NHS: Mental Health Patient Assessment Needs

Lord Prior of Brampton Excerpts

Monday 12th October 2015 Lords Chamber

[Baroness Gardner of Parkes (Con)]

I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I declare an interest, as my grandson is a severe case of autistic Down’s syndrome.

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

My Lords, we have not considered creating such a pathway. We would expect a patient’s mental and physical health needs to be taken into account when they access NHS services.

[Baroness Gardner of Parkes]

I thank the Minister for his formal Answer but I should go on to explain that my grandson, Christopher, now 23, has no speech and is unable to explain what is happening to him. He has changed from an apparently happy boy and a loving family member to a person suffering violent outbursts, in which he hits his head as if in pain or he attacks others. His increasingly erratic behaviour results in him being excluded from the health groups from which he has benefited so much in the past. Clinicians have already identified the need for a scan but this must be done under general anaesthetic. They are unable to access any NHS team able to do this as there is no clinical pathway, and in some cases patients known to these clinicians have had to wait up to two years. Why should any mentally disadvantaged child—as he was but he is now growing up—not be able to access a full and necessary examination within weeks rather than years?

[Lord Prior of Brampton]

It is obviously not possible for me to comment on an individual case but it sounds like a very tragic and a very difficult case. Of course, someone in that kind of position ought to have access to normal NHS facilities and care, and I am at a loss to know why my noble friend’s grandson has not been able to get proper access. The fact that a general anaesthetic is required, and has been said to be required by a clinician, should not make it any more difficult to access that kind of care. I am very happy to look at this as an individual case and, if it is not just an individual case but an example of a broader problem, I shall be very happy to meet my noble friend outside the Chamber to pursue the matter with her.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that NHS staff are a very resourceful group of people and that in the past many of them have found ways of helping patients through these scans and so on when they have found them very difficult? What are the Government doing to ensure that these creative responses to patients’ individual needs can be shared with other members of NHS staff? Will the Government consider some kind of restricted-access online resource centre, through which NHS staff can share their good ideas and what they have found to work?

[Lord Prior of Brampton]

My Lords, I think spreading best practice is a perennial problem in the NHS. The noble Baroness gave an example of that but I could give many, many others: we are not good in the NHS at spreading best practice. I hope that the newly reformed combination of the TDA and Monitor into NHS Improvement will be a very useful repository of good practice, in the same way as the IHI is in the USA.

[Baroness Howarth of Breckland (CB)]

My Lords, I find that reply singularly disappointing, as the Minister will know that any child exhibiting the kinds of problems that have been described today could be seriously ill—they could have a brain tumour or hydrocephalus. In addition, he also knows that the availability of good mental health services for young people, adolescents and those in their 20s is in serious difficulty at the moment. What are the Government doing to ensure that NHS England is improving these services and making a real effort so that we do not have cases such as this, for I am sure that it is not an isolated incident?

[Lord Prior of Brampton]

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

[Lord Hunt of Kings Heath (Lab)]

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

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

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

[Lord Prior of Brampton]

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

[Lord Christopher (Lab)]

My Lords, was it not the case that a good deal of spreading the news of good practice was usefully done by the Audit Commission, which the Government abolished?

[Lord Prior of Brampton]

I cannot comment on the Audit Commission. I do not know how much good it did in that regard because I was not here at the time. However, I am very conscious of the fact that spreading best practice across the NHS, particularly operational and clinical best practice, could be a lot better. That would be true in a clinical specialty such as orthopaedics. However, it is also true that, in some hospitals, the flow of patients through the hospital is much better organised than in others. There is a great deal to be learned by spreading best practice. There is also a lot to be learned from around the world. I take the view that we have, in the NHS, probably some of the finest hospitals in the world. We also have some very poor hospitals. It should not be all that difficult for the poor to learn from the best.

Child Health: Play

Lord Prior of Brampton Excerpts

Monday 12th October 2015 Lords Chamber

[Baroness Benjamin (LD)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare an interest as the co-chair of the All-Party Group on a Fit and Healthy Childhood.

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

My Lords, local authorities have responsibility for commissioning services to enable healthy lifestyles, including active play. However, recognising the health benefits to children and young people from play, since 2013 we have been providing Play England with funding of £1.1 million to promote play. Public Health England’s Change4Life campaigns have supported families to make healthy choices, including being active, and we continue to support school sport, with investment of £222 million since 2011.

[Baroness Benjamin]

My Lords, the latest report from the All-Party Parliamentary Group on a Fit and Healthy Childhood concludes that play is important to a child’s healthy physical and mental development. It found that, despite government funding for school sports, 20% to 30% of those who do not participate in sport are obese children—the precise group that we need to focus on and target. What are the Government doing to engage with these children? Does the Minister agree that reducing opportunities for play has contributed to the rise of childhood obesity and that play is part of the solution in a whole-child health strategy? Will he agree to meet me to discuss the findings of the play report?

[Lord Prior of Brampton]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Prior of Brampton]

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

[Baroness Jenkin of Kennington (Con)]

My Lords, I am not sure whether my noble friend saw the report recently of a primary school which has introduced a running challenge where the children run one mile every day, to enormous benefit both mental and physical. Following on from the Minister’s previous remarks about best practice, is this something that the department could encourage other schools to do?

[Lord Prior of Brampton]

I wonder whether Members of this House might like to set an example in that regard as well by running a mile a day. There is no doubt that exercise is good for you. Not only is it good for all the problems associated with weight but there is plenty of evidence to suggest that exercise helps with mental health problems. Whether you are running or on your bike, I am wholly in favour of it.

[Lord McColl of Dulwich (Con)]

My Lords, although exercise is very important in terms of the heart and so on, the real answer is to eat fewer calories. We may criticise politicians of one party, but does the Minister realise that politicians of all three parties kept on saying that the answer to the obesity epidemic was exercise when it was nothing of the kind? It was eating fewer calories.

[Lord Prior of Brampton]

Clearly, my noble friend is right: nutrition and diet are fundamental to the whole debate about obesity. That does not alter the fact that exercise is also very good for you.

[Lord Addington (LD)]

My Lords—

--- Later in debate ---

[Baroness Finlay of Llandaff]

Do the Government recognise that there is another group of children who must be considered—those who have illnesses limiting their mobility for a variety of reasons, some acquired and some congenital? The role of physiotherapy in paediatric departments is essential to ensuring that they can grow and develop and become as independent as possible. I declare my interest as president of the Chartered Society of Physiotherapy.

[Lord Prior of Brampton]

The noble Baroness makes a powerful and strong point. All I can do is agree with her 100%.

[Lord Addington]

My Lords—

--- Later in debate ---

[Lord Addington]

My Lords, does the Minister agree that if we are dealing with a sports policy that talks about competitive sport, getting some idea of creative play and competitiveness within play is vital? If we have a sports policy, it must have a foundation based on something like my noble friend suggested.

[Lord Prior of Brampton]

There is no question that competitive sports have a huge role to play, but many children do not wish to participate in competitive sports, so having resources and time made available for less competitive activities such as yoga, pilates or dance is also very important.

NHS: Financial Performance

Lord Prior of Brampton Excerpts

Monday 12th October 2015 Lords Chamber

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

My Lords, I shall now repeat in the form of a Statement the Answer given by my honourable friend the Parliamentary Under-Secretary of State for Care Quality to an Urgent Question in another place. The Statement is as follows:

“Mr Speaker, I thank the honourable lady for giving me this opportunity to come to the House and make a Statement on the financial performance of the NHS. On 9 October, Monitor, the regulator of NHS foundation trusts, reported that foundation trusts ended the first three months of the financial year with an estimated net deficit of £445 million. Monitor’s publication noted that performance in the first quarter of the financial year is usually worse than the rest of the year.

The NHS Trust Development Authority also published that day the financial position of NHS trusts for the first quarter of 2015-16. This showed that the NHS trust sector ended the first quarter of the year £485 million in deficit. The financial position of the NHS is undoubtedly challenging but it is important to recognise that, despite the difficult decisions we have had to make because of the calamitous deficit we have inherited, this party has chosen to prioritise funding for the NHS. That is why we are committing an additional £10 billion over the lifetime of this Parliament, starting with £2 billion this year.

However, additional government spending is not the only answer to the challenges faced by the NHS. The Government have taken action with their arm’s-length bodies to support local organisations to make efficiency savings and reduce their deficits. In the first three months of this year, NHS trusts spent £380 million on agency staff, while foundation trusts spent £515 million. That is nearly £10 million a day across the NHS. We need to reduce this spending and challenge the agencies, which are charging, frankly, outrageous amounts for their staff. To that end, a package of measures, including a ceiling on the amount that each trust can spend on agency nurses and mandatory central framework agreements, was announced by my right honourable friend in June. These measures came into effect on 1 October. If further action is necessary, we will not hesitate to take it.

