Young People: Suicide

Baroness Brinton Excerpts

Thursday 27th February 2014 Grand Committee

[Baroness Brinton (LD)]

My Lords, I declare my interest as a co-chair of the bullying APPG and a patron of Red Balloon. I thank the noble and right reverend Lord, Lord Eames, for instigating this debate so that we can discuss the root cause of so many avoidable deaths in young people. He was quite right to quote PAPYRUS’s data on the number of attempted suicides by young people: one every 20 minutes. That is three during this short debate.

The 2012 government report Preventing Suicide in England identified nine categories needing customised care, including children, those with untreated depression, LGBT people and ethnic minority groups. Although I am pleased by the emphasis placed on children as a separate category, we do well to remember that children can fall into most of the other groups as well.

A major factor leading to suicide is bullying. It is shocking that 69% of children in the UK report being bullied. The National Centre for Social Research report on bullying showed that each year 16,000 children are out of school long-term with depression because of bullying, and that there are at least 25 confirmed suicides as a result of bullying, but there are probably many more that do not meet the criminal standard that the noble and right reverend Lord, Lord Eames, spoke of earlier.

Early intervention is vital. Most children do not suddenly decide to kill themselves. ChildLine says that there has been a,

“trend towards younger and younger children dabbling in self-harm, with a 50% increase among those aged 12 in the last year alone”.

However, even younger children are at risk. Last year nine year-old Aaron Dugmore hanged himself after being targeted by a gang of older bullies at his school simply because he was new. Ayden Keenan-Olson, aged 14, overdosed on prescription pills after homophobic and racist bullying by his classmates. He had reported up to 20 instances of bullying since joining his school but no action was taken. He eventually bypassed security settings on his computer to research suicide.

That raises the issue of online suicide forums and cyberbullying. Later this year, family-friendly content filters will be set automatically for new broadband users. However, most kids are so tech-savvy that they are able to bypass these settings in minutes. There is much more to fear from the “dark web” free of filters than from known, visible sites, so we must educate and support our young people to protect themselves.

The launch of Zipit, ChildLine’s first app for smartphones, is great news. It is packed with humorous tips for teens and advice to help them to cope with flirting and messaging, equipping them to protect themselves from online sexting, bullying and trolling. In the two months since its launch, more than 45,000 young people have signed up.

Frankly, CAMHS are struggling to deliver mental health services or reduce the number of young people killing themselves. Pressure on services can mean many months’ wait for urgent appointments, or having to travel 300 miles to get a bed in a tier 4 clinic. I heard on Monday of a child who had had to go from Birmingham to Glasgow for such a bed. I ask the Minister what is being done to speed up access to CAMHS facilities and to minimise the distances that must be travelled in instances of urgent child referrals. The coalition Government are rightly demanding parity of esteem for mental health services, but we have yet to see it happen.

I want to end on a more positive note, although it may not seem that way at the start. First Capital Connect asked to work with Red Balloon, a specialist bullying charity, after three bullied children threw themselves in front of trains. One was a 14 year-old ballerina and the second two were a young Goth couple who jumped together in front of a train. Red Balloon works with suicidal bullied children, offering intensive recovery and education support so that children can return to mainstream school and to their friends and society. However, only a handful of places are available nationally, and CAMHS beds are also limited, not to mention the constant problems around funding. My worry is this: does that reflect the value we place on these tragically short lives? Much more is needed to get early support to youngsters before depressive thoughts of death turn into the horror of young suicide, which affects family and friends for ever.

NHS: NICE-appraised Medicines

Baroness Brinton Excerpts

Thursday 27th February 2014 Lords Chamber

[Earl Howe]

My Lords, this important class of drugs will be subject to a special evaluation process by the National Institute for Health and Care Excellence. That methodology has been worked through and over the coming months we will see NICE evaluating orphan medicines and medicines for highly specialised conditions to inform clinicians in the NHS and, where appropriate, provide a funding direction for those drugs.

[Baroness Brinton (LD)]

My Lords, perhaps I may follow on from the Minister’s answer to the noble Lord, Lord Hunt, on clinical commissioning groups. The previous year’s report on appraised medicines provided a very helpful algorithm of biologics for rheumatoid arthritis. Will NICE and other organisations involved in these specialist medicines follow a similar algorithm to make it even clearer to CCGs where they should not step out of line but must follow clinicians’ advice?

