NHS: Maternity Care
Baroness Cumberlege Excerpts(9 years, 9 months ago)
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Baroness Cumberlege (Con)
My Lords, my interests are in the Lords’ register. In addition, I am a vice-president of the Royal College of Midwives, and patron of the NCT and of Independent Midwives UK. Like others, I thank the noble Lord, Lord Harrison, for initiating this debate and for the briefing that I have had from other bodies, not least the Women’s Institute, of which I used to be a very active member.
The NHS Five Year Forward View states:
“Having a baby is the most common reason for hospital admission in England”.
For women with low-risk pregnancies, research shows that,
“babies born at midwife-led units or at home did as well as babies born in obstetric units, with fewer interventions. Four out of five women live within a 30 minute drive of both an obstetric unit and a midwife-led unit, but research by the Women’s Institute and the National Childbirth Trust suggests that while only a quarter of women want to give birth in a hospital obstetrics unit, over 85% actually do so”.
That document goes on to say that the NHS will commit to a commission to review future models for maternity units to report next summer—I will be watching that—and to recommend how best to sustain and develop maternity units across the NHS. It will ensure that tariff-based NHS funding will support the choices women make, rather than constraining them. It will make it easier for groups of midwives to set up their own NHS-funded midwifery services.
I really cannot tell noble Lords how delighted I was when I read that. This is such fresh thinking. It rides the wave of what women and midwives want: giving choice to women as to how they want their care provided, and to midwives as to how they want to work. Of course, this is just the beginning. The noble Lord, Lord Harrison, and other noble Lords clearly set out the immediate problems facing maternity services. The first concerns workforce issues and the shortage of midwives. One solution is to attract back into the service those thousands of midwives already qualified—some with a great deal of experience—who have chosen not to work in the current system, often because it is too dysfunctional, fragmented and rigid. The second is to stop the loss of newly trained midwives, who characteristically leave in their first two years after qualifying.
How are we going to achieve that? The NHS needs to enable midwives to offer a service to women that supplies genuine continuity throughout pregnancy, birth and antenatal care. Midwives who work with a caseload and who really get to know their women and their families—and especially the fathers of the babies—find the work rewarding, particularly when they have some control over their work/life balance. Then they stay in the service.
As the Five Year Forward View states, different models are needed. We already have some but they are very fragile and nascent and they need support. These different midwives want to work for the NHS. I should like to cite two models. One is Neighbourhood Midwives—a social enterprise, employee-owned and not-for-profit organisation based in the community. Midwives follow the women and work flexibly over 24 hours. This is possible because they are not needed to staff labour wards and clinics on 12-hour shifts. Likewise, Independent Midwives UK is a membership organisation that represents and supports 70 self-employed midwives, with a further 60 associate members. IMUK is a public benefit registered company with a very high-powered board. It has come a long way in its struggle to secure clinical indemnity, which it now has, and as a consequence I think it is destined to grow.
Both those organisations—and there are other, similar models—are pioneers, but they are up against the deep reluctance of the NHS to award them contracts. However, this coming year’s planning guidance, signed off by NHS England’s board in December, states that for 2015-16 commissioners should review the choices that are locally available for women. This may include choice about how women access maternity care, the type of care they receive, where they give birth and where they receive their antenatal and postnatal care.
Many of us may think that we have heard similar rhetoric in the past, but I think that this goes beyond rhetoric. For the first time, this spells action. I believe that many CCGs will want to implement this guidance, but can my noble friend tell me what will happen if they do not? If they do commission these services, that will enable groups of midwives to set up their own NHS-funded service based in the community and funded directly from a tariff or, in the future, from personal budgets. They will work in partnership with the trusts to offer a complete care pathway, but it will mean that both sectors can plan and manage their own staffing levels, and this will dramatically increase the offer and provision of a very reliable home birth service. It will also increase the use of free-standing birth centres. Working in group practices in the community will increase midwives’ autonomy, improve their clinical skills, and enhance their experience and confidence across the whole care pathway.
Caseload midwifery is seen as the gold standard of care, yet providing women with a midwife whom they can get to know and trust is still the exception rather than the rule. However, we know that this model of care improves outcomes, reduces interventions, saves money, improves women’s experience of birth and improves midwives’ job satisfaction, skills and commitment. What is now needed are commissioners who are brave enough to enable this model of care to be provided in a sustainable and innovative way. Does my noble friend agree? Does he see this as a way forward, and has he suggestions as to how the Government could encourage commissioners to commission such services?