Furthermore, we have taken action through tough new controls on consultancy spending and executive pay, and in supporting organisations to dispose of surplus land among other initiatives. The impact of all these actions will not have been seen in the quarter 1 figures published last week.

The Government and NHS leaders have taken national action to support local leaders in managing down these deficits. I welcome very much a constructive discussion with the party opposite on where we may be able to go further in driving the efficiency savings that the NHS must find if it is to provide the exceptional standard of patient care that we all on both sides of this House wish to see”.

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, I thank the noble Lord for those helpful comments. His first question was: what is the updated estimate for the full year? There is a general figure out there that the King’s Fund, the Health Foundation and others have come up with—£2.1 billion—as the underlying provider deficit for the year. That figure is largely based on the first quarter’s results because you cannot annualise the first quarter’s results; the first quarter is often much worse than the subsequent three quarters. We believe we can manage that £2.1 billion down quite significantly; interestingly, last year the underlying provider deficit was £1.2 billion. We have other ways of managing that deficit through the surpluses that may arise on the commissioning side and other sources of revenue.

The noble Lord talked about agency staff. I recognise some of what he says but there is no doubt that in the aftermath of the tragedy at Mid Staffordshire, the strengthening of the CQC when I was there has led to greater pressure to increase staffing numbers. I heard the noble Lord say, I think when he was chairman of the Heart of England trust, that if you are going to get shot it is better to get shot for not hitting your financial budgets than for not having enough staff on the wards. There has been a much greater emphasis on higher levels of staffing and that has put pressure on agency staffing. There are actually 8,000 more nurses and 9,000 more doctors in the NHS since 2010.

The noble Lord mentioned the cost of consultants. I recognise the strength of what he says—that it is a bit rich for us to complain about the cost of consultants when, through our arm’s-length bodies, we have been responsible for recruiting them. We expect much of the improvement methodology that has been provided by independent consultants to be provided by NHS Improvement; for example, the fact that we have now taken on Virginia Mason to help us spread best practice in running hospitals in the NHS is a model for things to come. I also hope that chains of hospitals will emerge and develop some of the best practice from hospitals such as Salford Royal, Frimley Park, the Royal Free and others, so that we can spread best practice without relying so heavily on external consultants.

Unfortunately, I have not read the article by Tom Hughes-Hallett. I would say to Tom, who I know, that he might spend more time focusing on his own hospital, which got a “requires improvement” notice from the CQC, than on spreading his views to all and sundry, although I recognise the strength of some of them. Sorry, I am running past my time. I had not realised that time was of the essence.

[Baroness Walmsley (LD)]

My Lords, quite clearly there is a crisis of funding in the NHS on an enormous scale and nothing I have heard from the Government indicates that the problem is going to be solved by any single party. This should be of cross-party concern. During the election, my right honourable friend Norman Lamb asked the Secretary of State for Health if he would co-operate with a cross-party commission to look at a cross-party solution to a new settlement for the NHS. He agreed, as did the Labour spokesman, yet five months later nothing has happened. Can the Minister tell me when it will?

In Scotland health and social care have been integrated and are already showing successes because of that. When will that happen in England? The situation in Scotland illustrates the fact that the challenges to the NHS are never going to be solved by the NHS alone. This is a whole-government issue. When will the Government beef up the Cabinet committee on health so that every department can be held to account for whether its policies contribute to the greater health of the nation or not? Until that is done, the NHS alone cannot be expected to solve the looming problems.

[Lord Prior of Brampton]

My Lords, it is worth reminding your Lordships that there was considerable consensus around the five-year forward view. I think that the noble Baroness’s party wholly signed up to it and, along with the Conservative Party, to committing £8 billion of extra money to the NHS over the lifetime of this Parliament. We stand by that. The NHS, in its turn, agreed to find £22 billion-worth of efficiency savings, which I think the noble Baroness accepted when she was part of the coalition Government. That is still the situation so I do not think that we need a new settlement. There is a settlement: it is called the five-year forward view and we are fully committed to it.

The noble Baroness raised the issue of integration. I agree 100% with her and it is an essential part of the five-year forward view—the vanguards are based on it. I remind noble Lords that the spending in the UK per capita on health is $3,200. In France it is $4,100 and in Germany it is $4,800. The NHS does a remarkable job in delivering world-class healthcare, which is rated by the Commonwealth commission and other independent agencies as among the best in the world, with considerably fewer resources than any other developed system in the world.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. What assessment have Her Majesty’s Government made of the potential contribution of accountable care organisations to addressing the need to advance quality outcomes in the NHS and its financial performance?

[Lord Prior of Brampton]

I thank the noble Lord for that perceptive and interesting observation. The accountable care organisation is one whose time has come. A health organisation with a capitated budget is indeed the way forward. It will drive the integration that the noble Baroness was talking about earlier on. It is a key part of this Government’s health strategy to support accountable care organisations.

[Baroness Wall of New Barnet (Lab)]

My Lords, I too welcome the Statement, as did my noble friend. I have to admit that Milton Keynes Hospital, of which I am chairman, has contributed to the £550 million deficit referred to in the Statement. I want to focus on the issue around agency staff. I presume that the Minister has not seen the Evening Standard today—it has only just come out, so that is quite acceptable. In it, however, the chief nurse at Guy’s says very much what all chief nurses are saying: that hospitals are really performing with their hands tied behind their backs and that we have no staff to fill all our vacancies and have to recruit agency staff. We have just had an instruction, which the Minister referred to in the Statement, to reduce our agency staff by 1 October. I think it is from 22% to 17%. We have obviously gone back with some mitigation around that, which has been accepted. That has been very helpful but it does not solve the problem: we cannot get nurses through.

We went to Croatia and got 60 nurses. Five of them have had visas to get through and the rest cannot come, so we have to carry on with agency nurses to cover them. We have more 1:1 nurses than any other trust around London. I am going to wind up but as the chairman of a trust, I am talking about what really happens—the Minister knows that. Can he tell us how he is going to get this other money to reduce the deficit that he talked about and which is going to happen? I would be very interested in that. Also, when is the NHS going to make sure that the people who have that remit for nurses being admitted into our country will do something about it?

[Lord Prior of Brampton]

I will have to be very quick in replying. Maybe we could discuss this outside the Chamber. There are three ways in which we can find the resources for this. The first is partly through extra government money: there is another £10 billion coming to the NHS over these next five years. The second is driving through efficiency improvements. There are vast efficiency improvements that we must make over the next five years. I regard efficiency as a moral imperative because every £1 that we can save from waste is £1 that we can plough back into patient care. The third way is through new structures of organisations—accountable care organisations are one example; chains of hospitals are another. I think that the days of the independent DGH ploughing its own furrow, or of the foundation trusts structure around the DGH, are behind us.

Health: Detection Dogs

Lord Prior of Brampton Excerpts

Thursday 17th September 2015 Lords Chamber

[Lord Astor of Hever]

To ask Her Majesty’s Government what assessment they have made of the merits of using dogs to detect medical conditions.

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

There is not, as yet, an established level of evidence to support the systematic application of the use of dogs within the NHS at this time. However, both the Department of Health and NHS England will be interested to see the outcome of the prostate cancer detection trials that recently started at Milton Keynes University Hospital with the charity Medical Detection Dogs.

[Lord Astor of Hever (Con)]

My Lords, each day that we sit in this House we trust dogs’ acute sense of smell of explosives to ensure our safety. Research shows that dogs detect human disease earlier than existing tests, which could increase survival rates and save the NHS millions of pounds. Will my noble friend’s department increase research capacity in this field and ensure that Britain remains a world leader?

[Lord Prior of Brampton]

My Lords, interestingly, the human nose contains some 5 million scent glands but a dog’s nose contains many more. In fact, the sniffing ability of a dog can be up to 10 million times that of the ability of a human being. Therefore we should not underestimate the contribution that dogs can make in this field. The trial being conducted at Milton Keynes University Hospital, which involves 3,000 patients giving urine samples, with nine dogs in a controlled environment over the three years, could indeed make a huge a contribution to the early detection of certain cancers. Therefore we will follow that trial with keen interest.

