Covid-19: Response
Lord Ribeiro Excerpts(4 years, 3 months ago)
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Lord Bethell [V]
My Lords, it is a horrible truth that this disease hits hardest those with vulnerabilities. We have put in place a massive national programme to seek to protect the most vulnerable, and those with disabilities have been very much the focus of our attention. I cannot make the commitments that I know the noble Baroness wants me to make, but I reassure her that those with disabilities are the focus of what we are trying to do.
Lord Ribeiro (Con) [V]
My Lords, the London Nightingale hospital was mothballed in mid-May and remains at standby for a second wave of Covid-19, having treated just 54 patients since it opened on 3 April. In a recent report of 19 July, Harrogate Borough Council questioned how the 500-bed field hospital based in Harrogate Convention Centre would be deployed. Given that £3 billion has been allocated to maintain the seven Nightingale hospitals until the end of March 2021, and noting that the Harrogate centre has not treated a single patient since it opened, can my noble friend the Minister say what the strategy is for those hospitals? Should they not be designated Covid centres to which all local hospitals can refer their patients, thereby allowing the NHS to resume its routine work and centres such as the London Nightingale hospital, which could reopen in six days with 250 beds, to provide assisted ventilation, hemofiltration and dialysis to support seriously ill Covid patients?
Lord Bethell [V]
My Lords, the Nightingale hospitals have been a huge success in helping us to protect the NHS at a time when our needs were greatest. Since then, when prevalence rates were lower, we reallocated resource into restarting the NHS to gain ground during the summer months on our backlog of business-as-usual work. Those resources are needed in the hospitals where people usually work. The mothballing of the Nightingale hospitals allows us to use that capacity for what is most needed right now.
Covid-19 Update
Lord Ribeiro Excerpts(4 years, 4 months ago)
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Lord Bethell
The noble Baroness talks of an incident that I do not know the details of, but I do not deny that we are on a learning curve. We will publish new guidelines tomorrow on our local outbreak response; we are publishing guidelines on the opening of venues for 4 July; and we are working extremely hard to stitch together much better relations between the centre, where a lot of the data inevitably ends up in a big system, and the insight of local actors in local PHE, local infection, NHS and local authority bodies. This has been happening for many weeks and we have already made huge progress, but there is still more to do.
Lord Ribeiro (Con) [V]
My Lords, the noble Lord, Lord Hussain, referred to the risks for the BAME population. The PHE report found that those of Bangladeshi ethnicity were at twice the risk of death compared with people of white British ethnicity. That, of course, is particularly relevant in relation to Leicester. The PHE follow-up report, Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups, which came out last month, identified long-standing inequalities exacerbated by Covid-19. Occupation, population density, the use of public transport, housing conditions and the risk to key workers are all factors in acquiring Covid-19. What actions will the Government take to address the seven recommendations in the report?
Lord Bethell
My Lords, we take the PHE report extremely seriously but there is still work to do in understanding how the disease affects different groups, including ethnicities. Some effects are behavioural, such as obesity; some are social, such as population density, to which my noble friend alluded; and some might be genetic. It is not clear which of those three is the main driver and what the balance is between the three. We are investing a large amount in medical and clinical research to understand that dilemma. In the meantime, we are prioritising the safeguarding of BAME workers in the NHS who might be at risk and in need of specific treatment.
Covid-19: Track and Trace System
Lord Ribeiro Excerpts(4 years, 5 months ago)
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Lord Bethell [V]
My Lords, we are enormously grateful to the people of the Isle of Wight for their collaboration on the pilot. There is no question of them needing to stand down. Other measures for “test and trace” are working extremely well on the Isle of Wight, and both the pilot app and the manual “test and trace” have helped break the chain of transmission. We remain extremely grateful for their support.
Lord Ribeiro (Con) [V]
My Lords, six weeks ago, the contact tracing app was launched on the Isle of Wight, since when, the emphasis has shifted from the app to the use of 25,000 call centre workers to identify the contacts of people testing positive for Covid-19. What lessons have we learned from countries such as Australia, Singapore, Italy and Switzerland, which all launched contact tracing apps, and is the purpose of the “test and trace” app to help end this pandemic or to protect us from the next?
