Government. To some extent they have been addressed by the better care fund. I think that pooling budgets between health and social care is a way forward but we have to await the out-turn of the spending round before we can be more definitive.

[Lord Cormack (Con)]

My Lords, might I express the hope that the meeting with the noble Baroness is not only productive but chaperoned properly? I ask my noble friend to take on board the very important point she made about travel time. It really is very wrong indeed that people should not be paid for travel time, especially in rural areas.

[Lord Prior of Brampton]

I thank my noble friend for that important observation, with which I agree completely.

[Baroness Brinton (LD)]

My Lords, the better care fund was a good starting point for the integration of health and social care, but the Government deferring the integration of the spending limits in the Dilnot review means, we are told, that there are £6 billion of savings. Will the Government ensure that that saving of £6 billion from not fully implementing the integration of health and social care is put towards the new minimum wage and the new contracts ensuring that staff are paid for travel between appointments?

[Lord Prior of Brampton]

The position on the savings from deferring the introduction of the Dilnot proposals is that they are being taken into account under the spending round and I cannot comment further today.

[Baroness Pitkeathley (Lab)]

My Lords, is the Minister aware that data from the Health & Social Care Information Centre show that without doubt the social care system is not just under pressure, as he has said, but at breaking point? The figures also show that family carers are under increasing pressure and receiving far less support and back-up. In fact, their quality of life and satisfaction with social services have dropped hugely in the past two years and now only 39% of them say that they have as much social contact as they want and need. Does the Minister agree that support for family carers is an absolute priority and must be maintained since they are, after all, the main providers of social care?

[Lord Prior of Brampton]

The noble Baroness says that the care system is at breaking point. The CQC’s report out today says that it is “fragile”. I think it is very variable. Some care providers are finding life extremely difficult but it is highly variable; it depends very much on the mix of clients that care providers are looking after and the extent to which they are funded by local authorities and the extent to which they are funded privately. But I take on board what the noble Baroness says and take it very much to heart.

[Baroness Morgan of Huyton (Lab)]

Does the Minister agree that one of the issues in the CQC report this morning was the hospital sector appearing to be in a level of crisis? We have also heard about the funding problems. That is directly related to the crisis in the social care system. It is one for thing for Ministers to say that the Government are aware of that but I suppose the real question is: what are the Government going to do about the huge current pressures in the social care system, which everybody recognises?

[Lord Prior of Brampton]

What the noble Baroness says is absolutely right—the two are linked closely, although it is interesting that the main concern coming from the CQC report is around safety, which is not directly related to the point that she raised. The better care fund is a start on this road. The devolution in Manchester is another point along the journey. Increasingly, over the next five or 10 years, we will see a coming together of the health and social care system.

[Baroness Jolly (LD)]

My Lords, I am sure we all welcome a living wage being paid to care workers, but when this was announced, did either the Treasury or the department do an impact assessment of this new expenditure on the sector?

[Lord Prior of Brampton]

The impact on the sector is very clear: it will push up costs in the sector. How those costs are funded will be part of the spending round discussions that are going forward at the moment.

[Baroness Wheeler (Lab)]

My Lords, today’s CQC report calls on health and social care providers to focus on ensuring that services have the right staff and skills mix to ensure that care is always safe. Does the Minister acknowledge the impact of the funding crisis on residential care and the commission’s concern at the delay in the introduction of the care cap until 2020? Both residential and daycare have high vacancy and turnover rates and a chronic problem in recruiting and training care staff, particularly under-25s. Would it not be outrageous if the Treasury kept the £6 billion and did not use it to try to address those issues?

[Lord Prior of Brampton]

The noble Baroness raises two interesting points. There is a recruitment and a training issue involved in many care homes. This is being addressed by the Government in two ways: first, by raising the minimum wage to the national living wage so that it rises to about £9 an hour by 2020; and, secondly, by the introduction of the care certificate which came out of the Camilla Cavendish report after Mid Staffs, which should improve training in the sector. The funding of local authority-provided care is the issue on which we are awaiting the outcome of the spending round discussions.

[Lord Patel (CB)]

Does the Minister agree that the pressures mounting across the whole range of healthcare, from prevention to primary care, acute care and social care, will just keep getting worse until we address the fundamental issue of adequate resourcing of all the aspects of healthcare? Is it not time to start the debate more widely as to how we are going to do that?

[Lord Prior of Brampton]

I thank the noble Lord for his comments and, of course, I understand exactly what he is saying. I will put just two points. First, the fundamental problem is that the Government still have a very high level of public borrowing, which we inherited and has been there—

[Noble Lords]

Oh!

[Lord Prior of Brampton]

It happens to be true. We cannot carry on spending in the way that we used to spend. We have to balance the books. That is a very fundamental point. The second point is that there is huge variation in the system. Some providers, some hospitals and some care systems are delivering much better outcomes with the same money.

Primary Care: Targets

Lord Prior of Brampton Excerpts

Tuesday 13th October 2015 Lords Chamber

[Baroness Walmsley]

To ask Her Majesty’s Government whether they will encourage general practitioners’ practices to employ nurse prescribers, nurse practitioners and pharmacists in order to achieve their seven day target for primary care.

