Dementia
Lord Touhig Excerpts(12 years, 5 months ago)
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Lord Touhig
To ask Her Majesty’s Government what steps they are taking to provide support for people with dementia.
Lord Touhig
My Lords, a debate on dementia is long overdue. Indeed, the last time your Lordships’ House debated dementia was on 25 June 2009.
Today there are 800,000 people with dementia in Great Britain, and two-thirds of them are women. Currently only 43 per cent of people with dementia have a formal diagnosis, yet we all know that diagnosis is the key to accessing information, treatment and support services. There will be more than 1 million people with dementia by 2021 in this country. This year alone it will cost us £23 billion. Currently there are 600,000 family carers of people with dementia.
While significant resources are being spent on dementia, they are often being spent inefficiently and in ways that do not meet the needs or aspirations of the people with dementia and their families. Improving services for people with dementia could therefore boost outcomes and also prove cost effective for the taxpayer. Over a million people living with dementia in the United Kingdom by 2021 will present a major challenge as people with dementia are significant users of both health and social care services, and there remains an unacceptable variation across the country in the quality of services and support. Too often, people with dementia are unable to access the support they need and are frequently failed by the current system. Urgent reform of the social care system is needed, along with a real priority attached to dementia, if we are to improve lives.
As a former member of the Public Accounts Committee in the other place, I well remember the 2007 report by the National Audit Office which found that the health and social care response to dementia was inadequate and that spending on dementia, while significant, was poorly used. The Alzheimer’s Society 2009 report, Counting the Cost, showed that there was an unacceptable variation in the care of people with dementia in the hospital service. It found that people with dementia were staying in hospital on average a week longer than other people admitted for the same reason. A report for the Department of Health by Professor Banerjee in 2009 estimated that 180,000 people with dementia were being prescribed anti-psychotic drugs but that two-thirds of the prescriptions were inappropriate. Anti-psychotics rob people with dementia of their quality of life and lead to 1,800 deaths a year. In January 2010, the National Audit Office’s interim report on dementia found that progress on implementing the national dementia strategy in England had been patchy and had got off to a slow start. The Alzheimer’s Society’s 2011 report, Support. Stay. Save., found that half of people with dementia were not getting the support they need.
Last March, the Prime Minister’s challenge on dementia laid out further key commitments on research, healthcare and dementia-friendly communities. The Queen’s Speech in May outlined the Government’s plans to introduce a draft Care and Support Bill for England. We are told that the Bill will set out how the Government will modernise care and support law to ensure that local authorities fit their services around the needs, outcomes, experiences and aspirations of the people. We are told that it will build on a personal budget agenda, simplify the laws around social care and improve the way in which people get information about their due entitlements. Dementia plans and strategies are in place in Northern Ireland, Wales and Scotland, all of which emphasise the need to improve awareness, diagnosis and services.
While the vast majority of care for people with dementia is undertaken by family carers, people with dementia frequently use social care services. The current system does not work for the person receiving care, it does not work for the person providing the care and it certainly does not work for the taxpayer. The chronic underfunding of social care over many years has driven down quality, choice and accessibility. Over the past four years, the increased demand for social care has outstripped the increase in expenditure by 9 per cent, and the ability of people with dementia to live well is increasingly under strain. People with dementia are being unfairly penalised by the existence of what is called the dementia tax.
Individuals and families are spending tens of thousands of pounds to access the care they need, while care for people with other medical conditions, such as cancer, is free. The Alzheimer Society’s 2008 report, The Dementia Tax, found that people with dementia and their families are willing to make a contribution to the costs of their care. However, they need a fairer deal which protects them against very high costs and which also guarantees the quality of care. Where one lives determines the level of care received, as councils decide locally at what level to start providing support. Across the country, people cannot get essential care, while some in a neighbouring authority can. A patchwork of complex rules and assessments makes claiming what people are entitled to difficult and off-putting. The highest spending local authority, Tower Hamlets, spends five times more than Cornwall, the lowest spending authority.
People have a limited say over the care they receive. Choice and control is the experience of too few people. Out of two million older people in England with care-related needs, 800,000 receive no formal support at all. The lack of support early in the condition leads to a substantial pressure on long-term care and acute sectors. Some 10% of the respondents to the survey Support. Stay. Save. reported that the person with dementia was admitted earlier than expected into long-term care because of inadequate support in the community early on. A similar proportion reported that the person with dementia was admitted to hospital when it could have been avoided because there was lack of early support in the community. This is despite evidence that early intervention is both cost-effective and is what people with dementia and their carers want. The care paid for by local authorities is too often provided to people who have significant need when evidence shows that investing in care earlier would reduce demands on the National Health Service. The Alzheimer’s Society has been campaigning for many years for a change in the way we pay for care. The forthcoming social care and support White Paper is an historic opportunity to overhaul our care and support system.