[Baroness Ludford (LD)]

My Lords, I thank the noble Lord, Lord Astor of Hever, for asking this Question, and also Claire, a young diabetes nurse with type 1 diabetes, who told me about her dog, Magic, which helps her avoid hypos—hypoglycaemic incidents. I declare an interest in that I have been married to someone who has had type 1 diabetes for nearly 45 years. Is the Minister aware that if the NHS did a serious cost-benefit exercise on type 1 diabetes, its investment in measures to assist strict blood glucose control and prevent hypos would be transformed? However, it seems to have a blind spot. Type 1 diabetes accounts for a large chunk of the 10% of NHS spending on diabetes but is not even mentioned in the NHS Five Year Forward View. Will the Government seriously look at extending access to technologies and, for people whom they would assist, access to detection dogs?

[Lord Prior of Brampton]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Prior of Brampton]

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

[Lord Ribeiro (Con)]

My Lords, the Minister is absolutely right in referring to the research in Milton Keynes. As far as prostate cancer is concerned, a man’s best friend probably is his dog. However, there is no doubt that the molecular markers can be detected in urine, and this may be the way to go in future research. It needs to be directed in that way because just a simple dipstick might well be able to detect the markers. If it is possible to detect prostate cancers using dogs, will the Government be prepared to fund such research and carry out a proper controlled clinical trial?

[Lord Prior of Brampton]

Clearly, molecular diagnostics is a growing field and will have a hugely important role to play in diagnosing many cancers. This was certainly a recommendation of the cancer task force led by Harpal Kumar. We are not by any means saying that we should pursue dogs at the expense of molecular diagnostics, just that we should try every opportunity. There seems to be some evidence regarding the number of false positives—for example, the use of dogs to sniff urine is considerably more accurate than more conventional forms of detecting cancer. We would not therefore want to rule out the use of dogs by pursuing solely molecular diagnostics.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that many diabetes patients who would like a dog and feel that they would be helped by one but cannot get one through the NHS are paying for dogs from unlicensed trainers? However, they are of variable quality and may not be as good as properly trained dogs. Will the Minister look into this to see what can be done about it?

[Lord Prior of Brampton]

The decision on whether to supply dogs locally must be left with clinical commissioning groups.

[Lord McColl of Dulwich (Con)]

Is the Minister aware that diagnosis may be helped not only by dogs, but by ants in India? One way in which to detect diabetes is to get the patient to urinate up a wall, and if the ants crawl up the column of urine it means that there is diabetes because sugar is there, and ants like sugar. It is a very cheap way to diagnose diabetes.

[Lord Prior of Brampton]

I seem to remember a noble Baroness asking a question about ferrets climbing up someone’s trousers. Now we have ants climbing up people’s trouser legs. We are open to all sensible suggestions.

NHS: Clinical Commissioning Groups

Lord Prior of Brampton Excerpts

Wednesday 16th September 2015 Lords Chamber

[Baroness Meacher]

To ask Her Majesty’s Government what assessment they have made of NHS England’s management of clinical commissioning group allocations under the current funding formula.

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

My Lords, decisions on clinical commissioning group allocations are taken independently of government by NHS England, in order that such an important issue as funding is made objectively and free from perceived political considerations. The Government set some broad principles to which they must conform. NHS England’s decisions are informed by the recommendations of the independent Advisory Committee on Resource Allocation.

[Baroness Meacher (CB)]

My Lords, I thank the Minister for that reply. As he will know, the Secretary of State is responsible for ensuring that NHS England allocates resources fairly across the NHS. Is the Minister aware that, at present, allocations to clinical commissioning groups are hugely variable in relation to the Treasury manual formula? For example, west London receives 31% more than the formula, while Hounslow receives 9% less than the formula, representing a discrepancy of some £110 million from one trust to another in relation to the formula? Despite some recent improvements, does the Minister share the concern expressed by the National Audit Office about the failure to end this unfairness—and, indeed, even the lack of any timescale within which to rectify this matter? Will he give an assurance to the House that within five years there will be a resolution?

[Lord Prior of Brampton]

The noble Baroness raises a very important issue. I think that she is raising issues not about the actual formula but about the speed at which NHS England reached the target levels of the formula. She points to the discrepancy of west London, which is 31% over the formula. I can tell her that NHS England is committed by 2017-18 to bringing all those under the formula by more than 5% up to that level. It will also be encouraged to address the issue of CCGs that are above the formula.

[Baroness Walmsley (LD)]

My Lords, given that the expertise of the CCGs is also very variable, in some areas the commissioning support groups are particularly important. Is the Minister satisfied that both the expertise and the funding of the commissioning support groups is appropriate?

[Lord Prior of Brampton]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Prior of Brampton]

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

[Baroness Murphy (CB)]

Does the Minister agree that the inequity of allocations to CCGs is reflected and made worse in allocations on mental health which, for historical reasons, are very skewed to where there are large hospitals? Not only that, but at the moment it seems that CCGs are not even spending the money that is allocated to them for mental health on mental health but are diverting it to other areas. What is going to be done about this in terms of the fairness of the allocations and the insistence that the money should be spent on what it is intended for?

[Lord Prior of Brampton]

My Lords, I am not convinced that the method of allocation is unfair. ACRA will soon be reviewing its method of allocation for 2016-17. I repeat that it is an independent process. How CCGs allocate the money they receive to mental health, physical health, public health or anything else is up to them. With the King’s Fund, we are introducing a range of measures to enable us to see how individual CCGs are performing.

[Lord Patel (CB)]

My Lords, is not the fundamental problem that we have more than 400 commissioning bodies commissioning in different aspects for different services, and that leads to variability? The answer has to be what the Barker commission recommended: a single commissioner that commissions for primary care, community care, acute services and mental health and asks for the outcomes that we need.

[Lord Prior of Brampton]

The noble Lord makes an interesting and perceptive point. I have no doubt that if we look at the commissioning landscape in five years’ time there will be a lot more integrated commissioning and that social care and healthcare will be much more joined up.

[Baroness Walmsley]

My Lords, the criteria that the Minister mentioned sound all very well, but they do not take account of existing levels of ill health in the most disadvantaged areas of the country. The criteria he quoted do not take account of the need for catch-up for those populations.

[Lord Prior of Brampton]

The report by the Public Accounts Committee raised the issue of whether deprivation was properly taken into account by the formula used by ACRA, and ACRA has agreed that in its new formulation it will look again at the adjustment it makes to the formula for deprivation.

Health: Children

Lord Prior of Brampton Excerpts

Thursday 10th September 2015 Lords Chamber

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

My Lords, giving every child the best start in life is central to the Government’s approach to reducing health inequalities. This ambition is supported by action across government and the health system at local and national level.

[Baroness Tyler of Enfield (LD)]

I thank the Minister for his reply. Is he aware of the report published this week by the National Children’s Bureau—I declare an interest as its president—called Poor Beginnings, which shows very vividly how the place where young children live can dramatically affect their health? In particular, it highlights really dramatic differences in areas such as obesity, tooth decay and getting injured, and shows very significant variations in child health outcomes between deprived local authorities. As local authorities take up responsibility for young children’s public health from this October, what steps are the Government taking to support them in their work to narrow the gap in outcomes?

[Lord Prior of Brampton]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Prior of Brampton]

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

[Baroness Masham of Ilton (CB)]

My Lords, are there enough paediatricians across the UK to look after the under-fives, and is prevention of cerebral palsy a priority?

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, I do not have the numbers for paediatricians—whether or not there is a shortage. Certainly, there are shortages in some specialties, particularly in A&E and other emergency specialties. I cannot give the noble Baroness a definitive answer on the shortage of paediatricians but perhaps she will allow me to go back, look at the figures and write to her.

[The Lord Bishop of St Albans]

My Lords, one of the most significant aspects of child health is to do with access to health services, which is a particular problem in rural areas. The phenomenon of distance decay, the further away you are from where the service is provided, is well documented. Will the Minister tell us what Her Majesty’s Government are doing to increase access to health services for those 900,000 rural households living in income poverty?

[Lord Prior of Brampton]

My Lords, access to health services is not just a rural issue; it relates also to deprivation, be it urban or rural. I would point out to the House the increase in the number of health visitors, which has gone up from 8,000 to nearly 12,000 over the past five years, and also to the Family Nurse Partnership scheme, which now has 16,000 places on it for younger and teenage mothers. So the Government are doing a lot to improve access. I guess they could always do more.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that in some areas fewer than half the five year-olds reach a good level of development? Given how important this is for their health, education and future employment prospects, why have the Government decided that from next year, the collection of early years foundation stage profile data is no longer to be statutory? How are the Government going to monitor how well children are developing across the piece, and how individual nursery settings are doing?

[Lord Prior of Brampton]

I am not sure that I can give that question a full answer. I am aware of the early years programme and I think that it is largely up to schools to monitor the development performance of children when they come into reception classes, which they are doing. I have seen the figures that the noble Baroness refers to—the 40% figure of children who have not reached the right development age by the time they come into reception class. It is a serious issue and I will take her words on board.