[Earl Howe]

It is important to distinguish between a technology appraisal, where, if favourable, there is a clear funding direction for the NHS—in other words, it must fund the drug if the doctor thinks that it is appropriate for the patient—and a clinical guideline, where NICE issues best practice advice for the NHS. There is no funding direction attached to that. However, clinicians are expected to take account of NICE guidelines in everything that they do.

Care: Financial Services Industry

Baroness Brinton Excerpts

Wednesday 26th February 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Lord, Lord Lipsey, on securing this important debate that joins together progress in health and social care for the elderly and how our financial services can help deliver this from 2016—two years’ time—in the wake of the Dilnot commission reforms.

The rising cost of care, however, has become an increasingly worrying issue. Two years ago, the commission estimated that the cost of the reforms was approximately £1.7 billion. Inevitably with an ageing society and limited resources, the state does not have sufficient funds to meet the increasing demand of social care for the ageing and disabled population. As Bruno Geiringer noted,

“with demand for older people’s social care expenditure currently touching £8 billion and actual spending sitting at around £7.25 billion, the gap between supply and demand is alarming”.

In 2011, the amount spent on care and support was 1.2% of GDP. However, in the same year, the figure was estimated to rise to 1.7% of GDP after the implementation of Dilnot.

As we have heard from other speakers, currently, individuals are meeting costs by drawing down equity from their housing assets, purchasing insurance, or taking from their pension funds. Where they do not have access to these sources, many have to sell their property, while still alive, to fund their nursing care, but, frankly, this is such a hard decision at a very difficult time in people’s lives as they face reducing their independence and losing their home. It is evident that there is, or will be, a market for the financial services to support the older generation. With a cap on the individual’s lifetime contribution, this can be much more clearly defined than under the present system.

The challenge is that the financial services industry must take greater initiative in funding these reforms. Several key financial products, some of which have been mentioned, are possible sources of funding. The disability linked annuity works by reducing the income of an otherwise flat annuity, but then doubles or trebles the income once care is required. In marketing this product, customers need to be aware of the tax treatment of annuities because they are treated as pay as you earn under current pension taxation rules. The second source of funding is products linked to housing assets. Many people fund their social care by utilising a portion of their housing equity to meet costs by either downsizing or taking out loans that are secured on their house, payable on death. The third source is linked to insurance. There is an opportunity for critical illness or life insurance policies to cover care costs. Similarly, top-up insurance can also assist individuals in the amount they spend on general living.

However, no providers currently offer pre-funded insurance, mainly because there is a lack of demand for it. This is why pre-funded insurance products have failed in the past, and consequently are no longer available on the market. However, such products could fit the new profile needed to fund social care in the future. I ask the Minister, if these insurance products are indeed beneficial in covering care costs, how can the Government help the industry stimulate demand for the products? A potential alternative to the previous options is a deferred payment scheme. Under this, people could pay insurance fees after they have died. This works by taking a portion of an individual’s life insurance and applying it towards paying for care fees.

Despite the potential of these products, there are many concerns that have been raised by both the Dilnot commission and the Government. As I have outlined, some products exist but face low take-up due to demand-side barriers, including reputational issues, a lack of public awareness, and the cost and complexity of the products. I am sorry to say that reputational issues have led to a loss of trust by many people in financial services. Research conducted by the Chartered Insurance Institute in late 2010,

“found that one in five respondents will never trust financial services again and 72% of people have not very much trust or no trust at all in financial advisers and life insurance providers”.

The most serious problem is the lack of awareness of social care costs. In several consumer surveys it was noted that most individuals do not know how much they will be paying for care in old age. The Local Government Association says that it found in a survey that,

“63% of individuals wrongly estimated the average cost of a care home as less than £25,000 per year”.

It is imperative, then, that we address issues related to engagement barriers in an effort to encourage people to seek private sector solutions. We must increase marketing for the products and raise awareness on the amount that people are likely to have to pay in future for their social care. This must start early. Worrying about it when you are 55 is, frankly, too late.