What can we do to make a difference? The Dilnot commission proposed a fair system where no one would lose more than 30% of their assets. That would help. However, without additional government funding, England’s social care system will not be fixed. The recent Nuffield Trust report identified a number of funding options that could release funds to invest in the social care system. The Government must begin a public debate on where money for care could come from. Money intended for social care must be used for care, and not for filling in potholes. At present, each local authority decides which of the four levels of fair access to care services eligibility criteria they will fund: low, moderate, substantial or critical. It is profoundly unfair that two people living either side of a local authority boundary—they could be living either side of a road—could be entitled to significantly different levels of care. The Government must introduce a national eligibility strategy to improve consistency and fairness across the country. Progress has been made, but we have a long way to go.
Just over two years ago I took part in a march. It was a memorial march in memory of people with dementia who had died. I walked with a man whose wife had not spoken a word in 18 months. He was her carer; he sometimes had respite when his son could take over. His wife was doubly incontinent; they had no shower or toilet facilities on the ground floor. He told me that the only day he was confident that she was kept clean was the day that she went to a day centre, where they had showers, and so forth. He was battling hard in order to find funds to provide these basic facilities on the ground floor of his home. I came away full of despair after talking to that man. I am sure that noble Lords must have had similar encounters.
When we last considered this subject, in a debate introduced by the noble Baroness, Lady Murphy, in 2009, she told us that the average age of your Lordships was 68 and that one third of us will die with dementia. That brings it home that every one of us must know or will have an encounter with someone who has dementia. We really must do something about it. We have a duty to those in our society who are desperately locked away almost as prisoners of illnesses of the mind. It is down to those of us who can still articulate and make the case to ensure that the Government and we as a society do something to improve the quality of life for people with dementia.
Autism Act 2009
Lord Touhig Excerpts(12 years, 8 months ago)
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Lord Touhig
My Lords, I thank the noble Baroness, Lady Browning—indeed, I am proud to call her my noble friend—for securing this debate today. Those concerned about autism and how we support people with autism and their families have no better champion in this House than the noble Baroness.
All too often in my experience, the public perception of the need to make provision to support people with autism is that it is a matter for the education services alone; it is about helping autistic children. But, of course, while providing educational opportunities for autistic children is vital, necessary and right and proper, I fear that it sometimes masks our appreciation that autistic children grow up into autistic adults, and the support is needed for adult life as well. All too often, I fear that our approach focuses on early years alone, and that is often seen as our priority. It is right that it should be a priority, but it should not be the priority to the exclusion of all else.
When I spent a day at the National Autistic Society’s day centre in Croydon a couple of months ago, I saw for myself how the team there is making a real difference to the quality of life of autistic adults but, like many others, I am concerned about the step before: the support given during the transition from childhood to adulthood. It is often taken for granted that people should be able to move in and out of education throughout their lives. We have to ensure that people with autism have the opportunity to be able to continue to access education throughout their lives and that it is a given right, not a gift which society may or may not bestow from time to time.
The need to improve the transition to adulthood for people with autism is mentioned in the autism strategy, but as far as I can see it contains no concrete proposals to deliver these improvements. I know that Ambitious about Autism has asked the Government to recognise that a good transition to adulthood delivers long-term cost savings to the state, as well as increased life chances for people with autism and their families. Good links between health, social care and education services are essential to a good transition. The current lack of reference to education in the autism strategy is, I think, worrying us all. I would like to see the review of the strategy next year lead to the inclusion of education services.
In its Finished at School research paper, Ambitious about Autism found that just one in four young people with autism goes on to any form of education or training beyond school. It also found that where young people with autism are supported to continue their education, they are more likely to live independently and access employment in later life. This reduces pressure on adult health and social care services. Until local commissioners and those driving the strategy nationally invest in making further education and training accessible to young people with autism, I fear we will continue to see them go down the default path into adult health and social care services. Will the Government consider what concrete measures to improve the transition will be included in the review next year?
In previous debates, I have spoken of the worries that the National Autistic Society has had about the proper guidance, better training and more robust data which services for adults with autism need if those services are not to fail them. A key National Autistic Society concern, which I and others share, is that specialist autism teams such as the Liverpool Asperger Team and the Bristol Autism Spectrum Service will, despite being recommended by NICE, not be commissioned in each area.
