The Long-term Sustainability of the NHS and Adult Social Care

Lord Rea Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Rea (Lab)]

My Lords, I add my congratulations to those that have already been given to my noble and professional friend Lord Patel and his Select Committee for a very complete and relevant analysis. I declare an interest as a retired NHS GP and a fellow of the Royal College of General Practitioners who has also worked in epidemiology. I am also honorary president of the UK Health Forum, a think tank linking some 60 organisations interested in primary prevention. I am pleased that evidence from both these bodies is cited in the Select Committee’s report.

I would like to say also that I have now joined the age group that gives the NHS the most trouble. I have had to use the NHS more in the past five years than I did in the whole of my life before that. Every time I have received care, I have been impressed by the courtesy, good humour and skill of the staff, even when they have been under very great pressure.

The report makes plain—as does most informed opinion—that greater resources are needed. I am repeating what nearly every other noble Lord has said. The Office for Budgetary Responsibility points out that the percentage of GDP spent on health in the UK, 7.4% in 2015-16, is low compared with other comparable countries, and projects that on present trends it will fall to 6.8% in 2020. As practically all other speakers have said, the NHS and social care have suffered for too long from short-termism and, recently, from serious underfunding, which makes intelligent planning difficult.

Our demographic problem of an ageing population with an increasing need for care is well documented but has not been acted upon adequately—if at all. Prevention in particular has been neglected. Despite the intention of the five-year forward view to step up preventive activities, progress has been slow and has not been made any easier by the Government’s recent cutbacks to local authority funding for public health.

The history of public health includes many examples of products that are harmful to health but whose manufacturers resist calls to reduce or change their composition or their promotion. The tobacco industry is of course the prime example of powerful and dishonest but extremely skilled resistance to all measures—and it is still doing so. The alcohol and food industries are now doing much the same. Simon Stevens says that,

“obesity is the new smoking”.

Voluntary agreements to make products less harmful have had only limited success. In the end, mandatory regulation will have to be brought in, as have most successful public health measures in the past, beginning with the water companies more than one and a half centuries ago when cholera was rife. Governments initially shy away from regulation, such is the lobbying pressure that industry can exert. Recently, proposed robust restrictions on food promotion to children were delayed and toned down. Why?

Health education messages will have less effect when the harmful habit concerned is ingrained and there are strong social and commercial pressures to continue it. Some noble Lords may have seen Hugh Fearnley-Whittingstall’s TV programme on fast food promotion last night—exactly this topic. Poor housing, depressing environments, unemployment and dead-end jobs make it more difficult to break habits that give temporary relief, such as smoking, alcohol, drugs or takeaway junk food, often sweet and containing too much sugar.

In such circumstances, to say that people need to change their lifestyle amounts to a form of victim blaming. More resources need to be directed to those living in deprived communities. To promote good housing and employment opportunities is part of the wider agenda of public health. The closer liaison of local authorities with public health, which was one of the better parts of the 2012 Act, has been frustrated by funding cuts.

Finally, I will say a word about the Select Committee’s recommendation to set up a new high-level independent standing body on the lines of the Office for Budget Responsibility, with the power to advise on all matters relating to the long-term sustainability of health and social care, and which will report directly to Parliament. It should continually look forward for 10 or even 20 years. I agree with the right reverend Prelate the Bishop of Carlisle that this is an excellent plan which should lead to continuity and diminish short-term political pressures on health policy.

Older Persons: Human Rights and Care

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Thursday 16th November 2017 Lords Chamber

[Lord Rea (Lab)]

My Lords, my noble friend Lord Foulkes has done an excellent job as rapporteur for the Council of Europe’s Parliamentary Assembly, and we should thank him for presenting this report so well. It is an important contribution to the increased international concern for the human rights of older people. Your Lordships’ House is uniquely qualified to debate this issue, since exactly half of our membership is aged 70 or over. In fact, the psychogeriatrician Professor Tom Arie once described the House of Lords as an excellent model for a psychogeriatric day centre.

The report to the Council of Europe is thorough and cogent. It lists 14 measures that states should take towards,

“combating ageism, improving care for older persons and preventing their social exclusion”.

It says member states should,

“adopt a charter of rights for older persons in care settings to be used, inter alia, to empower older persons, as well as in the monitoring of long-term care institutions by an independent body”.

