National Health Service (Mandate Requirements) Regulations 2017
Lord Reid of Cardowan Excerpts(7 years ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Walmsley (LD)
My Lords, we on these Benches support this Motion.
This debate shines a spotlight on the existential quandary facing CCGs and NHS Providers. I am sure that at the end of the debate the Minister, in his usual courteous and thorough way will, as he always does, give us lots of figures about how much more the Government are spending every year and how many more treatments are being delivered and how well the STPs are doing. With demand rising, naturally the raw numbers are higher, but the Government have chosen an RTT target in percentage terms and they must live with that decision and fund the consequences. Over recent years, the increase in funding for the NHS has not kept up with rising demand. This year we have a lower increase than before, and so now is crunch time. As the noble Lord, Lord Hunt, said, nobody is even pretending that providers will be able to deliver the targets while remaining within their budgets. So there is no point in the Government watering down the targets and pretending that no one will notice. The noble Lord, Lord Hunt, and many others have noticed, and I am grateful to him for giving us the chance to have an honest and open discussion about this.
NHS staff work hard and do their best to meet the targets under difficult circumstances. It is not their fault that the RTT targets have not been met for 16 months. But changing the targets is a political decision, whether it is being done openly or not, and that is only right. It should certainly not be left to local decision-makers, in a postcode lottery, to quietly ignore them or try and fail to live up to them and then take the flack when people criticise. If the Government choose to change the target, they should take the responsibility for the consequences. But the trouble is that patients will live with the consequences, living longer with debilitating and painful conditions. Having those conditions worsen and requiring more complex and expensive treatment, they may even become untreatable, and their quality of life and perhaps their mental health will deteriorate. So although the 2012 Act was intended to pass the blame on to anyone but the Government when things go wrong, everybody knows that the Government’s NHS mandate is the Government’s NHS mandate and nobody else’s. The NHS can spend the money only once, and the Government should not be expecting two treatments for the price of one. The bald facts are that, this year, demand was expected to rise by 5.2% while the funding is only going to rise by 1.3%, which is 2.3% less than last year—which was too little anyway. So this is a deliberate choice on the part of the Government.
Waiting lists are projected to rise to almost 5 million by 2020, and clearing this backlog will require not only funding but appropriately trained staff. With staff who are EU citizens leaving in droves because of Brexit uncertainty, and UK staff leaving because of overwork and stress, NHS Providers is finding it impossible to deliver waiting time targets. At the same time there is spare capacity in the private sector but it charges more than the NHS, so that is a hard choice for managers to make. I therefore ask the Minister a simple question: what assessment did the Government make of the potential impact on patients and waiting lists of deprioritising elective care and taking the decision to relax the 18-week target?
The RTT is not the only target the Government have changed, as the noble Lord, Lord Hunt, mentioned, and this is looking rather like a habit. For example, NHS England and NHS Improvement are reportedly setting new targets for CCGs and providers for bed occupancy levels, to keep them below 92%. This is significantly higher than the recommended safe limit of 85%. The Royal College of Surgeons has warned:
“Anything over this level is regarded as riskier for patients as this leads to bed shortages, periodic bed crises, and a rise in healthcare-acquired infections such as MRSA”.
This is another target that was routinely missed last winter, and the latest figures show that the overnight occupancy rate for general and acute beds hit a record high in the fourth quarter of 2016-17, averaging 91.4%. If the Royal College of Surgeons is right, this high level of bed occupancy is not a measure of efficiency but could lead to greater costs and crises, which put patients in danger.
Is it not time for the Government to stop pretending that all is well and that they have all the right answers, and set up a cross-party commission on the funding of health and social care, as recommended by my right honourable friend Norman Lamb MP? We on these Benches would be enthusiastic about taking part in such discussions. I think that the public are very fed up with health and care being a political football and would like to see us working constructively together. They want some honesty and realism. Of course we do not want to go back to the 1950s: I was waiting for a tonsillectomy and after two or three years, when my mother was fed up of waiting, she discovered that I had been taken off the list on the assumption that I had grown out of it. Actually, I had, but we need to be a great deal more ambitious for the NHS than that.
