NHS: Cancer Drugs Fund

Baroness Brinton Excerpts

Monday 16th March 2015 Lords Chamber

[Earl Howe]

My Lords, the noble Lord is right that there is a particular issue around the appraisal of new cancer drugs. That is why NHS England, the Department of Health, cancer charities, NICE and the Ethical Medicines Industry Group, as well as the ABPI, are working together currently as part of a new working party tasked with finding the best way to get new cancer drugs appraised and commissioned for patients. A number of proposals have been looked at to reach an integrated process between NHS England and NICE which results in clear and final decisions on baseline commissioning of chemotherapy drugs.

[Baroness Brinton (LD)]

My Lords, given the good news that the Minister just gave us about the working group looking at the future of some of these complex drugs, and the whole policy about “No decision about me without me”, would it not be sensible to have patients’ advocates, such as Prostate Cancer UK, able both to present and to appeal the case for a drug? It seems bizarre that this is the one area where there is no input of anybody other than the committee making the decision.

[Earl Howe]

I differ slightly from my noble friend on this point. I think that the key determinant for the reprioritisation process has to be clinical input, and that is indeed what happened. It is necessary to have as objective a process as possible when looking at how to reprioritise a cash-limited fund of this kind.

NHS: Medical Staff

Baroness Brinton Excerpts

Monday 15th December 2014 Lords Chamber

[Earl Howe]

I beg your pardon, my Lords. DfID has a number of programmes designed to support the health economies of developing countries. They have been in place for many years. They can take the form of training, not just of doctors but of all healthcare professionals. I am aware that DfID is extremely supportive of those programmes.

[Baroness Brinton (LD)]

My Lords, 10 years ago there were more Malawian doctors working in England than there were in Malawi and the Royal College of Surgeons, working with CBM UK, a disability charity, set up the College of Surgeons of East, Central and Southern Africa. In that time the number of African-trained surgeons has substantially increased through this joint practice. Are other royal colleges following their example in setting up similar projects?

[Earl Howe]

I am not aware of the answer to that question but I can tell my noble friend that the UK has been moving towards self-sufficiency for a number of years. For example, there was a 27% decrease in the number of registrations of non-European Economic Area nurses from April 2010 to March 2014, continuing a longer-term trend. The number of doctors in the NHS with a primary medical qualification from outside the EEA has remained relatively static over the last four years despite the full-time equivalent number of doctors increasing by more than 5% over the same period. I think we can take heart from those figures, mindful, of course, of the need to adhere to the World Health Organization code of practice.

HIV: Stigma

Baroness Brinton Excerpts

Monday 1st December 2014 Lords Chamber

[Earl Howe]

My noble friend, with his immense knowledge of this subject, is of course absolutely right. The 2011 UN Political Declaration on HIV and AIDS specifically includes a goal to eliminate by 2015 stigma and discrimination against people living with and affected by HIV through the promotion of laws and policies which ensure that human rights and fundamental freedoms are protected. Progress towards universal access cannot be made unless stigma and discrimination are tackled. They are a particular barrier with regard to the criminalisation of gay men and women, transgender people and sex workers. DfID is a constant champion of these groups internationally.

[Baroness Brinton (LD)]

My Lords, Prince Harry’s brave statement today to declare his secret reminds me of mine. A dear friend died of AIDS three decades ago. I cannot speak his name because to this day his family do not know that he had it. The point made by the noble Lord, Lord Fowler, is important, but we have children and young people in this country who are suffering from HIV and AIDS. What education is planned specifically for young people who are at risk, along with their school friends?

[Earl Howe]

My Lords, sex and relationship education plays an important part in exposing young people to the whole subject. Guidelines are available that schools must follow. They include sections on HIV and sexually transmitted diseases generally. As I say, secondary schools must follow those guidelines.