This has been touched on by several noble Lords already. The CQC is definitely a step in the right direction, but it needs better funding and more qualified staff. Here, I echo several other noble Lords who have spoken.

The purpose of the report is to stimulate Governments to take action to enact its recommendations, but it is not mandatory. If it were to be made part of an international convention, to be ratified by each of the states party to it, action would be more likely to follow. As the noble Lord knows, and as my noble friend Lord Foulkes mentioned, the UN has, since 2010, been hosting annual meetings of a working group on ageing. This is open ended, as my noble friend says, and is working towards the creation of a suitable UN convention on the needs of older people, to be ratified by member states.

However, a declaration such as the one we are discussing can still be influential in steering UN and national policy. I hope that it will influence the UN working group as it draws up a document to serve as a basis for an international treaty or convention. Perhaps the Minister can tell us about the progress being made by this group, and particularly the contribution of the UK representatives.

Life expectancy is increasing, but healthy, disability-free life lags behind by five to 10 years, strongly related to the level of social deprivation. Not only do those of lower socioeconomic status live shorter lives, but for more of that shorter life they live with disability, as has already been alluded to by several noble Lords. Many of the health problems of the old have their origins earlier in life. Most of their disease burden is due to chronic non-communicable disease—obesity, diabetes, cardiovascular disease, stroke, dementia and cancer—which is to a greater or lesser extent preventable, or at least whose onset can be postponed. A person with less disability in old age has usually had a lower burden of disease throughout life. Improving the health and lives of older people cannot be separated from measures needed to improve the health of the whole population. This is strongly influenced by the social determinants of health and disease, a topic which we have debated in the past in your Lordships’ House and which we will certainly debate again in the future.

NHS: Health and Social Care Act 2012

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Thursday 8th September 2016 Lords Chamber

[Lord Rea (Lab)]

My Lords, I thank my noble friend Lord Hanworth for bringing this important topic forward.

Before the 2010 election David Cameron specifically ruled out “a disruptive top-down reorganisation”, but this is what the Act has proved to be. It was also largely unnecessary: many of the changes brought about by the Act, particularly the beneficial ones—and, yes, there are quite a few—could have been achieved without new primary legislation. In my seven minutes, I will concentrate on public health and prevention, which is where my current involvement with health lies.

Twenty-three years after retiring from NHS clinical practice, I declare an interest as honorary president of the UK Health Forum, an independent but publicly funded body representing some 60 national organisations with an interest in “upstream” prevention of non-communicable disease—the “causes of the causes”. The Government have repeatedly emphasised the importance of prevention as the way to approach our current increasing load of chronic non-communicable disease. The Five Year Forward View, whose findings have been accepted by the Government, referred to the work of Derek Wanless, who warned some 15 years ago that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. The Five Year Forward View points out that that warning has not been heeded and that the NHS is,

“on the hook for the consequences”,

with an increasing burden of largely preventable chronic illness that can be expensively treated or cared for but mostly not cured. So I will concentrate on the sections of the 2012 Act which concern public health and the reduction of social inequalities which are at the heart of any policy to improve the health of the population.

Theresa May pointed out, in her first speech as Prime Minister, the “burning injustices” of the wide gap in health between the highest and the lowest socioeconomic groups of the population. As the noble Lord, Lord Prior, knows very well, this gap has been extensively studied by Sir Michael Marmot and his colleagues at UCL. They have shown that the mortality rates and incidence of most diseases—particularly those which form the main burden on health services today—are consistently related to social status across the board. The concept of the social determinants of health, first described in detail by Michael Marmot, is now recognised worldwide as basic to public health thinking. The 2012 Act includes changes in the provision of public health services that are potentially beneficial. Among measures that were given a guarded welcome by public health professionals in local government was the transfer of many public health functions from PCTs to local authorities. This change was logical, since local authorities have always been involved in some important public health activities. I could list other desirable changes related to the wider determinants of health, but it would take too long in a time-limited debate.

The concern of public health professionals about the move to local authorities was twofold: would the rearranged services be properly funded and would the status and independence of public health professionals within local authorities be assured? As noble Lords know, these concerns have been more than justified. The House of Commons Select Committee on Health’s report Public Health Post-2013, published just a week ago, states:

“There is a growing mismatch between spending on public health”,

which is set to reduce,

“and the significance attached to prevention in the NHS 5 Year Forward View”.