I know that the Minister makes the best of his brief but I would like to think that he will go back to his department and use his considerable powers of persuasion to stop the Secretary of State from burying his head in the sand.
Lord Reid of Cardowan (Lab)
My Lords, I join with this regret Motion, not as a matter of formality but because of deep and genuine regret at the position that the Government have now, by hook or by crook, engineered, which is the effective abandonment of the 18-week target.
I will briefly recall to the House where we were before that target was introduced. With respect to the noble Baroness, Lady Walmsley, we do not have to go back to the 1950s. We can go back less than 15 years, when my predecessor, Alan Milburn, became Secretary of State for Health. The maximum waiting time then was not 18, 24 or 52 weeks for elective operations but three years. Due to his sterling efforts and, I have to say, his adviser, who also advised me—Mr Simon Stevens—we reduced that, but not nearly as much as I thought was necessary in a civilised society.
Therefore I admit a conflict of interest in this debate: I introduced the 18-week target, against some considerable opposition—not in principle but because, I was constantly told, “it couldn’t be done”. But we did it. I remind the House that at that time the number on the waiting list, waiting for as long as three years, was the horrific figure of 1.2 million. It is now 2.7 million and it is estimated that it may rise to 5 million. Therefore there are more and more people, and undoubtedly, once this target has been effectively removed, those pressures will immediately start a process whereby it will go well beyond 18 weeks and we will go back to where we were some 15 years ago.
I will make a couple of points about this situation; the first has already been alluded to. These targets were also to reduce MRSA—hospital-acquired disease —in hospitals by 50% over four years, which we did, despite the fact that we were told that we could not do it. It was also to take hundreds of thousands of people off the waiting list. This was an effective way, not of making a political point but to remove people from pain, distress, discomfort and, above all, the insecurity of not knowing when and if they might have the condition treated. I recall that at the formation of the National Health Service one of Labour’s greatest heroes, Nye Bevan, produced his framework in a pamphlet that was not called “In Place of Pain” but In Place of Fear. The fear that people had for their families, their senior citizens, their children, of the prospect of waiting several years, even with what might appear to others to be relatively small difficulties and medical conditions, is inestimable. Therefore this was, more than anything else, about the relief of human discomfort and insecurity.
Secondly, having been there, I know that this is not easy. It is never easy. I have a great respect for Simon Stevens as a person and an administrator. However, he is caught between all sorts of conflicting demands—an increasing population, people living longer and, I have to say, a relative reduction in resources as well as a shambolic reorganisation which was the worst use of money I can think of in the health service in the past several decades. So I do not blame him, but it is the Government’s job to face up to difficult tasks, and it will take political will.
Lord O'Shaughnessy
That is the truth.
Next year the NHS turns 70. As my noble friend Lady Redfern said, it has a unique place in our society. The mandate to NHS England for 2017-18 goes further than ever before to ensure that we not only continue to deliver the best care and support for today’s NHS patients but also deliver the reform and renewal needed to sustain the NHS for the future. We know there is more to do, which is why we have put our commitment to support NHS England and the NHS in delivering the five-year forward view at the heart of the mandate. We will continue to do so. I hope that I have persuaded all noble Lords, including the noble Lord opposite, that their fears are unfounded, and that the noble Lord now feels in a position to withdraw his Motion.
NHS: Shared Business Services
Lord Reid of Cardowan Excerpts(7 years, 3 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord O'Shaughnessy
The noble Baroness will know that I was not in post at the end of last summer, so I cannot explain why there were the number of Statements that there were. I know that Governments of perhaps different hues have also tended to put out Written Statements, so I do not think any political party is entirely innocent in this regard. The point is that the information was made available to Parliament.