The Minister might recall that in a debate on 31 March last year I raised the issue of the National Audit Office investigation into public spending on autism. It found that if such teams are established there is a potential to save money. It estimated that if local services identified and supported just 4 per cent of adults with high-functioning autism and Asperger’s syndrome, the outlay would become cost neutral over time. In addition, it found that if it did the same for just 8 per cent it could save the Government £67 million a year. The Liverpool Asperger Team, which is the longest-standing specialist Asperger’s service in the country, currently reports identification rates of 14 per cent. Four per cent therefore seems a very achievable figure for newly established autism teams, and a cost-neutral level of service is an entirely realistic prospect. How will the NHS Commissioning Board ensure that clinical commissioning groups are given guidance on commissioning services, particularly specialist autism teams, for adults with autism? What steps are being taken to improve data protection and training for professionals in the NHS, and is autism being included in these discussions?
I have a couple more questions. The draft NICE guideline states,
“that the Care Quality Commission will monitor the extent to which Primary Care Trusts … responsible for mental health and social care and Health Authorities have implemented”,
these NICE guidelines. Given this role, will the CQC therefore be involved in the 2013 review? Recently, it was confirmed by the Department of Health that NICE will produce two quality standards for autism, one for children and one for adults. Is there a timeframe for when we can expect these standards to be published? Finally, how can stakeholders be involved in the development of these standards?
This debate has given us an opportunity to put these questions and I fully appreciate that the Minister might wish to reflect a bit further and write. As the noble Baroness, Lady Browning, made clear, this requires ongoing monitoring. If the Act is to be effective, we have to continue to monitor and ask these sorts of questions. I have no doubt that the Minister in his usual good way will make sure that we have an adequate and full response.
Health and Social Care Bill
Lord Touhig Excerpts(12 years, 10 months ago)
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Earl Howe
My Lords, I understand that the noble Baroness is asking me to deliver a certain message to my right honourable friend. I am not quite sure what that message was, but if it is to do with the Health and Social Care Bill, I have to say that we need that Bill. We believe that reform of the NHS is essential if it is to be sustainable in the future. Every penny saved from this reform will be reinvested in front-line patient care. The previous Government had, as we do, an ambition to save £20 billion—the so-called Nicholson challenge—over the next three or four years. This reorganisation will enable us to contribute to that total. The modernisation will also move the NHS to a much more patient-centred system where good providers are rewarded for high-quality services. We are spending money on redundancy now to gain in the future.
Lord Touhig
My Lords, will the Minister tell us whether the report in this morning’s Guardian that the NHS regulator is proposing that a hospital should be credit-rated is correct? If it is correct, why are the Government pursuing this commercialisation of our hospitals? They are not supermarkets; they are places of care.
Earl Howe
My Lords, I have not seen that report, but clearly there is concern, following Southern Cross, as to whether difficulties such as those should be predictable in some way. I am sure that a lot of thought is being devoted to trying to avert such crises in the future. I will look at that report and write to the noble Lord with any comments.
NHS Reform
Lord Touhig Excerpts(13 years, 7 months ago)
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Earl Howe
I am grateful to my noble friend. In answer to his first question, it is likely that the period of listening and engagement will extend through the Easter Recess and beyond. The precise duration of the intermission has not been fixed yet because much will depend on the volume of feedback that we receive. While I have not spoken to the usual channels about this, I am still working on the premise that your Lordships’ House will receive the Bill prior to the Summer Recess. I believe that, if the House agrees, we can thereby reach the Bill’s conclusion within a reasonable space of time. That will enable us to adhere to the current timetable for the implementation of our proposals. But that statement does come with what I might call a health warning because we are clear that we want to listen to the opinions of everybody who counts in this, and it could be that the period of reflection may extend into the late spring. But no doubt I will be able to enlighten him further in due course.
My noble friend mentioned the democratic input at health and well-being board level. This is one of the issues that we will want to receive opinions about because I know there has been disquiet on this front. He knows that his party was instrumental in building into our plans the democratic element of health and well-being boards and the fact that they should be situated at local authority level. That was a very positive contribution made by the Liberal Democrat Party which has, by and large, been widely accepted. If there are ways we can bolster that democratic accountability without cutting through the core principles that we have articulated for decision-making in the health service, then we are willing to look at them.
Lord Touhig
My Lords, the Minister said that the NHS was in a healthy financial position and that the Government intend to increase NHS spending by £11.5 billion over the life of this Parliament. Yet, in the last financial year, the NHS had an underspend of £5.5 billion and the forecast this year is a further underspend of another billion. The Chancellor has said that he intends not to hand this money over to the NHS but to keep it in the Treasury. The Nuffield Trust says that this is a retrospective cut in health spending. Does the Minister agree?