Nursing and Midwifery (Amendment) Order 2014

Baroness Brinton Excerpts

Thursday 27th November 2014 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, the Government have identified improvements that can be made to the legislation within which the Nursing and Midwifery Council operates, to improve public protection and increase public confidence in the Nursing and Midwifery Council. Therefore, the department carried out a UK-wide consultation on proposed changes to the Nursing and Midwifery Order 2001, which is the Nursing and Midwifery Council’s governing legislative framework. The majority of respondents supported these amendments.

The first of the proposed changes is to enable the Nursing and Midwifery Council to appoint case examiners who will be given powers currently exercised by the investigating committee to consider allegations of impairment of fitness to practise, following an initial screening which has considered that an investigation is appropriate. Two case examiners—one lay and one registrant—will consider the allegation, following the procedure set out in amendments to the Nursing and Midwifery Council (Fitness to Practise) Rules, which are being developed in parallel to this order by the Nursing and Midwifery Council.

The case examiners will then agree their decision on whether or not the registrant has a case to answer—this is the same process used by General Medical Council case examiners—and whether the allegation should therefore be considered by the health committee or by the conduct and competence committee. If case examiners fail to agree on whether there is a case to answer, the allegation will be referred to the investigating committee for determination. The introduction of case examiners should lead to the swifter resolution of complaints and thereby improve public protection and the efficiency of the Nursing and Midwifery Council’s fitness to practise processes, as well as reducing the stress to registrants caused by lengthy investigations.

The second change is to introduce a power for the council to review “no case to answer” decisions made at the end of the investigation stage in fitness to practise cases, and to make rules in connection with the carrying out of such a review. This will bring the Nursing and Midwifery Council’s power in line with the General Medical Council’s power.

The third change is to introduce a power to allow the council to delegate this function to the registrar—the chief executive. The amendments to the fitness to practise rules being developed by the NMC will provide that the registrar may review a “no case to answer” decision where new evidence comes to light that has a material impact on the original decision or if it is considered that the decision may be materially flawed, and in both cases that it is in the public interest to review. Save in exceptional circumstances, a review of a “no case to answer” decision cannot be commenced more than one year after the date of that decision.

The fourth change is to revise requirements for the composition of the registration appeal panel by removing the requirements for a Nursing and Midwifery Council member to chair the panel, which is intended to establish a clear separation of duties between the operational and governance functions to avoid suggestions of perceived bias and conflict. Additionally, it will remove the requirement for a registered medical practitioner to be on the panel in cases where the health of the person bringing the appeal is an issue. It is intended that medical advice will be provided by independent medical witnesses and reports to ensure the panel remains detached from that part of the process, and therefore making the process more robust and transparent. This will also ensure more consistency between registration appeals and fitness to practise appeals.

The fifth element is to clarify existing legislation that the Nursing and Midwifery Council’s Health Committee or Conduct and Competence Committee has the power to make a strike-off order in a health or lack of competence case upon a review of a final suspension order or conditions of practice order, provided the registrant has been the subject of such a final order for at least two years. This is not a new power but provides clarification of the existing legislation to protect patients and the public by ensuring that those whose fitness to practise is impaired cannot continue to practise.

The sixth change is to introduce a power for the Nursing and Midwifery Council to disclose to a third party certain information relating to a person’s indemnity arrangements for the purpose of verifying that information for the Nursing and Midwifery Council’s purposes. This will enable the Nursing and Midwifery Council to verify the information it receives to ensure that indemnity arrangements are in place and provide sufficient cover against the liabilities that many be incurred by a practising nurse and practising midwife registrant.

The seventh change is to give the Investigating Committee a new power to also make an interim order after it has referred a case to the Health Committee or to the Conduct and Competence Committee if that committee has not begun its consideration of the case. At present, once the Investigating Committee refers a case, the power to make an interim order rests only with the Conduct and Competence Committee or the Health Committee. This will ensure that if new information is received which suggests that an interim order is necessary for the protection of the public after a case has been referred to another practice committee, but before the committee has started to consider it, the Investigating Committee will have the power to make an interim order.