On the point about cost settlement, there are interested parties here and the costs need to be settled once we have got to the bottom of exactly what has happened and once those inquiries and indeed the investigations into the potential for patient harm have been settled. I underline that as yet no instances of patient harm have been discovered.
Finally, the point about privatisation is quite an important one. The noble Baroness will know that the private sector is involved in the delivery of all parts of the NHS. Breach of contract, which is what this is, and the covering up of mistakes happen in all parts of the health service—public, private, shared and all the rest of it. It is not a case of “private sector bad, public sector good”: we know that from instances like Mid Staffs and so on. The core point is that we need very strong data security standards, and that is why the Government will be responding in due course to the Caldicott review and the review of these issues by the CQC.
Lord Reid of Cardowan (Lab)
On one of the points the Minister responded to, perhaps I may politely offer him a piece of advice. Everyone here knows that officials advise and Ministers decide—but it is not convention, protocol or indeed courtesy to announce in Parliament that advice has been given by Ministers’ officials and he has decided to overrule it. That is not just a matter of useless etiquette; it is a fundamental aspect of maintaining the trust between Parliament and the Minister and between the Minister and his officials, which will serve him well in future.
Lord O'Shaughnessy
I take the noble Lord’s advice very seriously. Indeed, I note that he, as a former Secretary of State for Health, understands what is going on and the dynamics within the department. I would say only that the NAO report has described a set of actions that have taken place and why they have taken place. It has described the decision-making process, which is why the Statement responds to the content of the NAO report as it was set out today.
NHS: Debt
Lord Reid of Cardowan Excerpts(7 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Boothroyd
Order. That is a very good way to begin the week. My question is brief and very much to the point, and concerns the transportation of patients to and from hospitals. We are all aware that many patients often have to go to major hospitals—travelling 20 or 30 miles—on a daily, weekly, fortnightly or thrice-weekly basis. The cost must be horrendous; is this part of it? Can the Minister give any indication of the cost of transporting patients to and from hospitals?
Lord O'Shaughnessy
I will write to the noble Baroness with specific details of cost. It is certainly true that if you have to go to or be taken to a distant hospital for care, that is more expensive both in transport and setting terms. Part of the transformation that the NHS needs to make is that more care should be delivered in primary settings and in the community, which by definition will be closer to home.
Lord Reid of Cardowan
My Lords, first, I apologise to the noble Baroness; I thought it was the Liberal Benches. Has not the noble Lord missed the point of the Question? In the first sentence of his first answer, he said his first challenge was an ageing population. Is it not now obvious to even the most obstinate that cuts in social care have a knock-on effect on the ageing population in putting pressure on the NHS? It is not just that the deficits have trebled; 27 hospitals have now declared that they cannot provide comprehensive care, and more than 50 hospitals are asking for outside assistance every day of the week. The situation is getting worse every week. Will he not take the advice of my noble friend and urge his colleagues to reverse the cuts to social care in the Budget, which are not only affecting care provision but having a disastrous effect on provision through the National Health Service?
Lord O'Shaughnessy
It is certainly the case that one part of the system impacts on the other parts, whether that is primary, secondary or social care. There is no denying that and I do not seek to do so. On the picture the noble Lord paints of worsening deficits, in fact, the picture in 2016-17 is considerably better than it was in 2015-16. It has been helped not least by the sustainability and transformation plans. We are putting £1.8 billion into trusts, 95% of which have accepted control totals to get a hold of that financial sustainability. Extra funding is going in. There is a big increase this year for the NHS budget, which will help, as will the extra money for social care; but of course the challenges are there.