Earl Howe
My Lords, the noble Lord needs to bear in mind that the forecast surplus for 2010-11 represents a very small proportion of the department’s budget. It is greatly to the credit of the health service and the department that they have managed to come in on the right side of the line and by a margin that, in the scheme of things, is not significant. I say that without being at all blasé about the figure of £1.4 billion. I suggest to the noble Lord that that represents good financial management. Yes, the money that represents the surplus cannot be carried forward into the subsequent year but that is not the same thing as saying that providers, for example foundation trusts, may not use their carry-forward balances. That is still possible at provider level. I hope, on reflection, that the noble Lord will not think too badly of the way the service has been run in the past few months.
NHS: Standards of Care and Commissioning
Lord Touhig Excerpts(13 years, 7 months ago)
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Lord Touhig
My Lords, I join others in the House in thanking my noble friend Lord Turnberg for securing this debate. In the short time that I have at my disposal, I would like to focus my remarks on one area in particular: healthcare and autism. The noble Baroness, Lady Browning, and I, together with representatives of the National Autistic Society, recently met the Minister and we were given a very sympathetic hearing on matters that concerned us. We thank him for that.
The National Audit Office’s investigation into public spending on autism found that one of the best ways of overcoming the alarming gaps in training, planning and provision across a range of services was to develop specialist autism teams that could diagnose and support people with autism. It went on to say that, if such teams are established, there is the potential to save money. It stated that, if local services identified and supported just 4 per cent of adults with high-functioning autism and Asperger’s syndrome, the outlay would become cost neutral over time. In addition, it found that, if these local services did the same for just 8 per cent, the Government could save £67 million per year. The Liverpool Asperger Team, which is the longest-standing specialist Asperger’s service, reports an identification rate of 14 per cent, so 4 per cent is certainly achievable.
Will the Minister tell the House how teams such as the one in Liverpool will be funded if the Health and Social Care Bill is passed into law? In the Bill, health and social well-being boards have a duty to promote integrated working and, as such, would lead on commissioning specialist services. However, the White Paper published in July states that the NHS Commissioning Board will take responsibility for commissioning specialised services at both national and regional level, as informed by the specialised services national definitions set. These sets contain definitions of 34 services. Definition 22 covers specialist mental health services and includes specialised services for Asperger’s syndrome and autism spectrum disorder. There is clearly a difference between the White Paper and the legislation on how specialist autism teams will be commissioned to carry out their work. Will the Minister say whether the NHS Commissioning Board or, at local level, the health and well-being board will be responsible for this commissioning work?
Each of the commissioning scenarios is not without problems. First, specialist teams are often commissioned through pooled budgets. There is concern that, if 80 per cent of the commissioning budget sits with the GP consortia but the health and well-being boards are responsible for commissioning the joint services, the major budget holders—the GPs—may not commission services whose primary benefit in the short or medium term will be the local authorities. The commissioning problems could potentially become more complicated when health and well-being boards have a number of consortia in their areas. It is possible that the GP consortia might take a free ride and not contribute. Secondly, if these services are commissioned through the specialised services national definitions set at regional level, that could make it more difficult for the teams to respond to local needs and integrate themselves into each local authority that they serve.
The draft NICE guidelines on diagnosis, recognition and referral of autism in children and young people call for local teams to be created in each area. Teams such as the ones in Liverpool and Bristol are doing first-class work. A key way of getting over this problem of commissioning specialist teams is to strengthen the role of the health and well-being boards in creating pooled budgets and to ensure that the NHS Commissioning Board can intervene in any disputes over these budgets. I appreciate that this is a major problem still to be solved and I hope that the Minister will respond to that and to my other questions.
Health: Sickle-Cell Disease
Lord Touhig Excerpts(13 years, 8 months ago)
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Lord Touhig
One in 10 children diagnosed with sickle-cell disease will suffer a stroke. Unfortunately, a number will die. Those who do not will go on to have further strokes leading to disabilities and cognitive loss. The Minister talked about a screening programme. Do the Government have in mind any plans to get greater public awareness of sickle-cell disease by a public education programme right across the board among all groups in society?
Health: Care and Compassion?
Lord Touhig Excerpts(13 years, 8 months ago)
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Lord Touhig
To ask Her Majesty’s Government what action they plan to take in response to the Parliamentary and Health Service Ombudsman’s report Care and Compassion?.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the department has asked the Care Quality Commission to conduct a series of unannounced inspections on NHS trusts, and will report on its findings. The department wrote to NHS chairs on 15 February to raise awareness of this report and to ask them to assure themselves that their own organisations were up to standard. Similarly, the chief nursing officer also raised the report findings at her February meeting with strategic health authority directors of nursing.