[Lord Beecham (Lab)]

My Lords, what is the Government’s response to the recent concerns expressed by the Royal College of Nursing about the reduction in the number of school nurses in recent years, and what assurance can the Minister give that the reduction in the public health budget will not lead to a still further reduction in the number of school nurses?

[Lord Prior of Brampton]

I have not seen the figures that the noble Lord refers to on school nurses but I will take that away and look into it.

[Baroness Finlay of Llandaff (CB)]

Do the Government accept that intrauterine exposure to environmental toxins, psychological stress and nutritional deficiencies in the mother have long-term health effects on the child, as well as problems that arise in the immediate postnatal period? Will the Government therefore undertake to support epidemiological research in these areas, linked to their reviews of maternity services?

[Lord Prior of Brampton]

I am well aware of the impact on the health of children before as well as after they are born. I cannot give the undertaking that the noble Baroness would like me to give here today but I am very happy to pick it up with her outside the Chamber.

Health: Lymphoedema

Lord Prior of Brampton Excerpts

Wednesday 9th September 2015 Lords Chamber

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

My Lords, first, I thank the noble Lord opposite for raising this very important matter. We have had a number of serious contributions to this debate. Like the people that the noble Baroness, Lady Smith of Newnham, spoke to, I had not heard of lymphoedema until about two months ago. The noble Baroness said that they were surprised that we talked about medical issues in the House, but at times I think that we talk of little else. I start by saying that if an apology is due from NHS England, I will raise that directly with Malcolm Grant when I see him next week. I am sure that he will offer one, if it is right to do so.

A number of general issues have come up from the contributions that we have had today. The first is the importance of early diagnosis, which is critical. My noble friend Lord McColl made that point very strongly. That applies to so many issues, not just lymphoedema. The link with obesity is another issue that has come over strongly in the debate today. It is another example of the damage that obesity is doing.

I think that I will pick up most of the issues raised by noble Lords during my speech, but I shall refer back to them as I go through.

It is generally accepted that somewhere between 76,000 and 250,000 people in England suffer from lymphoedema. As we have heard, the condition is caused by abnormal accumulation of lymph fluid in body tissue, which can be the result of a congenital defect or of damage to the lymphatic system or removal of lymph nodes by surgery, radiation, infection or injury. Any medical undergraduate who wishes to get up to speed on this condition should just read this debate. Both the noble Baroness, Lady Finlay, and my noble friend Lord McColl went into the condition in considerable detail.

Regarding the issue of a national strategy for lymphoedema, which is the essence of this evening’s debate, I should first explain to the House that the British Lymphology Society has submitted a proposal for a nationally commissioned specialised lymphology service to the Prescribed Specialised Services Advisory Group, which I will call PSSAG for the rest of this debate, which is due to be considered at its next meeting on 15 October.

Ministers established PSSAG in April 2013 to advise the Government on whether certain services for people with rare and very rare conditions are specialised and should be prescribed in regulations for commissioning by NHS England. Section 3B(1)(d) of the NHS Act 2006, as amended by the Health and Social Care Act 2012, gives the Secretary of State the power to require NHS England to commission such services nationally.

PSSAG is a Department of Health-appointed expert committee with membership drawn from a wide geographical spread, involving clinicians, commissioners, independent experts and members of the public. I stress members of the public because we have heard in this debate the power of personal experience from several noble Lords, including the noble Baroness, Lady Masham. Its chair is appointed by the Secretary of State for Health. The chair is Sir Ian Gilmore, who some in this House will know. Sir Ian is a very distinguished gastroenterologist and a former president of the Royal College of Physicians, so it is what I would call a proper committee.

Specialised services are those services provided in relatively few hospitals to small numbers of patients. National commissioning ensures that there are enough centres delivering care to nationally set standards to meet the needs of small patient populations requiring specialist treatment, and that those centres receive sufficient throughput of patients to maintain the expertise of the clinicians operating within them.

The Health and Social Care Act sets out four factors that should be taken into consideration when determining which prescribed specialised services should be directly commissioned by NHS England: first, the number of individuals who require the provision of the service or facility; secondly, the cost of providing the service or facility; thirdly, the number of experts able to provide the service or facility; and, finally, the financial implications for clinical commissioning groups if they are required to arrange for the provision of the service or facility.

PSSAG discusses each proposal with regard to the four factors set out above, but these are not prescriptive criteria or set tests, so there are no particular thresholds which must be met. Each proposal is considered on its own merits, in light of what is known at the time.

PSSAG may also seek advice from professional bodies. It collates all advice on a proposal and then considers the proposal against the four factors. If it agrees that a service meets the four factors, it advises Ministers accordingly. However, the regulations require that Ministers must consult NHS England before a final decision is made. I will of course advise the noble Lord on the outcome of PSSAG’s decision in due course, and should the British Lymphology Society wish to discuss the outcome of its decision I am sure that Ministers—myself or others—or officials from the Department of Health will be happy to meet them.

A number of noble Lords have raised the issue of devolved Administrations in Wales, Northern Ireland and Scotland. It is true that national lymphoedema initiatives have been developed. The question was asked whether it was equitable that there should be national guidelines in the devolved Administrations and not in England, but health is a devolved matter. It may not seem equitable, but the point of devolution is that the devolved parts of the country will have different ways in which they treat different conditions. In England, responsibility for determining the overall strategic, national approach to improving clinical outcomes from healthcare services lies with NHS England, and the provision of lymphoedema care is the responsibility of local NHS commissioners. I would be very pleased to arrange a meeting with Martin McShane, director for long-term conditions at NHS England, so that the British Lymphology Society may discuss its concerns about improvements in lymphoedema care. Of course, that would include any noble Lords or noble Baronesses who want to attend that meeting.

The issue of education has been raised. The regulatory organisations of the UK medical professions, such as the General Medical Council and Nursing and Midwifery Council, set the standards for education and training and ensure educational institutions meet those standards in their delivery of the curriculum. I have no direct personal experience of this, and I know that the noble Baroness, Lady Finlay, for example, and my noble friend Lord McColl, do have direct experience, but, as I understand it, the lymphatic system and its important physiology is a fundamental part of undergraduate medical, nursing, physiotherapy and occupational therapy courses. I cannot verify that myself, but I am told that it is the case. This enables nurses, occupational therapists and physiotherapists to apply their clinical reasoning and manual skills to a patient suffering from lymphoedema. There are universities that offer postgraduate qualifications, including to Masters level, for those qualified healthcare professionals who wish to specialise in this area. In addition to this, the British Medical Journal provides an online learning course on lymphoedema.

Much of the service improvement guidance in England around lymphoedema has developed as a result of the national initiatives to improve cancer services and, more recently, a growing recognition of the support cancer survivors need for ongoing health problems after cancer treatment. A number of noble Lords have raised the point about the equity of those who suffer from this conditions because of cancer and those who suffer from other causes. That raises a broader issue about cancer more generally—that we spend more resource on cancer than almost any other condition, for all kinds of reasons. It is perhaps inevitable that those conditions associated with cancer get possibly earlier diagnosis and greater resources devoted to them. That raises broader issues about cancer and the treatment of other conditions.

Over the last five years, this Government have worked with Macmillan Cancer Support, NHS improvement organisations and NHS England to continue to drive forward the cancer survivorship agenda—first, through the national cancer survivorship initiative and then through the living with and beyond cancer programme, which was set up in June 2014. On 19 July 2015, Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020 was published by the independent cancer taskforce. It recommended that NHS England should accelerate the commissioning of services for cancer survivors, including the development of a minimum service specification to be commissioned locally for all patients, based on the recovery package.

The noble Baroness, Lady Masham, raised the issue of research. Through the National Institute for Health Research, we are funding a £1.8 million programme of research, looking at how breast cancer treatment can be individualised to improve survival and minimise lymphoedema and other complications.

I am sure that what I have said has not resolved a number of the issues that were raised by noble Lords. However, this debate has raised the issue and awareness of it. The issues are quite profound, and the differences between different parts of the United Kingdom are relevant to this debate. Whether the curriculum for medical students—undergraduates and postgraduates—is sufficiently geared to lymphoedema is a question that needs to be looked at by Health Education England and the various deaneries. I can assure the House that the PSSAG and Sir Ian Gilmore will read this debate and will no doubt take into account the issues that have been raised. As I promised at the beginning, I will raise it with Sir Malcolm Grant at NHS England and ensure that the British Lymphology Society gets a proper apology.

House adjourned at 6.20 pm.

Health: Skin Cancer

Lord Prior of Brampton Excerpts

Wednesday 22nd July 2015 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what has been the increase in diagnosed skin cancer over the past 10 years.