Covid-19: Response
Lord Ribeiro Excerpts(4 years, 5 months ago)
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Lord Bethell
The noble Baroness makes a powerful point. The frustrating truth is that many in the groups and communities of which she speaks take the fewest number of tests. Getting through to these groups is extremely important, so they can seek the clinical help they need if they are suffering from Covid. We have worked extremely hard with our marketing department to ensure that hard-to-reach communities get the marketing messages that will be effective. The noble Baroness provides a really reasonable reminder and I will redouble my efforts to ensure that those marketing messages are focused on the right communities.
Lord Ribeiro (Con)
My Lords, I appreciate that “test, trace and isolate” is in its embryonic phase and that we have yet to learn the lessons of the pilot on the Isle of Wight, but at the height of the pandemic Sir Paul Nurse and other academic researchers offered, in the spirit of Dunkirk, to assist the Government with their “little boats”. Sadly, this approach failed to find favour, with a central approach then being used. Will my noble friend assure me that, as we head to a national rollout of “test, trace and isolate”, the Government will remain open to offers of help from those in the security and medical fields?
In addition, the PHE report identifies worrying outcomes from BAMEs who contracted Covid-19, as others have said, but the analyses did not cover comorbidities such as hypertension, which is common in the Asian and African populations, diabetes or obesity, which was mentioned in 21% of Covid-19 death certificates. Can my noble friend say when these factors will be considered, in order to provide a clearer picture for BAMEs who are at risk of contracting Covid-19 now and when the next wave comes in the winter?
Lord Bethell
My noble friend makes an incredibly perceptive point on the BAME research. He is entirely right that this important aspect of our understanding in relating the ethnic, social and behavioural elements of the response to the disease is essential. The report has not covered all the ground yet: that work is being done at the moment, as I mentioned earlier. Frankly, only when all those elements are linked together will we get a full picture.
Regarding the “little boats”, we absolutely celebrate them. In order to get the industrial-level testing numbers up, it was correct to back big laboratories that could do the automation necessary to achieve that. I am a huge admirer of Sir Paul Nurse and have spoken to him often. The role of laboratories such as his is in connection with their local NHS trusts. Many local laboratories are doing extremely good work with local NHS trusts and we are putting measures in place to facilitate and encourage such connections.
Hospitals: Patient Safety
Lord Ribeiro Excerpts(4 years, 6 months ago)
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Lord Bethell
My Lords, I acknowledge the expertise of the right reverend Prelate the Bishop of London, who, in a former life, was the Chief Nursing Officer. She raises an important point; the mental health of staff is of enormous and grave concern to the NHS, to the department and to social care. We are investing money in providing additional mental care support and are working closely with the colleges to find out how best we can provide that important support.
Lord Ribeiro (Con)
My Lords, the specialist guidance on the management of non-coronavirus patients needing acute treatment, issued on 20 March, put senior decision-makers at the heart of triaging patients referred for admission. To assist them, what role would testing for Covid-19 play on admission, and what proposals are there to utilise the Nightingale hospitals as a step-down facility for Covid-19 patients, thus reducing their numbers in NHS hospitals and allowing those hospitals to deal with the backlog of cases?
Lord Bethell
My Lords, there was some interruption in hearing my noble friend’s question but, if I understood him correctly, the answer is that all patients are now tested on entry to hospital. Until their test result has arrived, they are treated as though they have Covid-19 and isolated wherever possible.
Care Homes: Covid-19 Testing
Lord Ribeiro Excerpts(4 years, 6 months ago)
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Lord Bethell
My Lords, I completely acknowledge the threat of a second peak. It focuses the mind and is very much a priority for the Government, but there is no squabble of the kind the noble Baroness describes. I pay tribute to colleagues at the CQC, Public Health England, the NHS and the private care providers with which we work. Care home testing is offered to all care home staff and patients who need it. We are prioritising those who ask for it first and working through the list for any who need it by early June.