National Health Service: Sustainability
Lord Reid of Cardowan Excerpts(9 years, 2 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Reid of Cardowan (Lab)
My Lords, I am speaking in the gap because I was not sure that I would be able to stay for the whole debate. I want to make a very short contribution. First, I thank the noble Lord, Lord Patel, who is, if I may say so, the right person, at the right time. He is the right person, because nobody can in any way doubt his commitment to the National Health Service, and it is the right time, because it is outside what has been probably the longest general election campaign, courtesy of the five-year Parliament. That refers to the point people have made about the National Health Service being used as a political football. I do not think that it will ever be taken out of politics, because politics is a series of moral choices about the commitment of scarce resources to infinite demands. But it can be taken out of party politics, and I think that today’s conversation begins to do that.
Let me make my position very plain. First, like everyone else here, it goes without saying that I am committed to the National Health Service, not just ideologically but, like the noble Lord, Lord Mawhinney, for very practical reasons—it saved my life over 50 years ago. Secondly, I am sure that there are efficiencies that can be carried out in the National Health Service. Some have already been mentioned, but I merely mention the fact that, in procurement, even in non-medical areas, there are more than 40,000 people purchasing for the National Health Service and most of them do not know the price being paid for a particular commodity by the person sitting next to them—the other 40,000. In an age where we can “compare the market” for everything and of one-click purchases through Amazon, it seems to me incredible that that is the position in the National Health Service.
Thirdly, I am not one of those who is opposed to the use of outsourced private services. I think that a diversity of suppliers, where appropriate, is a good thing—again, that is not just ideological, but because it was central to reducing the huge waiting lists, which were mentioned earlier, and waiting times. The provision of that range of services, appropriately used, can be efficacious in removing the pain of people who had to wait in pain for so long. However, I do not believe that the solution lies in an insurance-based system. Witness the fact that 10 years ago, when I was Secretary of State, we were spending 6% or 7% of GDP, going up now to 9%. In the United States, at that time, they were spending 17% or 18% of GDP on the combination of a private-based and supplemented system—it will be even more now with Obamacare—and over 20% of that went on bureaucracy. We have to get the balance right.
Having said all that, the real issue is that the betrayal of the National Health Service does not lie in addressing the fundamental challenges; it lies in ignoring them and hoping that somehow this will go on sustainably and indefinitely, with a hugely increased demand. We all know why that is happening. There is an increased population, people are living longer, diseases and illnesses will become more chronic, and new treatments and technologies will be invented every day, all at a cost and rate that is above inflation. As I say, I believe that if we are committed to the National Health Service, our duty is to address this question in the long run, not to avoid it. That is why the noble Lord, Lord Patel, has opened a conversation today that does us and the National Health Service a service.
NHS: Funding
Lord Reid of Cardowan Excerpts(9 years, 10 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
I agree with my noble friend that the primary purpose of the Better Care Fund is clearly to make care better, but it is also a major step forward in making our health and care services more sustainable, and moving to a preventive model that delivers care closer to home and keeps people healthy in the community. GPs have a major part to play in this and I am encouraged by the extent to which they are now engaging in the task of addressing the BCF.
Lord Reid of Cardowan (Lab)
Will the noble Earl correct the inadvertent misleading of the House by the last noble Lord who spoke? The obligation for doctors to serve at weekends and in the evenings was not removed in 2004 but many years before—as it happens, under the Conservative Government. What happened in 2004 was that although they were not serving at weekends or in the evenings, as had been allowed by the previous Conservative Government, doctors were spending an increasing amount of time on the bureaucracy of finding a replacement doctor. That bureaucratic burden was what was removed from them. Will he confirm that that was the case, not for the first time but for the second time, because I asked him last year and he confirmed that by 2004 almost 90% of doctors had already opted out of night work and weekend work?
Earl Howe
The noble Lord has huge experience in this area and his outline is of course right, in that before 2004 we had largely a system of co-operatives in which GPs could elect to work out of hours if they wished. The 2004 contract gave individual GPs and GP practices the option not to do that. While there was no obligation to move away from out-of-hours care, many GPs have chosen to do that.