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

My Lords, over the past 10 years in England, there has been a 61% increase in new cases of melanoma, the most serious form of skin cancer, and an increase of 41% in non-melanoma skin cancers. In 2012 there were 11,281 new cases of melanoma and 79,743 new cases of non-melanoma skin cancer.

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for that Answer, which shows an alarming increase in skin cancer. I understand that NICE is in the process of issuing new guidelines in this respect, due out this month. Will the Minister advise the House whether these guidelines are mandatory because they are so central to the Government’s campaign in fighting skin cancer, or are they merely “guidelines” and need not be followed? Secondly, is the Minister aware that there is concern among consultant dermatologists in hospitals that the clinical commissioning process may not be sufficiently robust to deal with this increased spate of skin cancers?

[Lord Prior of Brampton]

The NICE guidelines are due to come out at the end of July or in August. I believe that they are guidelines, not mandatory, although they should be read in the context of the report by Harpul Kumar, Achieving World-Class Cancer Outcomes. Cancer is a very high priority for this Government, and this may come out in further questions. In commissioning these services, we have to be very careful that we do not disaggregate dermatology services in hospitals; the provision of routine and complex emergency dermatology services and, of course, the training of dermatologists should be commissioned as a whole.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that consultant dermatologists often see patients who have been told by their GP that their mole was benign and did not require a biopsy? In the UK, the mortality rate is 20% compared with 12% in Australia for a similar number of cases. Given that outcomes are so closely linked to the thickness of the lesion and early diagnosis, what are the Government doing to make sure that GPs are trained to recognise the benign skin lesions and to refer the more dubious ones to consultants? I am aware that we ask a great deal of GPs, but what matters is training them to recognise these things and not wasting money and compromising patients by not referring them early enough.

[Lord Prior of Brampton]

Health Education England is aware that insufficient time is spent on dermatology issues in the training of junior doctors, and it is considering that very seriously.

[Baroness Gardner of Parkes (Con)]

My Lords, as someone who had skin cancer 40 years ago, I have a check-up every year. The services are excellent but the most important thing in the context of this Question is that we are now getting the early diagnosis. Does the Minister agree that the most important thing is to raise public awareness, as has been done in Australia, where malignant melanoma, it is believed, can pretty well be eliminated? The important thing is to raise public awareness so that the public go to their doctors and demand to be referred. That is how we will continue to catch more cases at a stage when they can be treated.

[Lord Prior of Brampton]

I agree with my noble friend. What is needed is a combination of public awareness and early diagnosis.

[Baroness Masham of Ilton (CB)]

My Lords, are there enough dermatologists in England?

[Lord Prior of Brampton]

The noble Baroness makes a very interesting point. It is recognised that there are not enough trained dermatologists in England—I think the figure I have seen is 177. To put it in context, there are 650 consultant dermatologists in England, so the answer is that there are not enough. The growth in the problem, if I can put it that way, seems to be running at about 3.5% a year. We are behind on this and need to catch up.

[Baroness Wall of New Barnet (Lab)]

My Lords, will the noble Lord share with us the discussion going on in the Department of Health about the many young people being treated for skin cancer because of the sunbed culture that has come about? Regrettably, we have noticed in my hospital in Milton Keynes that that is becoming an increasing problem. We did a grand job in making people aware of the dangers of smoking, and we still are, but nobody seems to be explaining just how dangerous some of these things are.

[Lord Prior of Brampton]

The noble Baroness is right but a law was passed in 2010, I think, banning the use of sunbeds on commercial premises by children under the age of 18. That law has had an impact but, in a sense, one can never do too much to raise public awareness, and we should do more.

[Baroness Sharples (Con)]

I have very recently had two areas of skin cancer. If you have any suspicions, is it not absolutely vital to see your doctor?

[Lord Prior of Brampton]

My noble friend makes a very sound point. Harpal Kumar’s task force produced a report entitled Achieving World-Class Cancer Outcomes. If anyone wants a little bit of holiday reading, it is well worth reading at least the three-page letter at the front of the report. He recommends in the report that if a GP has a 3% or greater suspicion of cancer, the person in question should be referred for further investigations.

[Lord Bradley (Lab)]

My Lords, there is a clinical trial known as Matilda at the world-renowned Christie Hospital in Manchester, funded by the Medical Research Council and the National Institute for Health Research. This aims to treat patients with melanoma using their own white cells, which can recognise and destroy cancer cells. It was approved in 2014 but then halted because excess treatment costs, which should be funded by the NHS, were not forthcoming. I understand that the Secretary of State for Health has said that this issue will be sorted by early 2015. Can the Minister advise the House when this crucial clinical trial for the treatment of skin cancer will be progressed?

[Lord Prior of Brampton]

I am not aware of the trial at the Christie called Matilda; I will take this issue away and write to the noble Lord.

Police: Ambulance Support

Lord Prior of Brampton Excerpts

Thursday 16th July 2015 Lords Chamber

[Lord Harris of Haringey (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and draw attention to my interests in the register.

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

The public deserve the right service from the right organisation at the right time. Only ambulances should be used to transport patients to A&E as only ambulances are clinically equipped and staffed to do so. Incidents where the police transport patients to hospital are very rare and the emergency services continue to work together to reduce them further.

[Lord Harris of Haringey]

I am grateful to the Minister for that Answer; however, I think he is incorrect in saying that it is a very rare occurrence. Freedom of information requests have shown that the number of cases of people being taken to hospital to accident and emergency departments runs in the thousands in recent times. He is also aware, because he sent the figures to me, that, for example, in London the ambulance service has failed to meet its emergency target in terms of time in every single London borough in each of the last three months. What exactly do the Government think they are doing about making sure that there is adequate coverage for the emergency services? Is the intention that, despite all the Minister’s fine words about the importance of ambulances, the reality is that the police will have to act as paramedics?

[Lord Prior of Brampton]

I do not think that the noble Lord is right. The actual number of times that police transport patients to A&E is less than 0.1% of all such conveyances. I agree that there are some particular problems in London. There is a shortage of paramedics and they have an active recruitment plan to correct that. There have also been management problems in the London Ambulance Service and its performance, to which the noble Lord correctly draws attention, has not been good enough. There is now a new chief executive of the London Ambulance Service, who is fully aware of the issues. She has recently published the report about the levels of bullying in the London Ambulance Service, which are very distressing. The fact that that has been published and that she has acknowledged it give me hope for the future.

[Lord Condon (CB)]

My Lords, building on the point made by the noble Lord, Lord Harris, is the Minister aware that in recent months in London—and also outside—there has been a significant increase in the use of police officers to invoke emergency powers under the Mental Health Act to take people who are mentally ill to a place of safety? While police officers have a can-do mentality, it is disturbing that they are being used to deal with mentally ill people because of an absence of other professions to deal with this. It warrants an assessment of their use in relation to mental health.

[Lord Prior of Brampton]

The noble Lord raises a very important point. Apart from being an extra drain on the resources of the police, it can often exacerbate a mental health problem if someone who is already very distressed ends up being transported in a police vehicle. Under the mental health concordat, to which all ambulance services are signed up, they are committed to reducing the number of times that people detained under the Mental Health Act are transported in police vehicles. We will monitor performance against that very carefully.

[Lord Patel of Bradford (Lab)]

My Lords, the Mental Health Act code of practice clearly says that people with mental health problems should not be transported by police vehicles. In the Midlands the ambulance service transports roughly 75% of people with mental health problems—that is reasonably good but not acceptable—while in Lancashire the figure is as low as 5% and in London it is 30%. Have the Government made any assessment of this, given what the Home Secretary said about police cells being completely inappropriate places of safety for people with mental health problems? Police vehicles should not, wherever possible, transport mental patients.

[Lord Prior of Brampton]

The noble Lord is right: it is quite wrong for people to be detained under Section 136 in police cells. It is also wrong that people suffering from severe mental health problems are transported in police vehicles. I am not aware of the figures that he gave for the West Midlands in comparison with other parts of the country but I will look at them very carefully.

[Lord Paddick (LD)]

My Lords, would the Minister—

[Baroness Gardner of Parkes (Con)]

My Lords, I am sitting next to a living example of the situation that we are discussing about the police helping. We are all delighted to welcome back my noble friend Lady Knight. She was found in her garden by her gardener, who was convinced that she was dead. He was terrified and immediately decided to call the police. Eventually she got to hospital by ambulance in enough time, but under those circumstances, when you call the emergency services, how much time does it take to decide who you are going to send—the police or an ambulance? Naturally, if she had been dead, the police would have been the most appropriate people.