The introduction of case examiners and the power to review “no case to answer” decisions, made at the end of the investigation stage in fitness to practise cases will bring the Nursing and Midwifery Council in line with the General Medical Council. The implementation of these recommendations requires a Section 60 Health Act 1999 order to amend the legislation governing the Nursing and Midwifery Council. I commend this order to the Committee, and I beg to move.

[Baroness Brinton (LD)]

My Lords, this amendment to the Nursing and Midwifery Order is to be welcomed. A regulatory body has to balance the respected traditions and structures of an informed 150 years of experience with the urgent needs of the current issues that the council faces when there may be rare problems with registered nurses and midwives. Much of what is proposed follows good practice. However, there is one area in which I have some minor queries and I wonder whether my noble friend the Minister can help.

The move away from independent consultants forming an investigation committee to having an in-house employed case examiner raises two minor concerns that are not reflected in the consultation response at paragraph 8.6 of the Explanatory Memorandum. Will the case examiners have extensive training in gathering the evidence that they will have to present to the quasi-judicial relevant committee considering each case? Will the benefits that other investigating groups such as Ofsted and local government inspectors have, given that at least one member of those teams comes in from outside, ensuring that there is always fresh challenge, be lost with this new arrangement?

Secondly, as employees of the council, will their job specification make it absolutely clear that they must conduct their role without fear or favour? It may be obvious when they are dealing with people outside the council but occasionally—very rarely—there may be a case where, for example, a decision not to have an interim suspension might have resulted in further injury or damage, and therefore members of the council themselves and other judgments might be being examined. The case examiners must be truly free to examine the council’s own processes and to feel no pressure from their own managers.

The no case to answer decision and the independent chair of the appeals panel are important and to be welcomed. However, given what I have just said about the case examiners, I find it slightly peculiar to remove the requirement for a registered medical practitioner to be on the panel, because that person in the past has provided that independent voice from the members of the council.

The points that I have raised are minor ones, and I welcome the order. However, I hope that I can have some reassurance on these points relating to the new role of case examiners.

NHS: Health Improvements

Baroness Brinton Excerpts

Wednesday 26th November 2014 Grand Committee

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Lord, Lord Kakkar, on securing this important debate on a key issue that is essential if the NHS is to be in the forefront of health improvement in the next few years. The noble Lord focused on the larger strategic picture, but I want to focus more on the impact on the patient and the citizen. The title of the debate refers to both innovation and research. I want first to talk about where innovation and research are providing improvement in treatment and in health, particularly the benefits of the new academic health science networks, which use pure and applied research to create very strong links between hospitals, commercial organisations and universities. These regional bodies are providing a country-wide system to deliver innovation.

I declare an interest as an arthritis patient; I am grateful to Arthritis Research UK for a briefing that it sent me. It has joined with the Medical Research Council to fund the Centre for Musculoskeletal Health and Work. Led by Southampton University, this centre seeks to find ways to reduce the impact of conditions that affect muscles, bones, and joints on the ability of people who work: people like me. At present, musculoskeletal conditions are the biggest cause of workdays lost through illness, with 30.6 million days lost a year. The cost to the economy is significant. For people with rheumatoid arthritis, seven out of 10 are unable to work because of the condition within 10 years of diagnosis. So research that is both scientific and applied can not only make a significant improvement to the individual and their condition, but can also reduce NHS costs and offer the chance of their returning to work and taking an active part in our economy again.

In another example of research innovation, Arthritis Research UK has joined with the Medical Research Council and other medical research charities to invest £230 million in a clinical research infrastructure initiative. This initiative will involve 23 key projects at centres across the country, and will use state-of-the-art technologies to find out how differences in the cellular and molecular make-up of people affect how they respond to disease and to treatment. It will take us forward on personalised treatment as that develops over the next few years.

Innovation does not automatically mean clinical research. The Scottish Health Informatics Programme is a good example, which we in England would do well to emulate. In a report to the APPG on Medical Research, a case study points out that SHIP is a Scotland-wide collaboration between the NHS and Scottish universities which analyses and links patient records. Although currently a developing resource, data linkage has also been used in a number of health studies in Scotland, using anonymous linked clinical diabetes and cancer data to show that patients using synthetic insulin were at no greater risk of developing cancer than those using traditional insulin.