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

My Lords, broadening the skill mix within general practice is an important part of improving access for patients. General practices are including nurse prescribers, nurse practitioners and clinical pharmacists in their multi-disciplinary teams and experience suggests that this results in significant benefits for patients. Earlier this year, NHS England launched a £15 million scheme to fund, recruit and employ clinical pharmacists in GP surgeries.

[Baroness Walmsley (LD)]

I thank the Minister for that reply, but is he aware that the GP shortage is made worse by the fact that a declining number of young doctors want to go into GP practice for various reasons, including pay, working hours and the volume of consultations? At the same time, we have a surplus of excellent young pharmacy graduates looking for jobs who would be very happy to go into clinical general practice. Is it not time for a new initiative to bring these two things together and ensure that doctors get the assistance of all these excellent young graduates?

[Lord Prior of Brampton]

The noble Baroness makes a very good point. There is plenty of evidence to suggest that where general practices employ clinical pharmacists, it relieves GPs of a considerable burden. Interestingly, the NHS Alliance produced a report last week called Making Time In General Practice. It identified that up to one in six patients seen by GPs could in fact be seen by someone from a broader skill mix within general practice, so what the noble Baroness says makes a lot of sense.

[Lord Patel of Bradford (Lab)]

My Lords, while one may applaud the intention of the 24/7 NHS service, does the Minister agree that the Government are potentially raising public expectations that are just not going to be achievable, given the deficit of nearly £1 billion that we have seen in the first quarter of this year alone?

[Lord Prior of Brampton]

My Lords, the deficit in the first quarter is indeed a matter of huge concern—I am not going to pretend otherwise—but the Government are wholly committed to seven-day services both within hospitals and in general practice. We are committed to investing £10 billion extra in the NHS over the next five years, and ensuring that we have enough GPs and enough support for them is a key priority.

[Lord Patel (CB)]

My Lords, does the Minister agree that, before anybody is qualified to prescribe, the important part is that the correct diagnosis is made before the prescription is given? Having said that, does he think that qualified high-street pharmacists may have a role in prescribing, apart from the clinical pharmacists who are attached to general practitioners?

[Lord Prior of Brampton]

I fully accept, of course, that diagnosis is extremely important but I think that advanced nurse practitioners can play a role in diagnosis, as well as in treatment, as can physician associates, given that both are supervised by GPs. I believe that high-street or community pharmacists can play a big part in supporting the role of clinical pharmacists.

[Baroness Wall of New Barnet (Lab)]

The noble Lord will recall yesterday’s discussion about how the integration of care is crucial. I am absolutely in agreement with the noble Baroness, Lady Walmsley—this is what integration in the health service really means. Providing the opportunity for pharmacists in hospitals to work in those practices should be encouraged.

[Lord Prior of Brampton]

I completely agree with those comments. Over the next five years, we will see much greater integration of acute hospitals and primary care and community care.

[Lord Roberts of Llandudno (LD)]

My Lords, the suggestion has been made that nurses from overseas who are not earning £35,000 after five years will be deported. Does this mean that the Government are going to think again on this issue?

[Lord Prior of Brampton]

This raises an important point—that we ought to train our own nurses. Relying on recruitment from overseas is not a viable long-term strategy and we must increase the number of training places in the UK.

[Lord Howarth of Newport (Lab)]

My Lords, in seeking to broaden the skills base in general practice, as the Minister has just said he wishes to do, will he consider encouraging GP practices to employ artists? Is he aware of the excellent outcomes for patients in GP practices that have an artist in residence?

[Lord Prior of Brampton]

My Lords, the short answer is no. I do not think that I could stand here and promise funding for artists in GP surgeries, but I do have an open mind. If the noble Lord would like to talk to me about it outside the Chamber, I would be very happy to do so.

[Lord Naseby (Con)]

My Lords, as the NHS has a problem with its cost base, rather than load GP practices with even more overheads, would it not be wiser to follow what a number of us experience in our own practices: much closer liaison between GP practices and local chemists, which account for only a partial amount of the NHS’s overheads?

[Lord Prior of Brampton]

My noble friend makes a very good point. There is an increasing and important role for high-street and community pharmacists in delivering healthcare.

[Lord Kakkar (CB)]

My Lords, I declare my interests as chairman of UCL Partners and as UK Business Ambassador for Healthcare and Life Sciences. What strategy do Her Majesty’s Government have to ensure that NHS prescribers can continue to provide innovative therapies and interventions for their patients?

[Lord Prior of Brampton]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Prior of Brampton]

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

[Lord McFall of Alcluith (Lab)]

My Lords, the number of 80 year-olds today—3 million—is estimated to double by 2030. According to the King’s Fund, this will be the biggest challenge facing society. In particular, the issue of caring for frail, vulnerable adults with complex needs is crying out for attention. What future planning will the Government do to address this human bombshell?

[Lord Prior of Brampton]

The noble Lord makes a very perceptive point. Demography is driving healthcare. The whole thrust of government policy is to treat as many people as possible outside acute hospital settings. Over the next five, 10, 20 years, I expect to see a far greater share of the health budget going to primary and community care, and a lower percentage to acute care.

[Lord Colwyn (Con)]

My Lords, in view of the massive costs of agency staff working in the NHS, could not the Government consider setting up their own agency?

[Lord Prior of Brampton]

My Lords, it is our intention —for all kinds of reasons; cost, safety and quality of care—to reduce our dependence upon staffing provided by agencies. We would much rather see staff employed on a permanent basis or through hospital banks.