[Lord Prior of Brampton]

I am sure that my noble friend will never die; she is clearly immortal. When you dial 999, the ambulance service has eight minutes to respond in such a serious matter as my noble friend has described. Then a fully equipped ambulance must arrive within 19 minutes. In the last two months, 75% of all such “A Red” calls have been met by the ambulance services.

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Prior of Brampton]

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

NHS: Reform

Lord Prior of Brampton Excerpts

Thursday 16th July 2015 Lords Chamber

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

My Lords, with the leave of the House, I will now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows.

“With permission, Mr Speaker, I would like to make a Statement on measures to improve the safety culture in the NHS and further strengthen its transition to a modern, patient-centric healthcare system. The failings at Mid Staffs detailed in the Francis report were not ‘isolated local failures’. Facing up to widespread problems with the safety and quality of NHS care and learning the appropriate lessons has been a mission which the Government and the NHS have shared, with a common belief that the best way to deal with problems is to face up to them, rather than wish they did not exist.

Measures taken in the last Parliament include introducing the toughest independent inspection regime in the world, more transparency on performance and outcomes than any other major healthcare system, new fundamental standards, a duty of candour and the excellent recommendations made by Sir Robert Francis QC. But because the change we need is essentially cultural, a long journey still remains ahead. The Department of Health was described during the Mid Staffs era as a ‘denial machine’. We therefore have much work to do if we are to complete the transformation of the NHS from a closed system to an open one, from one where staff are bullied to one where they are supported, and from one where patients are not ignored but listened to.

So today I am announcing some important new steps, including our official response to Sir Robert Francis’s second report, Freedom to Speak Up; our response to the Public Administration Committee report, Investigating Clinical Incidents in the NHS; and our response to the Morecambe Bay investigation. I am also publishing the report of the noble Lord, Lord Rose, into leadership in the NHS—a key part of the way we will prevent these tragedies happening again. I would like to thank everyone involved in writing those reports for their excellent work.

In his report, Freedom to Speak Up, Sir Robert Francis QC made a number of recommendations to support this cultural change. All NHS trusts will appoint someone whose job is to be there when front-line doctors and nurses need someone to turn to with concerns about patient care that they feel unable to raise with their immediate line manager. We will also appoint an independent national officer, located at the Care Quality Commission, to make sure all trusts have proper processes in place to listen to the concerns of staff, before they feel the need to become whistleblowers. Other changes will include information about raising concerns as part of the training for healthcare professionals and curriculum for medical students, as well as a greater focus on learning from reflective practice in staff development.

Dr Bill Kirkup’s report into Morecambe Bay brought home to this House that there can be no greater pain than for a parent to lose a child and then find that pain compounded when medical mistakes are covered up. We will accept all of the recommendations in this report, including removing the Nursing and Midwifery Council’s current responsibility and accountability for statutory supervision of midwives in the United Kingdom and bringing the regulation of midwives into line with the arrangements for other regulated professions.

Likewise, we agree with the vast majority of the recommendations of the excellent report of the Select Committee on Public Administration into clinical incident investigations. In particular, we will set up a new independent patient safety investigation service by April 2016, based on the success of the ‘no blame’ approach used by the Air Accidents Investigation Branch in the airline industry. It will be housed at Monitor and the TDA, which have the important responsibility of promulgating a learning culture throughout the NHS. Monitor and the TDA will operate under the name ‘NHS Improvement’ and Ed Smith, currently a non-executive board member of NHS England, will become the new chair, with a brief to appoint a new chief executive by the end of September.

For NHS managers, the report of the noble Lord, Lord Rose, Better Leadership for Tomorrow, makes vital recommendations to join up the support offered to NHS managers, to improve training and performance management and to reduce bureaucracy. He extended his remit to cover the work of clinical commissioning groups, which play a key role in the NHS, and today I am accepting all 19 of his recommendations in principle, including moving responsibility for the NHS Leadership Academy from NHS England to Health Education England.

These are important recommendations, which, in the end, all share one common thread: the most powerful people in our NHS should not be politicians, managers, or even doctors and nurses—they should be the patients who use it. Using the power of intelligent transparency and new technology, we now have the opportunity to put behind us a service where you ‘get what you are given’, and to move to a modern NHS where what is right for the service is always what is right for the patient.

A litmus test of this is our approach to weekend services. Around 6,000 people lose their lives every year because we do not have a proper seven-day service in hospitals. You are 15% more likely to die if you are admitted on a Sunday, compared with being admitted on a Wednesday. This is unacceptable to doctors as well as patients. In 2003-4, the then Government gave GPs and consultants the right to opt out of out-of-hours and weekend work, at the same time as offering significant pay increases. The result was a ‘Monday-to-Friday’ culture in many parts of the NHS, with catastrophic consequences for patient safety. In our manifesto this year, the Conservative Party pledged to put this right, as a clinical and a moral priority.

So, I am today publishing the observations on seven-day contract reform for directly employed NHS staff in England by the Review Body on Doctors’ and Dentists’ Remuneration and the NHS Pay Review Body. They observe that some trusts are already delivering services across seven days, but this is far from universal. According to the DDRB, a major barrier to wider implementation is the contractual right of consultants to opt out of non-emergency work in the evenings and at weekends, which reduces weekend cover by senior clinical decision-makers and puts the sickest patients at unacceptable risk. The DDRB recommends the early removal of the consultant weekend opt-out, so today I am announcing that we intend to negotiate the removal of the consultant opt-out and the early implementation of revised terms for new consultants from April 2016. There will now be six weeks to work with the BMA union negotiators, before a September decision point. We hope we can find a negotiated solution, but are prepared to impose a new contract if necessary. To further ensure a patient-focused pay system, we will also introduce a new performance pay scheme, replacing the outdated local clinical excellence awards, to reward those doctors making the greatest contribution to patient care.

I am also announcing other measures today to make the NHS more responsive to patients. These include making sure patients are told about CQC quality ratings, as well as waiting times, before they are referred to hospitals, so that they are able to make an informed decision about the best place to receive their care. NHS England will also develop plans to expand control to patients over decisions made in maternity, end-of-life care and long-term condition management, which I will report in more detail subsequently to the House. Finally, because the role of technology is so important in strengthening patient power, we must ensure no patient is left behind in the digital health revolution. I have therefore asked the noble Baroness, Lady Lane-Fox, formerly the Government’s Digital Champion, to develop practical proposals for the NHS National Information Board on how we can ensure increased take-up of new digital innovations in health by those who will benefit from them the most.

When we first introduced transparency into the system to strengthen the voice of patients, some called it ‘running down the NHS’. In fact, since then public confidence in the NHS in England has risen 5 percentage points. By contrast, Wales, which resisted this transparency, saw public satisfaction fall by 3 percentage points. Over the last Parliament, the proportion of people who think the NHS in England is among the best healthcare systems in the world increased by 7 percentage points; those who think NHS care is safe increased by 7 percentage points; and those who think they are treated with dignity and respect increased by 13 percentage points. This demonstrates beyond doubt the benefits of an open, confident NHS, truly focused on learning and continuous improvement.

But as we make progress in this journey, we must never forget the families who have suffered when things have gone wrong—in particular, the families and patients at Morecambe Bay and Mid Staffs, the whistleblowers who contributed to Sir Robert Francis’s work and everyone who has had the courage to come forward in recent years to help reshape the culture of the NHS. Without their bravery and determination, we would not have faced up to the failures of the past, nor been able to construct a shared vision for the future. We are all massively in their debt; this Statement remains their legacy and I commend it to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Baroness Walmsley (LD)]

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

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

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

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

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

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

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

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

[Lord Prior of Brampton]

My Lords, I thank the noble Lord and the noble Baroness for their comments. I was quite depressed listening to the noble Lord opposite. We had a debate in this House last week and we talked about a sense of political consensus on the NHS. I start by saying—rather personally—that, having listened briefly this morning to his right honourable friend Andy Burnham in the other place misquote me out of context from the debate that we had last week, I thought that there was no hope of a non-partisan approach to the NHS. For the avoidance of any doubt from anybody, and as I think I made pretty clear in last week’s debate, I believe fundamentally and passionately in a universal, tax-funded healthcare system—the NHS—that is free at the point of delivery and based on clinical need, not ability to pay. Having looked back on it, I do not remember uttering a word in that debate that would question that statement. Therefore, I hope the noble Lord opposite might have a word with his right honourable friend in the other place to make it absolutely clear that playing cheap party politics has no place in our discussions about the NHS.

Turning to the comments about my right honourable friend the Secretary of State for Health’s Statement today, seven-day services are in many ways at the heart of it. Thousands of people are dying because we do not provide seven-day services in hospitals. We cannot carry on with a system with thousands of people dying. It is not just that thousands of people are dying. The health of thousands of people is deteriorating in our hospitals over the weekend.