Lord Ribeiro (Con)
My Lords, given the press briefing by Dr Jenny Harries on Wednesday 13 May, when can we expect testing of all residents and staff in care homes? Covid-19 infects older people in care homes at different times. Therefore, a test is valid only on a specific day. Do the Government understand that one test per resident is not enough? Repeat tests are often required. Can my noble friend the Minister say what steps have been taken to increase the number of tests in care homes to save lives?
Lord Bethell
The noble Lord is correct: it is one test per resident for each infection. I pay tribute to the many care homes which have no infection at all, which have applied the correct disciplines and systems and for which no demand for the tests is currently present. We are prioritising homes that have infection and working through all their residents and staff, offering second and regular testing until the infection is eradicated. That logical prioritisation is exactly the right way to use the resources of both time and supplies, which are necessarily limited.
Health: Maternity Care Provisions in East Kent
Lord Ribeiro Excerpts(4 years, 9 months ago)
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Baroness Blackwood of North Oxford
The noble Baroness raises an important question, which I am sure will be considered as part of NHS England’s independent review and the CQC’s questions around quality of leadership, but I will make a wider point for those who may be listening about the safety of maternity care in the UK. We are rightly focusing on the questions of East Kent, but for those who may be considering giving birth at the moment it is important to state that the NHS is one of the safest places in the world to give birth. Some 0.7% of births result in a stillbirth or neonatal birth. We have stated that our ambition is to halve this rate of stillbirths, neonatal and maternal deaths, and brain injuries by 2025. We have already achieved our ambition of a 20% reduction by 2020. A message of reassurance, alongside the firm actions we are taking to address the concerns raised by the noble Baroness, is appropriate and important.
Lord Ribeiro (Con)
My Lords, I echo the comments of the noble Baronesses, Lady Thornton and Lady Brinton, about the role of the chief executive. I watched the news last night and was horrified to hear her say that she had no knowledge of the review until 2018, yet that review was requested by the medical director of the trust in 2015. If she is unaware of what is happening in her own trust, serious questions need to be asked. In view of what the noble Baroness just said about maternity services, it is important that we send a very clear message to our midwives on the front line. They need to be supported and we need to send the message, not just to the ones in East Kent but to those throughout the UK, that they have our support.
Baroness Blackwood of North Oxford
My noble friend is, as ever, very wise on this. A key plank of the maternity safety strategy, launched in 2016, is a number of initiatives to improve not only clinical care but culture in maternity services. They have been designed to improve leadership and to ensure that in every trust there is a midwife, an obstetrician and a board-level maternity safety champion to spearhead improvement. It is critical that we ensure that this is delivered so that incidents such as this do not occur.
Access to Palliative Care and Treatment of Children Bill [HL]
Lord Ribeiro ExcerptsFriday 7th February 2020
(4 years, 9 months ago)
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Lord Ribeiro (Con)
My Lords, it is a pleasure to follow the noble Baroness, Lady Finlay, who has devoted a lifetime to the care of the dying. I thank her for initiating this important debate. It is a pleasure to be able to support this Bill.
As a surgeon, one of the most difficult tasks in cancer surgery was deciding how best to approach a patient on whom you have operated in the hope of achieving a cure, only to discover that their tumour is inoperable. One can buy time and offer radiotherapy or chemotherapy, but inevitably the cancer will win through and the patient will face an uncertain future.
I faced this dilemma in my first month as a surgical house officer when I did not know how to control a patient’s pain after surgery. In those days, we called it an open and shut laparotomy because of the inoperable cancer in the abdomen. Distraught by his suffering, which did not respond to the four-hourly doses of pethidine I prescribed, I turned to the ward sister for help. There was a pause. “Morphine”, she said. It eased the patient’s pain, and they died peacefully.
Dame Cicely Saunders founded the first St Christopher’s Hospice in south-west London in 1967 —the year I qualified. In 1958, she wrote:
“It appears that many patients feel deserted by their doctors at the end. Ideally the doctor should remain the centre of a team who work together to relieve where they cannot heal, to keep the patient’s own struggle within his compass and to bring hope and consolation to the end.”