Ebola
Lord Reid of Cardowan Excerpts(9 years, 11 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, I believe that the WHO itself has acknowledged that its response could have been swifter. It is easy to say this in hindsight, but I am sure that the noble Lord’s view on that is shared by others. Nevertheless, the WHO has not been slow in rallying support for efforts in the three countries affected. It is now working energetically with many developed countries to provide support, and I would not wish to criticise the WHO in those respects.
On the disposal of corpses, the noble Lord makes an important point. We know that many cases of Ebola in the three countries have arisen as a result of people being in contact with the corpses of people who have died from the disease. That has been as a consequence of the cultural traditions in those countries, which are very hard to displace or persuade people not to follow. It is nevertheless part of our effort in Sierra Leone that we should inform people there that their burial customs need to be set to one side for the duration of the epidemic. This is a very difficult thing to do, for understandable reasons, but that is the effort we are making and it is bearing fruit.
As to the programme for building 700 beds, I do not have a precise date to give the noble Lord but if I receive advice before the end of this debate, I shall tell him.
Lord Reid of Cardowan (Lab)
My Lords, manifestly, this is a terrible disease, not only in its nature but in its scale. According to the rate of growth indicated by the Minister, within around six months we could be looking at between 150,000 and 500,000 deaths, and between 2 million and 5 million suspected cases. Let us hope that that does not occur. However, in view of that, may I ask him one question about screening and entry? I welcome the fact that there is to be extended screening at Heathrow, Gatwick and the Eurostar terminal—two airports and one train station. Manifestly, this does not cover anything like the potential entrants to this country from those regions. With cheap travel and so on, I understand the difficulties in covering every airport, particularly as people break their journeys and do not come directly. However, is it not possible, given the use of so many biometric passports and the technology introduced to UKBA, somehow to target at least people from that area as potentials for screening, wherever they arrive in this country, rather than limit the coverage to three geographical in-ports? Does the Minister have any information on whether this hypothesis has even been tested?
NHS: Out-of-Hours Services
Lord Reid of Cardowan Excerpts(11 years, 2 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Reid of Cardowan
My Lords, may I gently advise the Minister against complacency? Many of these changes in the NHS will take time to show whether they are beneficial or otherwise. Anecdotally, the successor of NHS Direct—111—appears to be in turmoil, both practically and commercially. The deterioration in accident and emergency services is getting exponentially greater; trolley waits are back, and predicted potentially to reach crisis point. Sir Bruce Keogh’s report, if read carefully, identifies as underpinning many of the problems in the major hospitals a chronic shortage of skills and finance. Can I please ask the Minister not to accept this with any degree of complacency and to introduce some scheme of forensic appraisal of 111 and some of the other issues which are arising from what looks increasingly like a costly and disastrous reorganisation of the NHS?
Earl Howe
The last thing I would ever wish to be is complacent, and I certainly am not. Whenever problems and concerns arise, we take them extremely seriously. I do not think anyone takes issue with the concept of 111. Unfortunately, however, we have seen problems arising in a few isolated cases. I emphasise that the vast majority of the country is receiving a good service. Incidentally, there is no evidence that attendances at A&E have been affected by the rollout of 111; in fact, attendances have not increased since 111 was introduced—the figures have actually gone down.
NHS: GP Services
Lord Reid of Cardowan Excerpts(11 years, 4 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
The noble Lord, Lord Laming, has summed up the situation extremely well. I am sure he knows that Sir Bruce Keogh, the NHS medical director, is currently looking at how NHS services across the piece can be provided seven days a week in a much fuller way than they are at the moment. Access to GPs out of hours is part of that wider consideration and NHS England is working with the royal colleges and professional organisations to develop a set of standards that will apply to seven-day services. Some trusts are already thinking about treating patients at weekends for non-urgent operations and procedures. We want to encourage that trend.