The Government have already established an expert working group that will involve the Government, the financial services sector, local authorities and the care sector. It is exploring ways in which individuals can best be directed to truly independent financial advisers, and will build links with pension benefits and other services. However, it is shocking that out of 53,000 self-funders in residential care only 7,000 received financial application advice in 2009. This may be a possible explanation as to why one in four self-funders ran out of money and sought help from the state. Clearly, there is a necessity for the support of financial industry in the form of products and advice. The Department of Health expects the financial services industry to respond by 2016. However, that is only two years away and most financial products take between five and 10 years to design before they come to market, let alone general take-up. I therefore ask the Minister, if this is the case, then where are these financial products and where is the early launch of information and advice to reassure the public on the adequacy of these financial options?

To conclude, there are too many individuals unaware of the social costs related to healthcare and the ability of financial services to help them finance costs. Although there is broad consensus that action needs to be taken, there is also a real fear that the commission’s recommendations could be left to rot because of the lack of products. This issue must be dealt with now because the financial services industry has the potential to minimise the full-scale effect of these costs on the lives of the ageing and disabled population. Equally importantly, it will remove the lottery of how much people have to pay for their social care, which has been a scandal for years.

NHS: Patient Data

Baroness Brinton Excerpts

Tuesday 25th February 2014 Lords Chamber

[Earl Howe]

My Lords, I cannot agree with that. The GP surgery is where the records are kept and would seem to be the natural place for patients to go. They do not have to make an appointment to do that. If they are concerned, they can write a letter or send an e-mail to the GP practice and then have a conversation later if they would like to. I do not think this is a difficult process.

[Baroness Brinton (LD)]

My Lords, it is clearly illegal for pseudonymised data to be worked back and then aggregated with other available data. Can the Minister assure the House that the Government will consider increasing the penalties for infringing personal data, including prison sentences for serious breaches and a ban on the offenders and their organisations accessing any data for up to 10 years? This is because current organisations are often not taking seriously breach-of- data fines.

Health: Folic Acid

Baroness Brinton Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My Lords, as the noble Countess says, the issues are in many ways similar. As she knows, in the case of fluoride, Parliament has taken the decision that it should be a local matter and that is how the system now works.

[Baroness Brinton (LD)]

My Lords, given that there is a delay in the Government’s decision, what is being done to ensure that young women are informed about the importance of having some supplements? Waiting until they are pregnant is clearly too late.

[Earl Howe]

My Lords, government advice on taking supplements is available to women through a number of channels, including Healthy Start, NHS Choices, Start4Life, The Young Woman’s Guide to Pregnancy and the Information Service for Parents. To improve maternity services for women, NICE has published a comprehensive suite of evidence-based clinical guidelines in this area.

Drug Companies: Medical Trials

Baroness Brinton Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My Lords, during the course of last year, the Government gave detailed evidence to the Science and Technology Committee on the issue of data provision in respect of clinical trials. The committee made a number of helpful recommendations on the removal of barriers to transparency. In our formal response, we set out how we would work to achieve the aims of greater transparency. In the light of that response, the Government are looking into the recommendations of the PAC report on the stockpiling of Tamiflu and access to clinical trials data, published in January. We will give our formal response to the report next month.

[Baroness Brinton (LD)]

My Lords, evidence shows that the chances of a complete trial being published are roughly 50%. The recent EU clinical trials draft directive will require all trials to be registered before they start, and full results to be published within a year. However, the regulation will be applicable only to trials starting from this year. How do the Government plan to ensure that pharmaceutical companies will release medical records for drugs that were launched before 2014?

[Earl Howe]

My noble friend raises a topical question. The industry’s trade body, the Association of the British Pharmaceutical Industry made clear, in its code of practice in 2012, that companies are obliged to publish all clinical trial results within a year of marketing authorisation and publicly register new clinical trials within 21 days of the first patient being enrolled. That, of course, is a forward-looking exhortation, but we are encouraged by the fact that the industry is taking an increasingly responsible view in this area by publishing data voluntarily, as demonstrated by companies such as GSK, AstraZeneca and Johnson & Johnson. We want to encourage more companies to do the same.

Food and Soft Drink Industry: Sugar

Baroness Brinton Excerpts

Tuesday 11th February 2014 Lords Chamber

[Earl Howe]

My Lords, the reason that we meet the food industry is to ask it to do more than it is doing at the moment. If that is what the noble Baroness means by the Government’s links to the food industry, then I make no apology for them. Our current emphasis is on overall calorie reduction, of which sugar can form a part. The scope for reformulation to reduce sugar levels varies widely depending on the food, and a reduction in sugar levels does not always mean that the overall calorie content is reduced. The Scientific Advisory Committee on Nutrition is currently undertaking a review of carbohydrates, as part of which it is looking at sugar. Its report will inform our future thinking.