We would all wish that hope and consolation for ourselves at the end, and that is precisely what the hospice movement has endeavoured to provide over the last 60 years.
As our population ages, more people are reaching an age where the demand on emergency services grows. It is estimated that in 2016 there were 1.6 million emergency admissions for people in the last years of their life. This is a huge burden on hospitals since they account for 30% of all admissions, costing the NHS £2.5 billion. Hospitals should be places for treating patients and, hopefully, curing them. They are not hospices for the care of patients needing terminal care. The provision of hospices nationally is such that many hospitals cannot avoid becoming hospices, for lack of these services.
We need more community-based care to support demand. The Bill is welcome, as it rightly asks for such care to be commissioned in the same way as other care, by the clinical commissioning groups—CCGs. Marie Curie, to which I am grateful for its briefing, estimates that without properly commissioned palliative care by CCGs, the cost of providing emergency admissions for patients in the last year of life is likely to increase by £1.6 million by 2041. We do not have the capacity to meet the extra beds required to support this need, particularly when innovations in medicine and surgery are designed to reduce patients’ length of stay, and while maintaining staffing levels is a continuing problem.
There is no clear national strategy for end-of-life care, and, despite the early pioneering work of Dame Cicely Saunders, hospitals are supported in the main by charities and the public, with the NHS providing about a third of the cost of adult hospices. I believe there are 200 hospices in the UK collectively caring for 225,000 people and their families per year, 80% of which is delivered in the patient’s home. It is time to provide a comprehensive nationwide service from which all can benefit, through the CCGs.
The Bill will ensure that access to hospice care is not determined by a postcode lottery where some areas are better provided for than others. It is important to recognise that many hospices will be running a deficit budget in 2019-20. As the noble Baroness, Lady Finlay, observed, the Prime Minister’s announcement in August 2019 that £25 million will be made available to hospices and palliative care services in England is to be welcomed, but it is non-recurring. It will fix the roof while the sun is shining, but without sustainable funding it is unlikely to fix the roof long term.
A National Health Service which delivers care to all at the point of need should also be able to do so for those at the end of their lives through a better-funded and provided-for hospice service. Perhaps the phrase “from cradle to grave” should have renewed meaning as we all get older and the demand for end-of-life care increases. I believe that the Bill will go a long way to deliver these aims, and I am delighted that it has wide and strong support from the BMA, Marie Curie, Hospice UK and, I hope, your Lordships.
On Clause 2, which has been mentioned, earlier this week, along with the noble Baroness, Lady Finlay, and the noble Lord, Lord Sheikh, I met Connie Yates and Chris Gard, who is here today. They are the parents of Charlie Gard. I was impressed by their quiet determination to avoid legal challenges in these cases which serve only to divide and entrench opinion. Their plea for mediation before litigation, put so eloquently by them on the “Victoria Derbyshire” programme yesterday, puts a human face on a problem that one must address to prevent others suffering the same fate. The BMA has raised concerns about Clause 2(4), believing that any medical treatment proposals put forward by any person holding parental responsibility for a child are in the child’s best interests. It believes that this may expose children with life-limiting illnesses to unproven or sub-optimal treatments. It is important to be clear where the balance of responsibility for treatment lies—with the doctors responsible for the child’s care or with the parents. I am sure that we will return to this thorny issue in Committee and I look forward to considering the amendment to be tabled by the noble Baroness, Lady Jolly.
With those reservations, I am pleased to give this Bill my full support and I thank the noble Baroness, Lady Finlay, for introducing it.
Paterson Inquiry
Lord Ribeiro Excerpts(4 years, 9 months ago)
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Lord Ribeiro (Con)
My Lords, as a past president of the Royal College of Surgeons, I wish to associate myself with the comments of the current president, Professor Derek Alderson. In response to the report, he said:
“The horrific experience of patients at Paterson’s hands is laid bare in today’s report. The healthcare system has failed hundreds of patients and their families, and we must learn from what went wrong. Following their thorough investigation, we welcome the inquiry’s recommendations today, designed to improve patient safety.