Lord Reid of Cardowan
My Lords, can I correct a serious misrepresentation and misconception that is constantly made regarding the GPs’ contract, and which has been made in the past few moments? The GPs’ contract for 2003-04 did not remove the requirement of a doctor to work out of hours. That was removed a decade earlier under the previous Conservative Government; indeed, by 2000 a huge percentage of doctors had already opted out. The GPs’ contract was to try to make sure that GPs were not spending part of their normal day bureaucratically chasing up a replacement doctor to take their place. It removed that bureaucratic imperative but it did not remove the right of a doctor to refuse to work out of hours. That was the case with some 70% to 80% by the end of the previous Conservative Government, before the GPs’ contract. That is a very important distinction.
Earl Howe
My Lords, I certainly did not mean to mislead the House and if I have done so in any way I apologise. The summary given by the noble Lord is broadly right. Under the old general medical services contract, GPs had a 24-hour responsibility for their patients, although most GPs delegated responsibility to GP co-operatives or commercial providers. At the beginning of 2004, as I recall, only a small proportion of GPs actually provided out-of-hours services themselves. However, 24-hour responsibility continued to be unpopular with GPs as they felt it was discriminatory, which is why the contract was renegotiated at that time. It has brought about a growth in GP co-ops, with more use of telephone triage and more patients offered emergency consultation with a primary care centre. But that has resulted in fewer home visits and I think that point in particular is one that is exercising many people.
NHS: Clinical Commissioning Groups
Lord Reid of Cardowan Excerpts(11 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
I am very grateful to my noble friend for her kind remarks. The information I have in my brief is as I have stated, in that the indicators reflecting deprivation are quite broad. However, it is for ACRA, the independent committee, to review those indicators to see that the measures are representative and accurate. I am grateful to my noble friend for pointing us towards some other indicators which could be relevant, and I shall make sure that her ideas are passed to the appropriate quarters.
Lord Reid of Cardowan
My Lords, when the Minister says that the decisions on these allocations are, of course, not taken by Ministers, that is correct. However, can he confirm that it is equally correct that the criteria by which those decisions are made are influenced, judged and promoted by Ministers? Is not the most important thing that he said today that the primary determinant of this should be need? Here I declare an interest, because I had to address this when I was Secretary of State for Health. During the period 1979 to 1997, there was almost an indirect, inverse relationship between increases in funding for areas and their social and health deprivation. I am sure that had nothing to do with the coincidence of voting patterns in those areas of social and health deprivation, but it would be reassuring if he could tell us that that is not likely to happen during the term of this Government.
Health: Stroke Care
Lord Reid of Cardowan Excerpts(12 years, 7 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, the unwarranted variations in services are quite clearly unacceptable. The value of the CQC report is that it shines a spotlight on where variations in care need to be addressed. We believe that that will help all stakeholders involved in improving opportunities for people who have experienced a stroke. As regards post-hospital care, on which the noble Baroness rightly focuses, the accelerating stroke improvement programme, which is quite new, is already doing very good work. It was developed specifically to improve care in areas where progress needs to be faster, and that work will most certainly continue.
Lord Reid of Cardowan
My Lords, has the Minister yet had a chance to reflect upon this morning’s report that illustrates that survival rates and the reduction in the death rate from strokes, cancer, heart attacks and many other serious diseases have improved considerably over the past few years? By any standards, when comparing productivity in terms of quantity and quality, there has been a huge increase in productivity. Since the premise behind the Health and Social Care Bill was that there had been little or no increase in productivity in the National Health Service, will he share with us his reflections on that report?
Earl Howe
The premise of the Health and Social Care Bill is rather different from the one that the noble Lord cites. We believe that there is a damaging and avoidable variation in care across the country. Of course the outcomes in many areas of clinical care have improved immeasurably, as he rightly says, over the past few years—not least in heart attack and stroke. However, we still have some way to go and clinical commissioning, we believe, will take us in the right direction. Stroke features in two of the domains in the NHS outcomes framework, representing work that we have put in train: domain 1, “Preventing people from dying prematurely”; and domain 3, “Helping people to recover from episodes of ill health or following injury”. It is those measures to which the NHS will be held to account.