That should be contrasted with some of the very practical problems of not linking data, where each hospital has its own patient number and does not allow data to be transferred between hospitals as a matter of course. A patient who has to have regular blood tests before treatment may have their test carried out at a GP surgery; it is then sent to the local district hospital, which will e-mail the result back to the GP, who often has to sign it off before the patient or the other hospital is allowed to know the result. The patient has to speak to the receptionist, sometimes to the GP as well, and the receptionist again when they go in to collect the blood test result. Because in this example the patient’s treatment is at a regional hospital, not their district hospital, they then have to text their consultant with the result to ensure that the treatment can actually be carried out. If the results are delayed for any reason, when they arrive at their regional hospital treatment may be delayed while a further blood test is carried out, and there is then a backlog of patients seeking treatment. All this is because the NHS cannot allow the transmission by e-mail of formal results. I am told that it is to do with data protection but if the Scottish system can make it work, surely the NHS can as well. Will my noble friend the Minister indicate whether England and Wales will follow the example of the Scottish Health Informatics Programme and solve what seems to me to be a straightforward and simple problem rather than the intractable and expensive problem that it has become?

There is another important area of innovation that provides significant health and well-being improvements, and that is the involvement of the citizen and patient in understanding their own disease and treatment. The National Institute for Health Research launched its “OK to ask” campaign on International Clinical Trials Day in 2013. More than 150 NHS hospital trusts took part and 80% of respondents who were followed up said that it had definitely helped to raise awareness of the importance of clinical research. The National Cancer Patient Experience Surveys of 2012 and 2013 show that only one in three cancer patients is having a conversation with their doctor about research. There is a good body of evidence to show that patients who talk to their clinicians and understand their illness and the treatments that are available—or even not available—are less likely to suffer from depression.

I have one anecdote from 10 years ago—I apologise for the aged anecdote. When I was the deputy chair of the East of England Development Agency, we did some work with the Williams Formula 1 team. As its social responsibility action, the team that changed tyres in the pits was working closely with the Great Ormond Street Hospital operating theatre teams to work out how they might be able to improve their performance to speed up operations. Both Great Ormond Street and Williams have found it extremely useful because Williams learnt something from it as well. That is an unusual form of innovation—actually, I think it is good lateral thinking—but it works very well in other ways. I know that many people involved in the Williams thing now sell that expertise for management teams to work better as teams in the future.

We have had some good cases this evening to show that the benefit of innovation is much wider than we imagine. Not only do Parliament and government have a key role to play but so does the citizen and patient. We need to ensure that innovation and research is at the heart of the NHS as it faces the challenges of the 21st century.

Care Sector

Baroness Brinton Excerpts

Tuesday 25th November 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Baroness, Lady Kingsmill, on securing this important debate. I want my focus to be slightly more positive by picking some of the good examples in the sector, particularly in training and skills, to show that there is a way out of some the problems that the sector faces at the moment. However, I start by reiterating the point made by other speakers: the care sector has some of the most dedicated staff in the UK workforce, who have the incredibly responsible job of helping to look after the most vulnerable adults in our society.

The vast majority of the 1.5 million staff do it very well, but sadly the small handful who abuse their clients and our trust are the ones who capture the headlines. My mother had domiciliary care for a decade until she moved into residential care about 18 months ago. I have seen, at first hand, carers and their managers at work. During that time, nurturing relationships have been created and sustained and her carers have travelled with her on her difficult journey. In other visits and meetings outside the family, I have seen some less good practice but also some unusual places—I will come on to the healthcare assistants in geriatric wards and prisons later.