We have repeatedly called for the same safety standards to be enforced across both the NHS and private healthcare sector. The inquiry has also stressed this and agreed with our recommendation that a single repository of information about consultants’ practice should be created. We recommended this in our evidence to the inquiry because it allows the NHS and private sector to share information and raise any concerns about patient safety much more quickly.”
When the Bill comes before us, we will be discussing the health service safety investigation body—HSSIB. Can the Minister say whether, in the light of the Paterson inquiry, the Bill might be amended to ensure that HSSIB has the power to investigate all patient safety incidents that occur in the independent private sector as well as in the NHS, not just NHS patients referred to the private sector?
In his introduction, Bishop Graham says:
“It is wishful thinking that this could not happen again.”
Well, this week the British Medical Journal reports on an orthopaedic shoulder surgeon working in the same Spire Parkway Hospital who has had 217 patients recalled because of concerns about his practice. A solicitor for the patients involved said:
“The main concern seems to be that people were having unnecessary surgery under general anaesthetic.”
There are echoes of Paterson’s behaviour. Another recall at the same hospital suggests systemic failings. Given the outcome of the Paterson inquiry, which showed that lessons have still to be learned, how can we ensure that these lessons are learned?
Baroness Blackwood of North Oxford
I thank my noble friend for that question, and for his important contribution. He is of course very experienced in this area. Obviously we are looking for time in the legislative agenda to bring forward HSSIB. It is appropriate that we consider the patient safety elements of this report’s recommendations in the context of that Bill. In the previous Second Reading debate, which we look forward to repeating, we discussed the issues around the independent sector. But we will also separately, and perhaps in conjunction with that, consult on the key changes necessary to enable data on admitted patient care to be transferred from the Private Healthcare Information Network and independent providers directly to NHS Digital, which should start to take us in the direction of closing the gap, which I know that many noble Lords in the House are rightly concerned about.
Health Service Safety Investigations Bill [HL]
Lord Ribeiro ExcerptsTuesday 29th October 2019
(5 years ago)
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Lord Ribeiro (Con)
My Lords, I too thank Jeremy Hunt for his contribution as Health Secretary and his interest in patient safety, and for driving the Bill to the position it is in now. In the Queen’s Speech debate on Tuesday 22 October, I drew attention to the title of the Bill:
“The humble Address refers to new laws to establish an independent body to investigate serious healthcare incidents”.—[Official Report, 22/10/19; col. 539.]
I pointed out that this was at odds with the title of the Bill, which deals solely with health service safety incidents and those carried out in the private sector on NHS patients. It does not apply to those receiving private treatment in the private sector, a point that has already been made by others.
The Joint Committee of MPs and Peers on the draft Bill made it clear that it should be amended to extend the HSSIB’s remit to the provision of all healthcare in England, however funded. It is therefore disappointing that this Bill fails to address the issue with the private sector. I gave the example of the Sellu case, where the evidence of a root-cause analysis of the surgeon’s work was not disclosed at the trial. Today I make reference to another case, that of Ian Paterson, a surgeon who was sentenced to 15 years in prison for undertaking needless breast surgery in the private sector. After his conviction, the Royal College of Surgeons called for a review of safety standards in the private sector. Both cases indicate why the scope of the Bill needs to be widened to include the private sector. The apparent exclusion of private healthcare providers and organisations, save for those that are treating NHS patients and providing service and equipment to the NHS, would appear to limit the potential scope and effectiveness of the HSSIB.
In the Queen’s Speech I declared my interest as chairman of the Confidential Reporting System in Surgery, CORESS, which serves to support surgeons in providing confidential reports of near misses and adverse incidents in surgical practice, with the aim of disseminating the learning from these incidents to inform the surgical community and prevent further occurrences. One of the committee members, Peter Tait, previously director of flight operations for British Aerospace’s commercial section and latterly the CEO of CHIRP, the confidential human factors incident reporting programme, worked closely with the chief inspectors of the Air Accidents Investigation Branch for 20 years. He described the aviation equivalent of the current scope of the HSSIB Bill as restricting the AAIB to investigating air transport operations and their service provision but excluding aircraft, engine and equipment manufacturers, air traffic services and airport providers directly or indirectly involved in the survey safety of the air transport system. It is a whole-system effect that needs to be looked at, not just one area.