National Health Service
Baroness Cumberlege Excerpts(9 years, 10 months ago)
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Baroness Cumberlege (Con)
My Lords, my interests are in the House of Lords register but I should declare that I am executive director of Cumberlege Connections and of Cumberlege Eden & Partners.
I, too, congratulate the noble Lord, Lord Turnberg, on initiating this debate. He is a truly remarkable man and is probably one of the most qualified and experienced of your Lordships when it comes to analysing the health service, as was evidenced today in his remarkable speech. I did not agree with it all, but it was remarkable. If one looks further, it is really interesting and fascinating to read his book, Forks in the Road. Does not that title really sum up the views of the nation? The NHS is hugely valued. We are at one in wanting to ensure its future. We are journeying on the same road, but there are many choices to be made on the way.
The ethic is inalienable. Whether we are rich, poor, young, old, black or white, we want a service that is largely funded by the taxpayer. I say largely because successive Governments, including the Labour Party when it was in government, have largely eroded the ethic by stealth—introducing prescription charges and other charges. The general public do not want to produce a credit card for services rendered but they are ambivalent as to who provides the service. If the service is compassionate, kind, professional, efficient and provides value for money, albeit that it is provided independently, the public are largely satisfied.
I endorse the views of my noble friend Lord Horam. Worldwide the NHS is recognised as a winner. We have been ranked as the top health system in the world by the Commonwealth Fund. We also know that when it comes to asking the British what makes them proud to be British, the NHS is top of the list, before the Armed Forces and even the Royal Family. We also know that there is always room for improvement. Lest we get complacent, we only have to think of North Staffordshire, Winterbourne View and so on.
The noble Lord rightly highlighted the challenges that we face and they are beyond dispute, but we should not ignore the progress that we have made. At a time of austerity, we have increased the NHS budget by £12.7 billion. “Not enough”, is the cry but it will never be enough. In the past five years, the number of clinical staff has increased by 12,500, and 850,000 more operations are being delivered each year compared with 2010. The number of patients looked after in mixed-sex wards is down by 98%, which is a subject I know is very close to the heart of the noble Baroness, Lady Jay, from when she was in opposition and when she was in government. Listening to her speech today, I was deeply worried when she quoted the shadow Health Minister as saying that he did not understand how the current system works. I respectfully suggest that he looks at pages 88 and 89 of the book by the noble Lord, Lord Turnberg, which clearly sets that out in a diagram.
Looking at the next five years, as has been said, NHS England’s priority is to engineer a radical upgrade in prevention and public health. It goes on to say that the NHS will,
“back hard-hitting national action on obesity, smoking, alcohol and other … health risks”,
which I welcome. I share the view of my noble friend Lady Barker that we should stay with the health and well-being boards, and not be tempted for another reorganisation.
In Britain, we attempt to run a fair society, a society which protects citizens from abuse by those unwilling to respect others. We have cracked down on drunken or reckless drivers and on faulty cars. People who abuse our roads are prosecuted and our roads are safer for it. The problems of the NHS are in some measure due to people abusing the system. Resources are spent on dealing with drunks, time-wasters and drug misusers, leaving the system in danger of being overwhelmed so that those in real need are deprived of life-saving treatment. The NHS constitution is very strong on rules for staff but is ineffective and weak when dealing with users. The contrast with drivers who have to learn and adhere to the law is very stark.
Looking to the future, we have to introduce rules to protect and enhance the treatment of people who are ill. Without known rules, any organisation, including this House, can descend into chaos. With a strong economy, we can afford to pay for its use but we should not fund its abuse. Does my noble friend agree?
Learning Disabilities: Health and Care Services
Baroness Cumberlege Excerpts(9 years, 11 months ago)
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Earl Howe
My Lords, the Bradley report, which was a seminal report, was subject to a five-year review earlier this year. We will consider reports of progress and further recommendations in that report in conjunction with the Ministry of Justice, the Home Office and NHS England with regard to future policy development.
Health: Midwives
Baroness Cumberlege Excerpts(10 years, 4 months ago)
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Earl Howe
My Lords, helping commissioners to reduce unwarranted variation in service delivery is one of the key roles of maternity and children strategic clinical networks, which are being established and supported by NHS England. We know from experience that these networks have a tremendously beneficial effect in ironing out inequalities in access.
Baroness Cumberlege (Con)
My Lords, will my noble friend rejoice with me that independent midwives now have professional indemnity? Does he agree that they make a very valuable contribution to maternity services, especially for vulnerable women?
Earl Howe
My Lords, we naturally applaud the professionalism of independent midwives. I agree with my noble friend that it is a positive step forward that all healthcare professionals in this country have professional indemnity insurance. We must think of the patient always and, should something go wrong, it is right that every patient is protected by indemnity or insurance.