[Baroness Brinton (LD)]

It is shocking that a 375-gram portion of Sharwood’s sweet and sour chicken with rice contains six teaspoons of sugar. Some of our supermarkets, notably Waitrose, are working with their suppliers to reduce the amount of sugar in processed food, but many are not. What steps are the Government taking to ensure that all supermarkets and suppliers follow those setting a good example and reduce the amount of sugar, as well as clearly labelling sugar, in their processed foods?

[Earl Howe]

My noble friend raises a series of important issues. I can tell her some encouraging news on this front. Sainsbury’s and Tesco, for example, have pledged to reduce the sugar content in their own-brand soft drinks. We are asking other supermarkets to follow suit. I think that the noble Baroness will be aware that Lidl made an encouraging gesture the other day in pledging not to display sweets at till exits. However, we are working across a range of areas, not just reformulation of food but pack size, introducing low-sugar or no-sugar alternatives, and looking at ways in which food is promoted.

NHS: Competition

Baroness Brinton Excerpts

Monday 10th February 2014 Grand Committee

[Baroness Brinton (LD)]

My Lords, I am grateful for being allowed to speak in the gap, and I congratulate the noble Lord, Lord Turnberg, on securing this debate. The noble Baroness, Lady Thornton, may wish to know that the noble Lord, Lord Clement-Jones, had hoped to speak in this debate, but is speaking instead on the Immigration Bill in the main Chamber.

I am pleased that he and other Liberal Democrats persuaded the Government to make some key changes to Part 3, on procurement, in the Health and Social Care Act, which limited private practice in the NHS and beefed up Monitor with regard to the promotion of competition, in order to provide reassurance that other factors could and should be taken into consideration.

This nuance in the debate is often lost by the two opposing views of pro- and anti-competition. Not all competition is bad, as the noble Lord, Lord Turnberg, has pointed out. The Labour Government were quite content to have it in the NHS. I, for example, was using Healthcare at Home, which was contracted by a number of hospitals prior to the coalition Government to provide domiciliary support for patients injecting medication at home. The service and support were excellent, and the economies of scale, I am sure, enabled them to provide that at a good price. The ancillary contracts are, I hope, less contentious than deciding how to contract out core clinical services: those issues are justly more sensitive. That is why I am grateful to my noble friend Lord Clement-Jones for his perseverance last year in pushing for amendments to the regulations to ensure that cost is not the only guide to winning a procurement contract. Transparent, proportionate and non-discriminatory processes must be evidenced to support procurement decisions.

The new guidance will remove doubt about where quality and competition interact, and Monitor’s role in taking the lead over the OFT and the Competition Commission is a positive step forward. The Monitor guidance on the National Health Service (Procurement, Patient Choice and Competition) Regulations 2013 makes this abundantly clear. For commissioners, this will mean a considerable change in approach to procurement. Finally, the guidance is so explicit that cost alone is not the route to follow that even the competition lawyers will have to take note. Patient need, quality, and improvement of service are key factors that must be taken into account.

The EU directive on public procurement due to be implemented during this year reinforces this. The new regime for health service contracts requires that,

“award criteria can take into consideration important elements in the provision of health services including quality, continuity, accessibility, comprehensiveness of services and innovation”.

Further, the directive makes it clear that,

“greater emphasis is put on considering environmental and social issues in public procurements … Simply considering price, rather than quality, as the only award criterion will be discouraged”.

I hope that this will provide clarity for future CCGs as they start to consider whether they need to tender.

Finally, we should remember the core principle in competition and choice in the provision of healthcare services in the NHS in England, which is that competition should be employed where it serves the interests of patients; it must not be an end in itself. NHS England has said that competition is just one means of improving the quality and efficiency of NHS clinical services and securing value for money. I would ask my noble friend the Minister, given all the noise we are hearing at the moment about problems with competition lawyers and others disagreeing about where the lines are drawn, whether the EU directive guidance and the Monitor guidance will clarify matters enough to remove that doubt. If that is the case, I hope that improved transparency, a focus on patient needs and proportionality will act as the guardians of our excellent services in the NHS.