In fact the ring-fenced levels of local authority funding for public health were cut by £200 million last year, a move that was questioned in the House at the time by my noble friend Lord Hunt. This funding is on a steady downward trend until 2020, and will then have fallen in real terms by 25% since 2013. In addition, overall central government funding allocations for local authorities have been cut drastically since 2012, as everyone knows, affecting many local authority services which have a public health component. The Commons Select Committee on Health’s report concludes:

“Cuts to public health are a false economy. The Government must commit to protecting funding for public health. Not to do so will have negative consequences for current and future generations and risks widening health inequalities”.

These are strong words for a Select Committee.

The committee reports many other concerns about the functioning of the new arrangements and makes useful suggestions about how difficulties can be overcome, often using verbatim reports from witnesses describing both good and bad practices. I commend its excellent report—it should have a green cover but in the Printed Paper Office it has a white one—to the Minister and hope he will be able to say that the Government will accept its recommendations and enact them in full.

National Health Service

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Thursday 14th January 2016 Lords Chamber

[Lord Rea (Lab)]

My Lords, in my three minutes I will concentrate on one section of the NHS Five Year Forward View, published 18 months ago, headed “Getting serious about prevention”. It makes the point that we are reaping the consequences of failure to prevent chronic diseases that would be largely avoidable if only suitable changes in behaviour could be made. The former Chief Medical Officer exhorted people to change their so-called “lifestyles” and live more healthy lives—I think we know the list.

The five-year view does not emphasise sufficiently that these diseases are all strongly related to social conditions. As Sir Michael Marmot has shown, there is a gradient in both mental and physical health through all socioeconomic groups from the top to the bottom. Health education messages to change behaviour are, however, less effective in the lower part of the spectrum. Poverty and inadequate housing may make it more difficult to give up harmful habits such as smoking, drinking or comfort eating, which can give momentary relief from economic and social pressures. Changing behaviour where it matters most is therefore the most difficult; powerful underlying pressures, some from the tobacco industry and parts of the food industry, are pulling in the opposite direction.

Professor David Gordon and his colleagues at Bristol University have drawn up an alternative list of desirable health behaviours to those advocated by the CMO. They take a rather different approach, which goes like this: “1. Don’t be poor. If you can, stop; if you can’t, try not to be poor for long. 2. Don’t live in a deprived area. If you do, move. 3. Don’t work in a low-paid, stressful manual job. 4. Don’t live in damp, low-quality housing”. There are six others, which I am afraid time precludes me from listing.

Those suggestions all have a direct bearing on health and longevity, but they lie outside the remit of the NHS and are mostly the responsibility of local authorities and other departments of state. If they were adequately funded, a great load could be lifted from the NHS, which at present is carrying a burden for which it is not really designed. I suggest that the continuing financial crisis of the NHS will not be solved until it is properly funded and other departments of state whose responsibilities have a bearing on health are enabled to carry their full share of maintaining the nation’s health and well-being.

Health

Lord Rea Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Rea (Lab)]

My Lords, I thank the noble Lord, Lord Crisp, for introducing this important debate and his excellent speech. I declare an interest as a long-time trustee and now honorary president of the UK Health Forum, the public health think tank co-ordinating some 80 national organisations interested in upstream or primary prevention of non-communicable disease. The noble Lord has drawn attention to the wide spread of social and environmental factors behind our current burden of disease, and shown that many causes of those diseases lie outside the remit of the National Health Service. To prevent or delay their onset requires political and economic engagement rather than traditional public health solutions, important though they still are.

Historically, public health measures have been regarded as an imposition on individuals and industry, because they require changes in behaviour or the products of industry. They are regarded pejoratively by some as the “nanny state”—a term particularly favoured by some who may be financially affected by the changes needed to protect public health.

To divert from the general to the particular, the marketing of harmful food products could be curtailed and their composition improved by regulation and taxation—for example, of their sugar content. Here, I echo other noble Lords. The voluntary approach, the responsibility deal, has not worked, although it has been in place for five years. If all sections of society enjoyed the health status of the best off and best educated in the population, the health status of the whole nation would be greatly improved. To achieve the noble Lord’s health-creating society, we should logically consider the factors that favour the upper layer and bring them, as far as possible, to all sections of the population, to bring the bottom section closer to the top.