This is an anecdote, which may be unfair. However, two years ago, I met a radiologist walking down the corridor in an NHS hospital on a Friday morning. His wife had been admitted through A&E. She had abdominal pains. He could not get her a scan. She was going to have to wait in that hospital until Monday. Had it been a bank holiday, she would have had to wait in that hospital until the following Tuesday before she had that scan. That is an anecdote, but we know that it is happening all the time. It is unacceptable.

So I ask the noble Lord opposite to be more enthusiastic about this. Of course it will be difficult. This Government are putting in £8 billion of new money. This is more money than his party was prepared to offer before the election. It is the same amount of money that the noble Baroness’s party was offering to put in. This is £8 billion of additional money that we are putting into the NHS. It is a critical part of our strategy. It was laid out in our manifesto and is in the NHS Five Year Forward View that we would make seven-day services a main plank of these reforms. For those people who think that this cannot be afforded, put yourself in the position of a chief executive of an NHS hospital that works four and a half days a week because theatres stop work at lunchtime on Friday. Often, they do not start again until Monday lunchtime because every bed is taken up when they come in to work on Monday morning. Across the country, thousands of consultant surgeons, theatre staff and anaesthetists are hanging about on Mondays because they cannot start their work. This is because there is not a bed in the hospital because the flow of patients through that hospital came to a grinding halt on Friday. The noble Baroness is right that this is not just a hospital issue but about joined-up care. You cannot get the discharges out of the hospital unless social care, the physios and the OTs are working—the whole system needs to be working. Seven-day working is not only right for patients but will enable our hospitals to work much more efficiently.

I will pick up a few other issues. I remember when the 2003 contract was voted on by consultants. In my view, it was a disastrous contract, which deprofessionalised many professional consultants. They voted against it the first time and voted for it, grudgingly, only the second time. They voted for it because their pay went up by 28% as a result of it and they could opt out of providing care over weekends and outside normal hours—of course they voted for it. Looking back on it, some of the noble Lords and Baronesses opposite will maybe accept that it was a disastrous contract. It deprofessionalised a deeply vocational profession and fundamentally changed the culture of the NHS—a culture that we are now trying to change once again.

I welcome the comments of the noble Lord and the noble Baroness about Sir Robert Francis’s report on whistleblowing. We want an open culture, in which whistleblowing is a thing of the past. I agree with the noble Baroness that whistleblowing is not a great name. It would be great if we never heard about whistleblowing ever again because people felt able to raise their concerns in a proper, central and safe way and knew they could raise them without fear of any detriment to their employment prospects. The proposals put forward by the Public Administration Select Committee, which have been taken up by the Secretary of State for Health, are absolutely right. We need a safe place for when things go wrong.

I turn to the Rose report. Leadership is fundamental. Around a hospital, one ward will be doing well and one will not because there is a good ward sister in the first one; one hospital will be doing well and one will not because of good local leadership in the former. Leadership is absolutely fundamental, and I subscribe to all the comments that my noble friend Lord Rose has made in his report.

The noble Lord’s comments about the TDA and Monitor are harsh. David Bennett and others in those organisations have done a very good job in very difficult circumstances. We are fundamentally changing the roles of TDA and Monitor. Together, they are now, as the name suggests, an improvement agency first and a regulator second. The new role of the TDA and Monitor in NHS improvement will fundamentally change the way we approach performance management and improvement. The Secretary of State for Health alluded to the contract that the TDA recently signed with Virginia Mason, one of the safest hospitals in the world, which is one way of bringing best world practice into the NHS.

I will conclude on the context. Times are difficult in the NHS and we should not pretend differently. This Government are absolutely committed to seeing this transformation programme through. The noble Lord opposite said he did not know anybody who thought that we could achieve the £22 billion in savings that are set out in the NHS Five Year Forward View—he knows me.

[Baroness Blackstone (Lab)]

My Lords, I declare an interest as the chairman of the Great Ormond Street Hospital Foundation Trust. Before I put my questions to the Minister, I will just make one brief comment on his remarks about the Opposition. I have no idea what the shadow Secretary of State for Health said in another place, but I will defend what my noble friend Lord Hunt has just said. He said that he agreed in principle with a great deal of the Statement, but it is legitimate for the Opposition to ask questions about how a Statement of this sort might be implemented, which is what he was doing.

I have two questions, the first about bureaucracy. The Minister said that he wished to see a reduction in bureaucracy. As a chairman of a trust, I entirely identify with that. However, some of the bureaucracy is in the regulators, and I hope that his attack on bureaucracy will cover the regulators. The Government are about to set up another outside agency, which will put further bureaucratic pressure on those who are delivering services upfront. Anything he can do to try to reduce that would be helpful.

My other question concerns seven-day services. Again, I entirely endorse what the Government wish to do with respect to seven-day services—if anything, they are overdue—but there are questions to be asked. What is the timetable for this, if it is only going to apply to new consultants? It will take a very long time to introduce seven-day services if only new consultants are going to go on to the new contract requiring them to work at weekends. I understand why the Government are doing that, but it will make for a very long delay. What steps will the Government take to try to encourage existing consultants, who will be far greater in number than the flow of new consultants, to adjust to a new approach where seven-day services are introduced in the interests of patients?

[Lord Prior of Brampton]

I can only agree with the noble Baroness on bureaucracy. The new body that we are setting up to look at incident reporting, as recommended by the PAC, will only look at big incidents so will not be an added bureaucracy for the day-to-day running of a trust. I am always struck by the figure that nurses spend only between 70% and 80% of their time dealing directly with patients because they are dealing with bureaucracy. The bureaucracy argument falls into two parts: it is partly about the way hospitals run their affairs and partly about external regulators. We believe fundamentally in intelligent transparency. I see the CQC, for example, as less a regulator and more a means of providing intelligent information to boards of hospitals and to patients. But I take on board what the noble Baroness says. We will do everything we can to reduce the level of bureaucracy.

As far as the timetable is concerned, junior doctors will switch over much more quickly than consultants, because they turn over much more quickly. It will take time for consultants to move over to the new contract, but we hope that we can make it more attractive to consultants and that it will be more of what I would call a professional contract, so that existing consultants will switch over to it as well as new consultants. We will have to watch that very carefully.

[Baroness Finlay of Llandaff (CB)]

The way that the Minister has been speaking has made it sound as if the majority of consultants do not work on weekends, and I question the validity of that. The consultants who are on and on call are dealing with emergencies at the weekend and are very often in. However, without diagnostic back-up, without physiotherapy and occupational therapy, without specialist nurses and without community services to which they can discharge patients, they effectively have to function with one hand tied behind their back—sometimes both. You cannot provide modern medicine without that broader team. If you are going to free up hospital beds, you have to be able to discharge patients safely, knowing that they will have the care they need. The 24 hours post-discharge is when patients are at their most vulnerable.

I will question one thing the Minister said. He gave a six-week timeframe for the BMA. Does that also apply to the NHS Pay Review Body negotiations? What will be done to make sure that all the other staff also move on to contracts that will provide that infrastructure, right through from operating department staff to, as I said, allied healthcare professionals and so on?

The Statement referred to end-of-life care. Could the Minister inform the House when there will be a response to the report What’s Important to Me. A Review of Choice in End of Life Care, which was undertaken for the National Council for Palliative Care? I declare an interest as its incoming chairman. It has been submitted to the Department of Health, but there has still not been a response to it, even though it has been universally welcomed by both providers and patient groups.

My last question relates to digital innovation. I welcome the fact that the noble Baroness, Lady Lane-Fox, with her tremendous skills, will be brought in. What are the Government’s targets and how rapidly are they planning to roll out digital innovations? Will they undertake in the process to decrease the paper-load bureaucracy, so that staff can be freed up to deliver front-line patient care, and are not caught by risk-averse processes and procedures that force them to spend a lot of time in documenting or double-checking, when the evidence base for that improving patient care is extremely thin?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Baroness raises a number of points. Of course, she is right that it is no good just having senior doctors in a hospital without the right back-up, particularly diagnostic specialist nursing. She has just mentioned OTs and physios, and I agree with her completely there.

The noble Baroness mentioned the NHS pay review. There is not an opt-out clause in the Agenda for Change contract. Discussions will be taking place with the RCN and other trade unions later this year. I will have to write to her about the timing of the response on the end-of-life care point that she raised; I do not know it offhand. Digital information will be rolling out progressively over the next five years. I certainly hope that we will have electronic patient record in place for the vast majority of patients over the lifetime of this Government.