Lord Touhig
I thank the Minister for his Answer, which is very helpful. We in this country are blessed with a National Health Service staffed by very dedicated and committed people but, as this report highlights, there are instances of neglect and a lack of care for the elderly. The best way to prevent cases like the 10 listed here happening again is to ensure that everyone in the National Health Service, if possible, reads the report. It is available online at www.ombudsman.org.uk, but can the Government find ways to help to distribute the report so that everyone working in the health service can read it?
Earl Howe
My Lords, I understand and applaud the noble Lord’s reason for making that suggestion. I will overlook the issue of cost, but I am not sure that his idea would necessarily have the desired impact. What is needed here is for local leaders to take charge. That is why the chief executive wrote to every chairman and chairwoman in the NHS asking them to share the report with every member of their board, so that they can examine the services in their particular organisation and assure themselves that these situations are not happening on their watch. Nevertheless, I am certain that boards around the country will wish to take heed of the noble Lord’s suggestion.
Health: Mental Health Strategy
Lord Touhig Excerpts(13 years, 9 months ago)
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Lord Touhig
My Lords, I join others in congratulating the noble Baroness, Lady Murphy, on securing this debate. She seems to have a knack of securing debates of this nature at an important time. In 2009, she secured a debate on dementia, and anyone who reads it will realise the power, information and knowledge that a debate of that sort in your Lordships House brings to the issue.
It seems that society increasingly expects GPs to have the answer to every health problem. While the demands on the National Health Service grow, more and more patients turn up at GP surgeries expecting answers to ever more complex medical problems, compared with, say, just 10 years ago. The plain fact is that GPs are inadequately equipped to provide the overspecialist diagnosis that many patients, perhaps unreasonably, expect from them. For me, the big worry is that the Government intend to place an even greater burden on GPs by making them the local health commissioners through GP commissioning.
Under the Government’s Health and Social Care Bill, local commissioners and GP consortia will be responsible for ensuring that the mental health needs of their local communities are properly and adequately met. The worry is that they are inadequately trained and prepared for this. GPs have a small degree of training in mental health and their knowledge of it is varied, sometimes with worrying consequences. In my former constituency of Islwyn, we have a wonderful group called SHADE. It is a self-help group of ladies who have suffered with a range of mental health problems, especially depression. When I first got to know the group many years ago, one lady who was suffering with depression told me that when she went to see her doctor he listened carefully to her problems and then said, “Nothing wrong with you, love. Go home and get your husband to buy you a new dress”. What worries me about the Government’s plans is the lack of any proposal to remedy such ignorance.
The one exception—and as a former Minister for Veterans I welcome this—is on page 45 of No Health without Mental Health, where there are proposals to provide training for GPs and other NHS staff who may come into contact with veterans with mental health needs. That is most welcome. If the Government propose to do this for veterans, it is an admission that there is a training gap, and the Government should extend this sort of training on general mental health matters to GPs. This would significantly decrease the risk of poor-quality mental health provision posed by some of the plans to give GPs commissioning powers over health provision.
As I understand the Government’s NHS changes, only a small number of specialist high-cost low-volume services, such as secure mental health services, will be commissioned directly by the new GP commissioning board. The majority of mental health services will be commissioned by GP consortia in place of primary care trusts. It will therefore be vital that GPs properly understand mental health and the services needed to help people with mental health problems. Yet, the Government’s own evidence on page 58 of No Health without Mental Health shows that only one in every six older people with depression discusses their symptoms with their GP, and fewer than half of those receive adequate treatment.
In my time as a Member of Parliament, too many elderly people came to see me and complained that they were unhappy with the care offered by their GP, who would often say: “What do you expect at your age?”. Senior citizens expect a first-class health service. Citizens of whatever age are entitled to and deserve that. The evidence suggests that if GPs are going to take responsibility for commissioning mental health services, it will be necessary for them to receive further training on how best to treat mental health problems. At the very least it will be necessary for the Government to carry out a full assessment of whether GPs are in a position properly to commission mental health services.
On page 51 of No Health without Mental Health, the Government say that they want GP consortia to be,
“well placed to understand the broad range of mental health problems experienced by people in the local population and to commission high-quality services across primary and secondary services”.
We can all sign up to that aspiration, but GPs will need further training. I fear that the proposal from the Government may simply be storing up even greater expectations of what GPs can do for their patients that will not be fulfilled, leaving many with undiagnosed and inadequately cared for mental health problems. Like other noble Lords, I welcome this document, but I see it as a work in progress rather than as the final answer to our difficulties.