Most of us know the most common risk factors for heart disease, stroke, obesity, diabetes and some kinds of cancer. These are, of course, cigarette smoking, physical inactivity, poor diet and so on. It is true that the least well off have higher risk scores and that these show a gradation from the poorest to the most favoured groups of the population. A number of studies, particularly those by Sir Michael Marmot—who seems to be the father of this debate—and colleagues, have shown that when all the known risk factors are taken into account, the social gradient of health remains. The NHS can affect only a small part of these health inequalities, which have their roots in the social fabric and economy of the country.

From conception onwards, the odds are stacked against the less privileged in diet, housing, working conditions and social status. Low income is the dominant feature of the lives of the underprivileged. The environment in which children are brought up is particularly important, especially the early years from conception onwards, as other noble Lords have pointed out. Poor nutrition and social deprivation may lead to chronic disease in later life. To protect children from the effects of poverty and deprivation should be number one on the list of any policy to promote health.

In this connection, I ask the Minister about the present status and funding of Sure Start centres. They were beginning to have some effect, but some of them have had to close and others are struggling because of local government cuts. Has the Minister any news for us on Sure Start centres?

To build a resilient society, a wide range of improvements need to be made, and many or most of them have already been mentioned. Nearly every government policy has a health dimension. This should be assessed. I suggest that the Cabinet-level committee looking at the health impact of all government policy should be restored. Here I very much agree with the suggestion of my noble friend Lady Jay that a Cabinet-level Minister should look after public health.

Welfare benefits have been developed over the past century for good reason: to protect the vulnerable. To cut them further, as is still planned despite the Chancellor’s decision to listen to your Lordships’ House on tax credits, will diminish the health and resilience of the population.

Atrial Fibrillation

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Wednesday 4th November 2015 Lords Chamber

[Lord Rea (Lab)]

My Lords, I congratulate the noble Lord, Lord Black: he has done us all a service by bringing atrial fibrillation before us. It is not the first time it has been debated in the House, but it is very relevant. Like him, I suffer from the condition of paroxysmal atrial fibrillation. What he and many other people have said more or less follows what I have prepared; I agree with nearly everything that has been said so far. Atrial fibrillation is on the increase and is a really serious problem, in that it can cause a stroke.

It is also relevant that I am a former GP who has treated a number of people with atrial fibrillation, but that was some years ago and we did not have the tools and medications—the drugs—that we have now. Some of my information, therefore, has been gained through reading rather than practice.

Atrial fibrillation increases with age, so it is not surprising that a number of your Lordships suffer from it. Some of us may not even be aware of it, as has been said, since it gives rise to quite mild symptoms and sometimes none. Sometimes it is continuous, but sometimes it is episodic or paroxysmal. Treatment consists of measures to detect and, as far as possible, correct any conditions that might underlie the atrial fibrillation—and there are quite a few—and then to restore normal rhythm, if possible, with drugs, electrical cardioversion, or surgical ablation, as has been mentioned. Most important is the prescription of suitable anticoagulants to minimise the formation in the left atrium of clots, which can be carried around the body, block an artery and deprive an area of the brain of its blood supply, leading to an ischaemic stroke. A stroke caused by atrial fibrillation is often more serious than one from other causes, so it is particularly important to detect it as soon as possible and start treatment with effective anticoagulation. Until recently, this was not emphasised adequately by clinicians and the standard drug used was inadequate—low-dose aspirin.

Trials have shown that more powerful anticoagulants have a measurably better effect than aspirin in reducing embolic stroke. The first of these, as has been said, is Warfarin—rat poison—which inhibits vitamin k action, an essential part of the clotting process. It is remarkably cheap, and its cost is amply repaid by the savings incurred by the National Health Service that it gives rise to through stopping atrial fibrillation-related stroke. I take warfarin, like the noble Baroness, Lady Gardner. My condition is under control, but having to be tested from time to time is a nuisance. I thoroughly agree with the suggestion that self-monitoring should be made available. The instruments cost about £200.

The main trouble with warfarin is that it takes some time for its effects to cease, and it can cause internal bleeding. If such bleeding occurs and cannot be brought down quickly, that is a worry. Despite what the noble Baroness, Lady Masham, said, NOACs allow the clotting time to increase quite rapidly after stopping taking them, so they are safer than warfarin.

On detection, it is very important, as has been said, to find the cases that do not have much in the way of symptoms. I will say a few words on that. Sadly, detection has been woefully inadequate up to now. That may be simply because the doctor or nurse has failed to take the patient’s pulse.