In the main, those services that are excellent are often unseen; problems, many of which seem to be appearing more frequently, are the result—I believe—of pressure from above which comes from two sources. The first is the still very small pool of people prepared to work in the sector, and the second is the funding packages for social care that cause organisations to take short cuts. Some local authorities now offer ridiculous hourly rates to organisations that do not cover travel time, annual leave and training in particular. I am afraid to say that the tri-borough in London is one of those and Bradford is another, so it is not just a London problem. I ask my noble friend the Minister: what can the Government do to ensure that the living wage and the overheads that healthcare organisations ought to be paying should be included in a contract from local government?

I want to reflect briefly on the social care workforce demographics for 2012, which I think is the most recent year for which we have figures, and Skills for Care’s report, The Size and Structure of the Adult Social Care Sector and Workforce in England, because some interesting points come out of them. I suppose it is no surprise that over 80% of the workforce are women but it is worth highlighting that for managers it is still 80% women, which is encouraging and shows that there is not a glass ceiling there. However, that is not reflected in the black and minority ethnic data, which show that 18% of the workers are BME but for carer staff the figure rises to 29%, while for managers it drops quite considerably. Will my noble friend the Minister say what support is being offered to junior BME staff by employers or Skills for Care to help them progress their careers and get through that glass ceiling?

Interestingly, the data also show that 82% of staff are British, 4.5% are from the EU and 13% are from non-EU areas. Given the debate that your Lordships’ House has just had, if UKIP wanted to repatriate non-British workers, we would have an urgent and immediate shortfall of 17.5%, which rises to nearly 20% among front-line carers.

There has been considerable focus on the qualifications of the care workforce over the past 10 years, much of it introduced by the previous Government and continued by the present one, and with some considerable success. There has been the development of the national vocational qualifications—NVQs—at levels 2 and 3, as well as the national occupational standards, where each standard is a unit of care that demonstrates that the worker can effectively look after that particular thing; it might be bathing an elderly patient or working with them to try to bring back some memories. At the higher level there is certainly work on dementia care as well.

One difficulty was that the focus of the previous Government was on NVQ level 3, the equivalent to an A-level, rather than level 2, which left many in the sector concerned about those staff with no qualifications at all. The data show that almost half the workforce are now qualified to level 2, which is great news, and over 15% to level 3, both of which are improvements. But 37% of the workforce have no qualifications at all. We want anyone in a caring role, or who is managing carers, to have the national occupational standard—NOS—qualifications to at least level 2 to guarantee a minimum level of understanding about the care that is being given, and for the safety of the clients and patients. Inevitably, the majority of people without qualifications are direct carers. I ask my noble friend the Minister: what incentives can the Government provide for small businesses particularly to help train their staff, especially those who have no qualifications at all, given that there is an excellent national framework and many employers offer these qualifications?

This raises a further point. The future workforce projections to 2025 show that the workforce will need to grow by 800,000 in the next 11 years. If we do not have training and recruitment plans in hand, we will not be able to provide the skilled workforce we need as our ageing society needs more and more assistance.

To end on a positive note, I mentioned earlier the geriatric ward in a prison, the number of which is increasing. One healthcare assistant I met was just beginning training to qualify as a nurse because her employer realised the benefit of a proper progression pathway. That is the way this business should be going in the future.

Health: Mental Health

Baroness Brinton Excerpts

Tuesday 28th October 2014 Lords Chamber

[Earl Howe]

I hope that the noble Baroness will agree that the five-year plan is truly ground-breaking in many respects. We have identified £40 million to spend this year to support people in mental health crisis and end the practice of young people being admitted to mental health wards. Another £80 million has been freed up for next year to ensure that waiting time standards become a reality, not just for those with mild mental health conditions but across the piece. I will write to the noble Baroness if I can glean any further information about those with a specific disability.

[Baroness Brinton (LD)]

My Lords, one of the worrying consequences of the shortage of mental health beds is the number of patients who leave mental health wards and subsequently commit suicide within a short space of time. If a patient commits suicide within a short period of leaving in-patient care, it should be regarded as a never event. That would provide real parity of esteem alongside parity of funding and ensure that patient safety is at the heart of every patient’s release.