I believe that by limiting the Bill to the NHS we are ignoring the lessons learned by the AAIB and others in dealing with rail and marine accidents. The Royal College of Surgeons has similarly expressed concern about the narrowness of the scope of the Bill and believes that the Bill should give the HSSIB the power to investigate non-NHS patient safety issues in the independent sector, as recommended by the Joint Committee. It is not enough to limit the remit of the HSSIB to those who provide NHS services to the private sector.
In its response to the Ian Paterson case that I mentioned earlier, the Royal College of Surgeons published recommendations for assessing standards in the independent sector, including the need for equivalent reporting requirements for independent and NHS hospitals in terms of safety and outcome data. Thus, by extending the remit of the HSSIB to the non-NHS-funded independent sector, errors or potentially dangerous activity identified in the private sector could be addressed, to the benefit of the NHS and non-NHS patients. This is all the more important as the majority of surgeons work both in the NHS and in the private sector. The Joint Committee enforced this point when it asked for the draft Bill to be amended to extend HSSIB’s remit to cover the provision of all healthcare in England, however it is funded. This is likely to require consequential amendments to other parts of the Bill, as well as to the title, and I look forward to introducing these in Committee.
The Royal College of Surgeons is also keen to widen the scope of the Bill to include the regulation of surgical care practitioners in the UK. These practitioners increasingly support routine care of surgical patients under the supervision of senior surgeons and provide continuity of care while surgeons focus on more complex and advanced patient care. The Government believe that surgical care practitioners should be regulated by the Nursing and Midwifery Council. As more surgical care practitioners enter the profession directly, rather than through roles such as nursing, it is appropriate for regulatory oversight to be introduced. Failure to do so may pose an increased risk to patient safety.
The safe space proposals have been modelled on approaches used for many years by the air accident and transport safety investigation bodies, which have contributed to safety in these industries. However, the provision in Part 2(3)(19), on disclosure to coroners, differs from the UK regulation relating to disclosure for the AAIB. The International Civil Aviation Organization sets out regulations relating to disclosure in Annex 19:
“The State conducting the investigation of an accident or incident shall not make the following records available for purposes other than accident or incident investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs the adverse domestic and international impact such action may have on that or any future investigations”.
All of this was highly pertinent to the Shoreham air display accident, which noble Lords may recall, as a full statement was given to the Air Accidents Investigation Branch and the judge refused to give the police access to this evidence. It is important that a public interest case should be made by a High Court judge in order to release information, and this approach should be applied similarly to HSSIB.
I am advised that when applications for disclosure have been made in the case of the AAIB, only one successful application for the release of cockpit voice recording data, fitted to a privately owned aircraft, was granted to the estate of the deceased pilot. The High Court judge ruled that the disclosure would not set a precedent for the release of information related to public transport systems and their investigation. Any exceptions to the safe space protection to accommodate coroners will be problematic and the same standards should apply across the board, whether to the AAIB, the Marine Accident Investigation Branch or HSSIB. Otherwise, HSSIB will not hold the same powers or protections and coroners will be able to draw on their access to individual statements to determine how they question witnesses during inquests. Thus, information taken in confidence by HSSIB could be indirectly made public. I am reassured by what my noble friend the Minister said earlier in this respect, but we may need to tease this out in Committee, as the noble Lord, Lord Hunt of Kings Heath, observed.
Safe spaces do not prevent coroners accessing information if they have justification for it and can do so through the High Court. Healthcare staff need to be confident that HSSIB can protect their information in line with the original safe space proposals. Fear of legal, regulatory or managerial sanctions against clinicians is high and recent high-profile court cases such as Sellu and Bawa-Garba do little to reassure the profession. HSSIB must be allowed to enjoy the confidence of the profession, otherwise its work will be seriously compromised.