[Baroness Chisholm of Owlpen (Con)]

Order.

[Lord Rea]

Yes, I understand. I back the suggestion from the noble Baroness, Lady Murphy, that people should always learn how to take their own pulse.

The other thing that I wanted to ask the noble Lord quickly—

[Baroness Chisholm of Owlpen]

I am sorry, but time is up.

[Lord Rea]

May I ask him afterwards?

[Baroness Chisholm of Owlpen]

Yes.

Health and Social Care (Safety and Quality) Bill

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Friday 6th February 2015 Lords Chamber

[Earl Howe]

My Lords, I am sure that anything is possible, but I would hesitate before giving a commitment along those lines because it seems to me too granular to be included in statutory regulations rather than in guidance or best-practice manuals.

[Lord Rea (Lab)]

Perhaps I may be the third Member of the House to ask the Minister to answer a question before he sits down. There has been a lot of talk about there being no government time properly to discuss many issues that have been brought up in this debate. The Minister did not answer the point made by my noble friend Lord Hunt, but there is very little government legislation in the pipe now and time could almost certainly be found. I accept that Private Members’ Bills are normally considered only on Fridays—there are not very many Fridays left—but, as this Bill is a quasi-government Bill, I feel that perhaps the Government could make time for it.

[Earl Howe]

My Lords, I am sure that the noble Lord is aware that the timetabling of business is not a matter for the Government. My understanding from the usual channels is that Private Members’ Bills cannot be given government time or priority treatment. However, I have no doubt that, having listened to the comments made in this debate from all sides of the House, the usual channels will wish to have further discussions.

National Health Service

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Thursday 8th January 2015 Lords Chamber

[Lord Rea (Lab)]

My Lords, I am sorry that we are missing a contribution from the noble Lord, Lord Ribeiro. He is always worth listening to. I hope that being scratched from the debate does not mean that he is unwell.

I thank my noble friend for bringing up this wide but highly topical subject, given the daily headlines about one NHS crisis or another, including today. The issue is also high on the agenda of all parties in the run-up to the election. What is becoming increasingly clear—my noble friend Lord Turnberg referred to this—is that the NHS and social care are underfunded and that this is the main reason for longer waiting times and deteriorating services. To call for greater efficiency in a health service that is recognised internationally as highly cost-effective can only mean staff reductions or lower salaries, and worse care. Some say that this is deliberate to encourage more people to move to private medicine.

I want to focus on prevention, which is highly relevant to today’s pressures, as described in the Five Year Forward View, to which several noble Lords have referred. It is better written than the average document from the Department of Health and freer of jargon and acronyms, although I noticed one or two lapses—for example,

“the need to transition to a more sustainable model of care”.

The report puts prevention of disease high on the agenda in the section headed, “Getting serious about prevention”. This phrase is taken from the health review written by Derek Wanless 14 years ago. At this point, I should declare an interest as trustee of the UK Health Forum, formerly the National Heart Forum, which advised Wanless when he was writing his report. He suggested, as the noble Baroness, Lady Barker, said, “a fully engaged scenario”, in which all sections of society should become aware of the health implications of their activities and products. He warned that unless the country took prevention seriously, we would be faced with a sharply rising burden of avoidable illness. As the Forward View put it,

“that warning has not been heeded—and the NHS is on the hook for the consequences”.

Instead, one in five adults still smokes, a third of people drink too much alcohol or do not take enough exercise and almost two-thirds are overweight or obese. This has had consequences in increasing the flow of costly treatments.

Our expectation of life, however, continues to go up. Part of this is due to the success achieved in reducing cigarette consumption, partly due to the measures introduced by the last Government, including banning tobacco advertising. This Government have also brought in some tobacco control measures but, rather worryingly, they seem to be dragging their feet on the important issue of plain packaging. It is important to get this legislation on to the statute book before the election and to do that it must be laid before Parliament before the end of this month or sooner. I think that the noble Earl is aware of the widespread desire from across the health professions and elsewhere for this to be done. I hope that he will be able to assure the House, perhaps today, that this legislation will reach the statute book before the election. If not, the Government and the Conservative Party will lose even more credibility when they claim to safeguard the nation’s health.