[Earl Howe]

My noble friend makes an extremely important point. NHS England is currently reviewing the never events framework. My honourable friend the Minister of State for Care and Support will shortly be meeting NHS England officials to discuss the possibility of including suicide following in-patient care as a never event and how the new never events framework will support parity of esteem.

NHS: Five Year Forward View

Baroness Brinton Excerpts

Thursday 23rd October 2014 Lords Chamber

[Earl Howe]

Many food companies—not all, but many of the larger ones—have already taken steps, for example, to reduce the levels of salt and saturated fat in their products. We need to go further. This has been done by the previous Administration and the current Government on a voluntary basis. We think that that has worked well. Nevertheless, we have never excluded the possibility of regulation, where we think that it is justified. At present, we believe that there is sufficient scope to make progress without regulation, but that is a matter we will keep under review.

[Baroness Brinton (LD)]

My Lords, from the Liberal Democrat Benches, we also welcome the five-year report, particularly because it accepts that the business-as-usual model needs to move on. In particular, we welcome the public health aspects and the fact that strong democratic accountability with councillors and local authorities is providing substantial change in public health. Does the Minister agree with the report that there should be more enhanced powers for local authorities to develop this further? If so, can he guarantee that there will be cross-departmental discussions to make sure that there are more responsibilities, powers and funding?

[Earl Howe]

My noble friend has alighted on an area to which the whole Government will have to give very careful thought. It is not simply a matter for my department. This will entail cross-departmental scrutiny and agreement. However, on the strength of the performance of local authorities in grasping the public health agenda, as they have very enthusiastically, I am sure that we should look at that particular proposal very constructively.

Mental Health: Beds

Baroness Brinton Excerpts

Tuesday 29th July 2014 Lords Chamber

[Earl Howe]

My Lords, on the very last point, I do not have up-to-date figures, but I will certainly write to the noble Lord. However, on his main question, detention as a mechanism solely to secure access to hospital treatment would not be lawful. If hospitals or local authority staff think that that is happening or feel pressurised to admit people in that way, they should report it to their trust and, if necessary, to the Care Quality Commission. Sectioning under the Mental Health Act, which denies people their liberty, is a very serious matter. It should be done only when a person is a risk either to themselves or to other people and, as the noble Lord knows, it is a legal process. A patient cannot be sectioned merely to secure a bed.

[Baroness Brinton (LD)]

My Lords, the survey referred to by the noble Lord, Lord Bradley, was of junior doctors in the Royal College of Psychiatrists. If it was somewhat anecdotal and they felt that they were unable to report it formally, can Ministers ask NHS England to ensure that there is a survey of how many doctors are having to use sectioning, to prevent this continuing?

[Earl Howe]

It certainly is important that we get to the bottom of what is really happening. We take this issue very seriously. The Care Quality Commission intends to explore the issue of people being detained in order to access psychiatric units in its ongoing review of emergency mental health care. The findings of that review will be published later this year. The CQC’s Mental Health Act commissioner regularly and routinely looks at the lawfulness of detention. In fact, the Care Quality Commission is currently developing a new approach to its responsibilities as a regulator of the 1983 Act.

NHS: District Nurses

Baroness Brinton Excerpts

Thursday 10th July 2014 Lords Chamber

[Earl Howe]

My Lords, we recognise the need for urgent action, and that it is required across the piece. We need to train more district nurses, and therefore training places have gone up both last year and this year. We also need to equip district nurses with technology. To that end, the nursing technology fund will address the issue that the noble Baroness referred to initially, which is the time that nurses have to spend with their patients. Technology can make time management much more efficient, and it is also good for the patient, who feels more in touch. NHS England and Health Education England have set up a workforce project which, as I said in my initial Answer, is designed to address not only workforce numbers but also the attractiveness of district nursing to trainees.

[Baroness Brinton (LD)]

My Lords, there has been a 47% reduction in district nurses over the previous 10 years. Does the Minister agree that if we are to have real integration of health and social care, then commissioners, NHS England and Health Education England should prioritise support for district nurses and community posts, not least to reduce the pressure on hospital beds?