NHS: Front-line and Specialised Services
Lord Touhig Excerpts(13 years, 10 months ago)
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Lord Touhig
My Lords, I am pleased to be here for this debate, if only to have listened to the speech of the noble Baroness, Lady Jolly, because she spoke from the heart about the National Health Service and her family’s personal understanding of and reception by the NHS recently. She was also able to speak with some authority as someone who has been involved in the provision of healthcare. I look forward to her future contributions on this matter.
I am delighted to follow the noble Baroness, Lady Greengross, because I, too, want to relate my remarks to dementia. She does a tremendous job in chairing and leading the all-party group.
If you are a man who has had a stroke and as a result you have no recollection of the wife you have been married to for 30 years, and then you develop dementia, you have no voice. If you are a woman who one day stops talking to her family and has not spoken a word in 18 months, retreating into a valley of silence, you have no voice. If you are a dementia sufferer who is doubly incontinent and you have no downstairs shower and toilet, and the only day of the week when you can be sure that you will be made really clean is the day you go to a healthcare centre, you have no voice. As Parliament, at the behest of the Government, prepares for a major shake-up in the provision of NHS services, I believe that we must be the voice for dementia sufferers and their carers.
Three-quarters of a million of our fellow citizens have dementia and it is forecast that by 2025 the number will be over a million. I welcome the success of my noble friend Lord Turnberg in securing this debate so we can press the Government to tell us how front-line specialist services will be protected in this shake-up. We currently spend £20 billion a year on dementia and, as the noble Baroness, Lady Greengross, pointed out, one in three people over the age of 65 will die with dementia—yet currently only one in three receives a formal diagnosis. As a member of the Public Accounts Committee in the other place, I well remember a National Audit Office report in 2007 which found that money was being wasted on poor quality care. The report went on to say that rates of diagnosis were low, cost-effective interventions were not widely available, and health and social services were often disjointed and inefficient. A further NAO report this year said that the National Dementia Strategy for England, first published in 2009, was comprehensive and ambitious. It found that there was early progress towards implementation, but warned that not enough priority was being given to dementia. There has been some progress, but not enough.
I share the worries of the Alzheimer’s Society, which is concerned that the pace of structural change that is going to come in the NHS has the potential to undermine the progress we have made so far. That is all the more reason why these changes, as the noble Baroness, Lady Greengross, said, have to be managed very carefully indeed. When I was a Minister in the previous Government, I well remember the former Prime Minister, Tony Blair, saying to me that for him healthcare was not about the doctor, the nurse or the latest high-tech scanner, it was about the patient. Of course, he said, we need the doctor, the nurse and the high-tech scanner, but the focus the whole time must be on the patient—and that, I believe, is right.
Over the past couple of years, we have seen increasing knowledge and ability among many NHS commissioning managers in commissioning better and improved care for dementia. However, the number of people with these particular skills is relatively small. It is vital, therefore, that the pace of structural change which will come about as a result of the Government’s NHS changes does not undermine this progress. Valuable dementia commissioning has been developed and must be retained. Perhaps the Minister can say something about this. GP commissioning will play a major role in the future, but only 31 per cent of GPs believe they have received sufficient basic and post-qualification training to diagnose and manage dementia. Can the Minister say what specific steps the Government will take to ensure that the small pool of dementia care commissioning expertise is not lost, a point well made by the noble Baroness, Lady Greengross?
A recent survey showed that only 5 per cent of GPs had discussed the national dementia strategy with their PCT commissioners. What is important, therefore, is that the current coterminosity of boundaries for commissioning health and social care is not lost. People with dementia are major beneficiaries of effective joined-up working between the NHS and social care because they use the two services. In order to continue to meet the needs of people with dementia and their carers, can the Minister assure us that the new GP commissioning arrangements will result in a comprehensive primary care response, including improved home care, so that admission to the acute sector is used only where it is necessary?
We can only imagine what it must be like to suffer with dementia. A dementia sufferer is like a prisoner locked away by an illness of the mind in a world of their own. That is why we must be the voice for those people and their carers.
NHS: Reorganisation
Lord Touhig Excerpts(13 years, 11 months ago)
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Lord Touhig
To call attention to the reorganisation of the National Health Service; and to move for papers.
Lord Touhig
My Lords, it is a privilege to open this debate on a matter as important as the National Health Service. The NHS was the subject of my maiden speech in the other place more than 15 years ago and, like many noble Lords on all sides of the House, I feel very passionate about the service. It is easy to take this great service for granted, but we should never forget how fortunate we are to live in a country that has such high-quality healthcare available for each and every citizen, free at the point of use.