[Baroness Browning (Con)]

I welcome my noble friend’s announcement—I hope that he will take some cheer from that. I have too often been an emergency admission at a weekend and know only too well that if you have to wait to see the consultant on Monday you simply end up bed-and-breakfasting for two or three nights in hospitals. I hope that my noble friend will take into account how having a consultant available for those sorts of patient would save a lot of money, free up a lot of beds and achieve what he is describing.

I know that Ministers do not like to micromanage what goes on in hospitals, but with the transition to new contracts for new consultants, I hope that my noble friend will find a way to identify those particular disciplines in hospitals where there are more deaths—he mentioned this—so that attention can be given to consultants with new contracts in those disciplines. An aortic aneurysm needs a consultant standing by the patient, but with other easily identifiable conditions it would be good if the Government could make sure that hospitals proactively recruit consultants on new contracts to ensure that the 6,000 deaths that he mentioned come down as rapidly as possible.

[Lord Prior of Brampton]

I was interested by my noble friend’s comments about waiting until the following Monday when she has been in hospital. That is a good illustration of why we want to bring in seven-day services. My noble friend might be interested to read the report in Future Hospital, written by the Royal College of Physicians, that came out a year ago. I think that we will see over the next few years a significant change in the way that our hospital consultants are trained and deployed, and more generally what is called in America hospitalists, who can have a broader range of disciplines.

When it comes in, the new contract will enable us to differentiate payment for those consultants who are working more anti-social hours, such as A&E consultants who will have to work much more regularly out of hours than others. It will enable us to identify those consultants who may be on call but are more likely to be summoned in, like those that my noble friend just mentioned, at short notice. Depending on the surgical specialty, the on-call requirements can be much more demanding than others. For example, this is more the case if you are a vascular surgeon than if you are a dermatologist, who do most of their work in normal time. I take on board what my noble friend says.

[Lord MacKenzie of Culkein (Lab)]

My Lords, no one will disagree with the concept of a seven-day-week health service. I was at the wrong end of a catastrophic surgical error that meant instead of one night in hospital I was there for six months. I dreaded weekends, and I dreaded them even more if there was a bank holiday attached, as has already been mentioned.

If we want to deal with party politics, can I explode the myth that has been peddled that the Labour Government were responsible for the five-day-week approach, because of the consultant contract? For many years I was a theatre nurse. I never scrubbed on a Saturday or a Sunday in the 1960s or 1970s. Hospitals ran on a five-day-week then, so it is quite wrong to suggest that this is all the fault of the consultant contract a few years ago.

I agree with my noble friend Lord Hunt of Kings Heath. If we want to have endoscopy suites open, radiography, radiologists, and nurses manning theatres and recovery rooms on Saturdays and Sundays, we must have more of these professions. If we do not, we shall diminish them on Mondays, Tuesdays and Wednesdays, and we will not be much further forward. Will the Government commit to increasing training places for all of these professions, together with consultants such as radiologists, as I suspect that we have many fewer of those than in most other developed countries?

[Lord Prior of Brampton]

Interestingly, the number of consultants has increased very significantly over the past 15 years across not all but most specialities. The noble Lord refers to dreadful weekends, and how he dreaded them, particularly bank holidays. That is really why we are here today, so that in future patients like him do not dread them.

If I indicated earlier on that I blame the 2003 contract for the difference between five days’ and seven days’ working, and if that was the implication of what I said, I withdraw it. What I meant to say was that I felt that that contract to some extent de-professionalised the profession.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, most people will welcome much of what is in the Statement.

I would like to come back to the issue of seven-day working that in principle this side supports and accepts. Some of the problems that we have at the moment in the NHS are the top issues with patients. We keep talking about patients being “top of the tree” and being in charge. Can the Minister tell the House what issue about NHS performance at the moment disturbs patients most of all? We have a list of issues where we are doing well: tell us what is worst.

The worst is the inability to access a GP, on a timely basis, five days a week, not seven days a week. This is not new. The position was bad in 2010, when Labour, my party, was in power, but it deteriorated while the Lib Dems and the Conservatives were in the coalition. I can point to Questions in Hansard raised in 2012, when we were promised by the noble Earl, Lord Howe, that discussions were taking place in the profession about trying to improve access to GPs, particularly where there were problems in London. I speak as a patient with a GP in London, who asks how he is to provide a seven-day week service when he cannot get the GPs and does not have the money to do it.

My noble friend Lord Hunt asked a basic question which is of prime concern to people, particularly in London. Will spreading this over seven days until such time as you can provide the 5,000 trained GPs who were promised, which will be seven years down the road, lead to a further deterioration in the ability to access a GP during the week?

[Lord Prior of Brampton]

There is no doubt that, looking forward over the next five years, the resource to be put into primary care will be greater, relatively, than it has been in the past. We wish to deliver more care outside hospital. That is why we are committed to training and having in place 5,000 more doctors in general practice by the end of this Parliament—not just GPs, but others who will support GPs.

The model of primary care will change significantly over the next five years, and it is fundamental to the five-year forward view that we reduce the number of people going into acute hospitals and that we discharge people at the other end of their journey through an acute hospital much quicker.

[Baroness Tyler of Enfield (LD)]

My Lords, I welcome the principle of working towards a weekend service—indeed, I think it is hard not to—but I certainly do not underestimate the difficulty of achieving it, particularly in a fully joined-up way. This morning, I attended a meeting with many children and young people who had experienced a serious mental health crisis at the weekend and had real difficulty accessing the treatment they needed. Indeed, some of them had turned up at A&E but there had simply been no mental health services available for them. In the light of that, will the Minister reassure me that the principle of seven-day working will apply to consultants from mental health disciplines, particularly those treating children and young people whose access to those services seems to be even harder to secure than it is for adults? Secondly, the Statement talked about CQC quality ratings as well as waiting times being made accessible to patients. Will he confirm that these will include waiting times for mental health services?

[Lord Prior of Brampton]

The Government are committed to parity of esteem, and if we are truly committed to parity of esteem the answer to both the noble Baroness’s questions must be yes. We must have the same standards for physical health as we have for mental health. If someone has a psychotic crisis on a Friday afternoon and they cannot get access to any help until the following Monday, that is clearly extremely poor care. If they end up in an A&E department being looked after by people who have no experience of dealing with mental health problems, it is a very poor environment to be in, so I agree entirely with the noble Baroness.

[Lord Turnberg (Lab)]

My Lords, I, too, welcome the Statement and many of the things in it. We accept that higher mortality rates at weekends in hospital are unacceptable, so we have to try to think of ways of reducing them. Seven-day working for consultants is just one element. Consultants are important, of course. The Minister is probably aware of Brian Jarman’s publication some years ago which showed that there was an inverse correlation between the number of doctors in a hospital and the mortality rate; that is, a hospital with more doctors had a lower mortality rate. There are lessons to be learned there, especially as we in the UK seem to have fewer doctors per head of population than almost any other OECD country, and fewer beds come to that—so we are starting from a low ebb, and the points made by noble Lords about where we are going to get the extra people from are important.

However, the consultant element is just one part. The noble Baroness, Lady Finlay, made a very good point about the need for radiologists, physiotherapists and pathology laboratories. All the machinery of the hospital has to be there. Equally, there is the whole business of general practice and community care. Primary care at the weekend is poor, by and large; that is one of the major problems. Patients are not getting into hospital until they are in greater extremis, so they are more ill when they get there: then they require more service, and once they are there, they cannot get home because there is no one to see them home. Concentrating on consultants is just one element. What is the Minister’s response?

[Lord Prior of Brampton]

The noble Lord, Lord Turnberg, knows the situation on the ground as well as anybody in this House and, of course, he and the noble Baroness, Lady Finlay, are absolutely right that this will not be solved just by having more consultants in acute hospitals. We have to look right the way across social care, primary care, community care, mental health care and acute care. We are talking about a system. In many ways, one of the reasons why we find ourselves in the position we find ourselves in today is that we have not had a system for some time. We have deliberately broken up the system for good reason.

I was very much in favour of foundation trusts having their own balance sheet and their own profit and loss account because of increased accountability, but disadvantages have flowed from that. Chief executives in acute hospitals look after their own. They have treated themselves as an island. We are not part of an island. Rebuilding the system will take some time. It is not going to happen tomorrow, and there is no silver bullet. All I can say is that the Government are committed to the five-year forward view, the new models of care and joined-up care. We are committed to experimenting with accountable care organisations, integrated care organisations and all kinds of joined-up models. We are seeing exciting developments in Manchester and possibly, in time to come, in Cornwall and other parts of the country where we will have pooled budgets between social care and healthcare. I am confident that over the next five years we will if not solve these problems, at least go a long way to doing so.