The NHS should also take some credit for the continuing increase in life expectancy, but the increasing incidence and prevalence of avoidable non-communicable disease is a major cause of the heavy pressure that the NHS is now under. One example of this is the avoidable burden that heavy drinking places on A&E departments at weekends. The Government have not taken the first step in reducing alcohol consumption that minimum pricing would provide. There is little doubt that the drinks industry is putting pressure on the Government to avoid this simple measure. It would have most impact on cut-price off-sales, which many young people indulge in, “preloading” to avoid higher bar prices when having a night out. In the past few days, the alcohol health association has said that there should be more information on alcohol products, giving not only the strength but the calories and other health implications.

The Five Year Forward View puts it rather admirably:

“We do not have to accept this rising burden of ill health driven by our lifestyles, patterned by deprivation and other social and economic influences. Public Health England’s new strategy sets out priorities for tackling obesity, smoking and harmful drinking; ensuring that children get the best start in life; and that we reduce the risk of dementia through tackling lifestyle risks, amongst other national health goals ... While the health service certainly can’t do everything that’s needed by itself, it can and should … become a more activist agent of health-related social change”.

Health and Social Care (Amendment) (Food Standards) Bill [HL]

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Friday 8th November 2013 Lords Chamber

[Lord Rea (Lab)]

My Lords, not only the Members of your Lordships’ House but the whole country should be grateful to the noble Baroness for securing this debate.

For too long the topic of hospital food has been a running sore. It has a reputation for being of poor quality and indifferently served, as borne out so clearly by my noble friend Lady Gibson. Often too little help is given to those who have difficulty feeding themselves. This is not to say that nothing has been done about it. As all the previous speakers have said, a large number of initiatives have been launched over the years at considerable cost but with, by and large, disappointing results. Governments of both political persuasions have launched initiatives and guidelines but these have all been on a voluntary basis with no sanctions for non-compliance. Although there have been a number of successes where good standards have been reached, as has been mentioned, many more remain far from satisfactory. Many of us are grateful for the briefing provided by Alex Jackson of Sustain, co-ordinator of the Campaign for Better Hospital Food, which has been referred to. He has drawn up details of no fewer than 21 voluntary initiatives since 1992 which have come to nothing after initial fanfare, as the noble Baroness, Lady Miller, said.

At least four celebrity chefs have been called in to advise the Department of Health. Sadly, their hard work has not had a lasting effect. Albert Roux, for example—to continue the quotation given by the noble Baroness, Lady Cumberlege—said:

“If we have learned anything from the last 20 years it is that meetings, speeches and gimmicks do not work—what we need now is change to the whole hospital food system, starting with the introduction of food standards for every patient meal”.

This lack of progress is shameful when the results of a number of studies demonstrate that good nutrition has a beneficial effect on patients, thereby speeding recovery from infections and other diseases as well as from surgery.

Good, enjoyable food, as has been pointed out, boosts morale, which in itself has healing qualities. A surprisingly high proportion of NHS in-patients have some signs of malnutrition—around 40% by several estimates; an amazingly high number—which delays recovery and lengthens hospital admissions. There is evidence that this has improved little over the years. Good nutrition is likely to save the NHS a lot of money. A recent international study published in the Lancet has shown that faulty or inadequate nutrition plays a part in 40% of deaths world wide. That applies not only to the developing world but to our main problem—chronic, non-communicable disease, which is also very much diet-related.

Another important possible benefit from good nutrition in hospital is that it could act as an example of good practice, or a beacon—an overused word—demonstrating the principles and practice of providing a nutritionally sound diet. In other words, good nutrition could play an educational role in helping patients and their carers to improve their diet after they are discharged. This would be an appropriate task for any institution looking after the nation’s health.

Of course, providing for large numbers of patients in an average-sized hospital on a limited budget is not easy; the logistics of the operation can be formidable. Quality tends to be inversely proportional to the size of the hospital. However, there are examples of good systems in large units that work. Earlier this year I spent a week in UCLH having a knee-joint replacement, and it was clear that thought had been applied to the catering on offer. For one thing there was a choice of menu, although you had to decide on this a day in advance. The food was unexciting and rather too substantial for my post-operative appetite, but was of fairly good quality, courteously served and adequately hot, having been reheated on the ward. A healthcare assistant was on hand to help those with a problem feeding themselves. I am not too sure of the food’s nutritional credentials, however. I found that the halal choice was the most attractively presented and tasty, though a bit too spicy for a westerner. But the experience of friends and relatives in NHS hospitals has not been so good, as my noble friend Lady Gibson most graphically pointed out.