I pay particular tribute to those who work in the National Health Service. Their commitment to their patients and to ensuring the best outcomes for those whom they treat is the bedrock of the NHS. Without their dedication, the NHS would be nothing. The fact that the service provides some of the best healthcare in the world is a reflection on their professionalism and hard work. We should never lose sight of that.
We have a health service that we can be proud of and that has certainly improved over the past 12 or 13 years, but we now have a new Government who seem determined to impose their own vision on the National Health Service—a vision which, perhaps not surprisingly, is riddled with inconsistencies and risks having a negative impact on patient care. It is notable that the British Medical Association has reacted in a decidedly mixed way to the Government’s proposals. In response to the White Paper, Equity and Excellence: Liberating the NHS, which was published in July, the BMA reacted most strongly against the increased commercialisation and competition that the Government seem determined to foist upon the service. I am sure that I am not alone in sharing those worries.
Most concerning is that, despite the increased emphasis on competition in the recent past, there is still little evidence that such measures have any benefits for the patient. The Government came to power promising to make policy that was evidence based, yet expanding competition in the NHS flies in the face of that pledge. Indeed, increasing competition seems to have more to do with ideology rather than the welfare of the patient. I share the BMA’s view that high-quality care can be delivered in the most cost-effective way by encouraging co-operation across primary and secondary care.
I fear that, rather than encouraging co-operation and collaboration between care providers, the Government’s policy risks discouraging the sharing of information and good working practices. Such discouragement, it seems to me, is the logical consequence of forcing care providers into competition. It is normal commercial practice for competing service providers to keep new information or successful developments to themselves so that they can exploit them and improve their market position. Obviously, such providers do not share information that gives them an advantage over their competitors. That makes perfect sense in the commercial private sector, yet in the NHS such an approach would massively undermine the ability of care providers to adapt to changing circumstances and ensure best practice. Decreasing co-operation and collaboration would, I fear, be the natural consequence of further increasing competition in the NHS—a view that is shared by the BMA. Therefore, I hope that the Government will put patients’ interests and the views of professionals before their ideological agenda.
I am also concerned by the Government’s “any willing provider” policy, which risks exacerbating the difficulties with increased competition. The policy has the capacity to undermine local health economies by replacing existing multiservice natural monopolies with a plethora of smaller units that provide more limited services. As well as radically undermining the efficiency and value for money achieved by the NHS, that risks creating obstacles to the NHS working co-operatively for patients as a public service.
The concept of competition and of the “any willing provider” policy is supposed to allow patients to make meaningful choices about their care, but in my experience—which I am sure is shared on all sides of the House—what most patients want is high-quality providers close to where they live that offer timely and competent diagnosis, treatment and support. I fear that the Government’s policy risks undermining this central patient wish. It risks turning care providers into nothing more than businesses which, rather than supporting each other and striving for better provision of healthcare across the whole NHS, seek only to improve their own market position. If the outcome of increasing competition is to undermine the central priority of patients, I have to question the benefit of increasing competition.
The Government have also decided that they want all NHS trusts to obtain foundation status within three years. That undermines the whole rationale of the concept of foundation trusts, which was that foundation trust status was supposed to be a mark of quality and achievement. Evidently, if all trusts become foundation trusts almost overnight, foundation status will cease to be a mark of quality and in some regards will become meaningless as a concept.
The White Paper signals the Government’s intention to return to the GP fundholding scheme that we had under a previous Tory Government. The noble Lord, Lord Walton, who is held in high regard by noble Lords on all sides of the House, spoke about this in July. He said to the Minister who made the Statement on the White Paper,
“Many of those who are so proud of the NHS have major concerns about the GP-commissioning element of the White Paper”.
The noble Lord continued:
“No doubt the Minister will remember GP fund-holding under the previous Conservative Government, which was not a great success and had to be withdrawn in the end because it failed to fulfil the objectives”.—[Official Report, 12/7/10; col. 537.]
He was right. The House will not need reminding that GP fundholding, which was first trialled the last time that the Conservatives were in Government, did not work.
There are many other lessons that the Government must learn from pushing ahead with such a policy. In 1992-93, 5 per cent of GP fundholders overspent their budgets by more than £100,000. In the same year, 21 per cent—one in five—underspent their budgets by more than £100,000. Across the NHS last year, the underspend was almost £32 million—millions of pounds that Parliament voted for the health service but were not used.
There is now another worry concerning funding. In an analysis of the comprehensive spending review and of the White Paper that the Nuffield Trust published in October, the trust points out a little-noticed proposal in the spending review that would make a major change to the rules governing underspends across government and would have a profound impact for health. The NHS had a £5.5 billion cumulative underspend at the start of the financial year and plans to have a further underspend of around £l billion in 2010-11. The CSR announcement will mean that none of that money will be returned to the NHS. The Nuffield Trust said that, in effect, that amounts to a retrospective cut in health spending.