NHS: Black and Minority Ethnic Nursing Directors

Baroness Brinton Excerpts

Monday 10th February 2014 Lords Chamber

[Earl Howe]

My Lords, just to correct the noble Lord, the latest figure I have from 2012 is that total ethnic minority groups in nursing, midwifery and health visiting comprise 19.7% of the nursing workforce. That underscores the basic point that he made. One cannot aspire to 19.7% of those ethnic nurses becoming nurse leaders because there is only a limited number of leadership posts. However, we are clear that this should be a priority for the NHS.

The answer to the noble Lord’s second question is that the Equality and Diversity Council has published some refreshed guidelines. One of its goals is to have a representative and supportive workforce throughout the NHS. It is putting that in train by asking NHS organisations to monitor their equality performance jointly with their patients, communities and staff.

[Baroness Brinton (LD)]

My Lords, ten years ago, the noble Lord, Lord Crisp, described the NHS as being snow-capped—that is, all white at the top. Since his departure as Chief Executive of the NHS in 2005, there are now fewer leaders from visibly different backgrounds and, as we have heard, pitifully few executive directors of nursing. What are the Government doing to ensure that this matter is kept at the top of the agenda and to assure us that we will hear about the success of the programme as it continues?

[Earl Howe]

My Lords, I have already mentioned some of the initiatives that are in train. However, I can tell my noble friend that, within the NHS Leadership Academy, there are two programmes specifically for nurses and midwives that map to foundation, mid and executive level leadership development. There is the front-line leadership programme which is for staff who have leadership responsibilities—for example, ward sisters and nurses working in primary care. We expect 6,000 nurses and midwives to participate in that programme in the first year. There is also the senior operational leaders programme which provides senior nursing clinicians with an opportunity to enhance their leadership skills.

NHS: Seven-day Working

Baroness Brinton Excerpts

Thursday 6th February 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I, too, thank the noble Lord, Lord Ribeiro, for securing this key debate. It is shocking that your chances of receiving prompt treatment and, indeed, of surviving are worse if you are admitted to hospital over a weekend or on a bank holiday. The 2011 Freemantle report provided the evidence that more than 500 deaths could be prevented in London each year purely by increasing consultant cover in acute medical and surgical units.

The good news is that there are early adopters and pathfinders who are demonstrating that it can be done. I hope your Lordships’ House will indulge me with a personal anecdote. I was very unwell over Christmas and had the good fortune to be admitted to the acute admissions unit at Watford General Hospital. The unit was set up in 2009 to help reduce pressures on A&E and the main hospital. The £12 million 120-bed unit shares the building with A&E but all referrals have to come from a GP and the maximum length of stay is 72 hours, although stays are usually much shorter. Consultants are on duty 24 hours a day and see patients as they are admitted so care is tailored very quickly. The AAU and A&E share their own MRI scanner, X-ray and ultrasound unit, a catheterisation unit for angioplasty, blood testing facilities and pharmacy. My experience of the care was outstanding: tests, scans, monitoring and observation and treatment were all prompt, and I felt that the entire clinical team worked smoothly as one unit. I know that I am not alone in my praise for the unit.

Seventy-two hours seems to be about the right length of time. I have seen reports of other acute units where the time is only 36 hours. Recently a Leeds hospital reported that there is still pressure on the main wards from this shorter timescale.

The briefing from the Royal College of Surgeons states:

“Seven day services may also reduce pressure and stress on doctors. For example, consultants can spend much of Monday morning dealing with weekend admissions that are waiting for review or discharge”.

However, this does not affect just doctors: radiologists and many other clinical support staff are similarly affected by the Monday morning catch-up that impacts on an already busy week. Can the Minister assure the House that the NHS will provide robust modelling and review structures using the examples of early adopters to ensure that seven-day working is introduced carefully and effectively?

There needs to be a realistic timetable and a full understanding of the workforce issues—not just consultants or contracts and payments, but also appropriate staffing levels right through the NHS. It therefore seems sensible to move ahead on urgent and emergency care first and then reassess for wider clinical services, rather than rushing ahead with elective care at the start.

Many people are concerned about the costs of adopting a seven-day working system. With careful modelling—and with units such as the one I described earlier—in addition to inevitable new costs, we will find that there are some cost savings. Overall, the biggest change will be in culture and attitude. The NHS heart is willing. We all need to use our heads and energy to make it happen.