The ward kitchen has an important role. While it is mostly not used for the actual preparation of meals, it is important in their presentation to patients. Its role could perhaps be expanded to include the preparation of simple meals such as a boiled egg or piece of toast for those unable to eat the main meal provided. Perhaps ambulant patient should be able to use the kitchen, when convenient, with the help of their visitors, relatives and friends. They could make a cup of tea, for instance, when they felt like having one.

Sadly, poor nutritional standards are still to be found in some hospital food, as has been graphically pointed out. Recently, as the noble Baroness, Lady Cumberlege, mentioned, one hospital meal was found to have a higher fat and salt content than a Big Mac. As we all know, the diet of many people in England is far from optimal and contains too much sugar, saturated fat and salt, and too few of the vitamins and trace elements found in fresh vegetables, fruit, fish, lean meat and eggs. Dietary intake is more often than we realise too low in many older people. In hospital there is a captive audience, an ideal population on whom to demonstrate how well cooked good food can be attractive, delicious and not too expensive. The food will taste better and may have better nutrient value if it comes from sustainable sources with good animal welfare standards. I am glad that there is provision for that in the Bill.

Why have so many initiatives failed? My guess is that hospital food is of low priority on the agenda of hard-pressed managers who are often struggling to meet targets and stay within budgets. The effects of poor diet do not show up in most hospital statistics, whereas mortality rates or waiting times can easily be measured, and executives and clinicians held to account. The considerable benefit that good nutrition can have is not fully appreciated. Poor ward diets are often complacently tolerated by management because their quality and acceptability is often not monitored. The introduction of mandatory standards with strong sanctions for non-compliance would eliminate any complacency because the relevant manager would be held to account. As the noble Baroness, Lady Cumberlege, said, other public sector institutions and schools are now required to conform to and have adopted mandatory nutritional standards, as has the National Health Service in Wales and Scotland. Interestingly, Compass, probably the largest catering firm in the country, has said that it supports mandatory standards because they level the playing field among suppliers and caterers while maintaining a high standard.

I am puzzled as to why the Government have been so reluctant to adopt mandatory standards for hospital food. A response to Sustain’s hospital food standards campaign was published by the Department of Health in September this year. It does not directly give the reasons for the Government’s reluctance, given that mandatory standards have been widely adopted elsewhere in the public sector. However, I hope the noble Earl can report that the Government are coming round to the idea and will agree to support the Bill.

Before sitting down, I have one question for the noble Baroness, Lady Cumberlege. Clause 1(6) states that the Bill,

“applies to … food provided to patients at a hospital”.

Does this apply to a private hospital as well as an NHS one?

NHS: London

Lord Rea Excerpts

Wednesday 30th October 2013 Lords Chamber

[Earl Howe]

I do not think that it is appropriate to talk about downgrading in this case. However, it is appropriate to talk about changing the way in which services are delivered to the local population. In the case of two hospitals, we are seeing fully fledged A&E departments becoming 24/7 urgent care centres. That means that the most serious A&E cases, such as trauma and cardiovascular emergencies, will be taken to centres of excellence where patients will have a much higher chance of survival. That is a pattern that we are seeing throughout the NHS and one that has been proved to be successful and in the interests of patients. On ambulances services, we are already seeing in London, for example with stroke care, ambulances taking patients to centres of excellence for stroke care. Eight of these centres now exist compared to 32 some years ago. That means longer journeys in an ambulance but also much higher survival rates for the patients. I do not think that we should look on the kind of reconfiguration that I have described in a negative way. On the contrary, the whole thrust of these proposals is to improve the quality of care for patients.

[Lord Rea (Lab)]

The noble Earl said that, as part of this reconfiguration, there will an increase in the services available in the community. Can he say whether this will be done in co-operation with the royal colleges and the British Medical Association rather than being imposed from above? The latter solution is unlikely to work.

[Earl Howe]

The noble Lord is absolutely right. These solutions should not be imposed from above. Indeed, the Shaping a Healthier Future proposals were designed by local clinicians in consultation with their patients. It was not a prescription dreamt up in Whitehall. We are very clear that the local NHS should continue to feel local ownership of these ideas as it takes them forward. I have no doubt that, if it feels it necessary, it will turn to the royal colleges for particular kinds of advice. It is free to do that as it wishes.