There is more. It is important in the context of GP-led commissioning that GPs are properly accountable for the decisions that they take. The big concern must be that GP commissioning will be less transparent and less accountable. Inadequate experience of commissioning a range of treatments will lead to a postcode lottery in NHS provision. For example, it would be possible for a group of GPs with a specialist interest who know where to obtain the best treatment to provide high-quality care for cancer patients. Another GP commissioning practice may have no such knowledge or specialist interest so its patients would might not be so well provided and cared for.
The Secretary of State this week attended the Britain against cancer conference hosted by the All-Party Parliamentary Group on Cancer. When the audience of health professionals, doctors, patients and politicians was asked whether GP commissioning would improve or worsen cancer care, the conference voted unanimously for the proposition that care would worsen. With great respect to the Secretary of State, he seemed not to pay much attention to that. He went on to say that GP commissioning was a chance to improve GPs’ knowledge. Turning the National Health Service upside down to improve GPs’ knowledge is one hell of a risk to take. The Secretary of State left the conference with the message that he wanted GPs to be thinking new thoughts. What in God’s name is that supposed to mean? I have no idea whatever.
So far, some 52 GP practices have signed up to become pathfinders for GP commissioning. That number could increase to 500, and those commissioning consortia would replace 150 primary care trusts. However, that leads to further problems. The NHS relies on data collection to improve healthcare. How will that be done, when some 500 consortia are doing the job of collecting the data that are currently collected by 150 PCTs?
The National Audit Office and the Public Accounts Committee in the other place have done excellent work in establishing best practices to achieve value for money across public spending. In achieving value for money, will GP commissioning consortia be incentivised to save money? Perhaps the Minister can tell us. If that is the case, what will the Government do to ensure that the NHS does not drown in a sea of medical negligence claims? If a GP consortium is incentivised to save money, there is a danger that patient care will suffer and that someone will then rush off to the lawyers—it will be a litigant’s paradise—in order to get some redress.
There is a common GP contract in England and Wales. How will the new arrangement in England intersect with what is happening in Wales? Will it mean separate GP contracts? How much will that cost and who will pay? It is clear from the response to the White Paper that many GPs lack the experience to run a commissioning service and many do not want to do so. Will they be encouraged to buy in solutions from private healthcare providers, such as the American-owned UnitedHealth or Humana, which on its website describes itself as the “Human Face of Healthcare”? Those companies are already touting for business and advertising their ability to manage GP consortia on their websites. Does the Minister agree that outsourcing the management and commissioning of health provision can, and probably will, lead to conflicts of interest? What steps will be taken to ensure that a healthcare company brought in to manage a GP consortium will not place work with itself as a healthcare provider?
Many noble Lords want to speak so I shall bring my remarks to a conclusion, but there is one further point that I should like to make. Much has been said in recent times about the enhanced role of the third sector in providing services. Earlier this week, together with a number of noble Lords whom I see in the House today, I attended a meeting of the All-Party Parliamentary Group on Stroke—stroke is the second major contributor to dementia—where we had a general discussion about the planned changes for the National Health Service. Some of the comments that were made at that meeting are worth repeating. “Left entirely to market forces, stroke will slip down the agenda”, was one view. Talking about top-down targets, another contributor commented, “If not targets, we certainly need objectives”. Another asked, “What is the future for the stroke impairment network?”. A final comment was that, “PCTs are at last understanding stroke. If we have to start from scratch again, let’s not lose the gains we have made in transition”. Those remarks will, I am sure, be repeated right across the health-supporting third sector.
The White Paper risks undermining the very fabric of our National Health Service; it risks reducing co-operation within the NHS; and it risks undermining the progress that has been made in improving patient care and outcomes. Most important, the proposals risk moving us away from a National Health Service that works co-operatively for patients as a public service—a move that I think would deeply harm patient care. Those outcomes would be disastrous for patients, doctors and the country as a whole. I hope that the Government will think again about their proposals.
Lord Touhig
My Lords, as barely a minute is left in this debate, I am unable to thank all noble Lords individually for taking part. Other than a general thanks, I cannot comment on all the points that were made. The standard of debate here was much better than in the other place. There is such wide experience, which is a huge benefit. I thank the Minister, who did very well in responding to all the questions raised by noble Lords. His eloquence does not equate to the power of his argument, as those who expressed doubts and questioned these changes won the argument. I have no doubt that we will return to these issues.