Health Care and Associated Professions (Indemnity Arrangements) Order 2014
Baroness Cumberlege Excerpts(10 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, in July 2010 the four UK health departments accepted the recommendations of the Finlay Scott review, which recommended that all regulated healthcare professionals should be required to hold appropriate insurance or indemnity cover as a condition of their registration when carrying out work as a regulated healthcare professional.
The Government are committed to requiring all practising regulated healthcare professionals to hold indemnity or insurance cover, and have been for some time. The Government are also required to implement Article 4(2)(d) of the EU directive on patients’ rights in cross-border healthcare, which reinforces that direction of travel and further commits us to legislation. The purpose of this policy is to ensure that people have access to appropriate redress in the unlikely event that they are negligently harmed during the course of their care. All patients should have that by right. The overwhelming majority of regulated healthcare professionals will be unaffected by the proposals because they already have insurance or indemnity cover. For employees in the NHS or independent sector, cover is already in place because of an employer’s vicarious liability for the negligent acts or omissions of their employees. Personal cover is required in relation only to self-employed practice.
The order makes provision that all practising regulated healthcare professionals must hold an appropriate insurance or indemnity arrangement as a condition of their registration—and, in the case of medical practitioners, a licence to practise—with the relevant regulatory body. It will be for individual healthcare professionals to assure themselves that appropriate cover is in place for all the work that they undertake. Unless healthcare professionals, who are practising or intend to practise, can demonstrate to the satisfaction of the regulatory bodies that such arrangements are or will be in place, they will be unable to be registered as a healthcare professional and will be unable to practise. I commend this order to the Committee, and beg to move.
Baroness Cumberlege (Con)
I declare an interest as a fellow of the Royal College of Obstetricians and Gynaecologists, a vice-president of the Royal College of Midwives and a patron of the National Childbirth Trust and Independent Midwives UK. I have other interests that are in the Lords’ register. I thank my noble friend for introducing this statutory instrument so clearly and for meeting the noble Lord, Lord Hunt, and myself, when we discussed the issue of independent midwives.
Draft statutory instruments are not usually a very gripping subject, but this one is because it affects the livelihood of so many people. It is therefore being introduced as an affirmative resolution. Not many statutory instruments, when enacted, will ensure that a professional is denied the right to practice—denied their livelihood. However, I start from the premise that every practitioner should have professional indemnity insurance. Some independent midwives are possibly the only group reluctantly acting without it but not only do they recognise the need for it, they want it and are prepared to go to great lengths to achieve it. This statutory instrument has concentrated minds and focused on the practicalities to achieve it, and from that point of view I welcome it.
It has been a struggle because insurance bodies draw no distinction between midwifery care and obstetric care, and of course the service given by each profession is very distinct. Obstetric treatment is very often a high risk activity, whereas midwife care is much less so. Successive Governments have adopted a policy that women should have choice—choice in healthcare but particularly choice in maternity services. This policy has been very widely welcomed by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the National Childbirth Trust, which have listened to women and have fought fairly long and hard to achieve this choice. All the evidence that they and others have gathered shows that women and their partners want choice. After all, there is nothing more important in life than giving life and bringing up the next generation.
Over the years, choice has been eroded thanks to the closure of maternity units, but in some places midwife-led units or birth centres have replaced them. They are often under threat as well. I welcome midwife-led units because they are another form of choice but I regret the diminution of home births because that is a choice denied. I ask my noble friend: how many home birth services in the NHS are on temporary hold and how many have closed? I know that they are very detailed questions and I would welcome a written reply if that suits my noble friend better than responding now. I am asking these questions because Independent Midwives UK provides for home births. That is a government policy and one that has been strongly endorsed by NICE. Independent Midwives UK provides continuity by a named midwife throughout antenatal care, birth and postnatal care—another government policy. Throughout the NHS this has proved to be pretty unachievable because community midwives are drawn into the acute services whenever there is a shortage, and because there is frequently a shortage it happens frequently.
The department’s new definition of continuity is co-ordination. A named midwife should co-ordinate the care, as my noble friend said previously. We should ask women what they think. Is co-ordination the same as continuity? Of course it is not, when in extremis women cannot even get their co-ordinator on the telephone 24/7 but they can with an independent midwife. Do they build a relationship with the co-ordinating midwife, assisting at that seminal moment of giving birth? No, because she is not there; she is too busy co-ordinating.
Independent midwives in all their forms—as social enterprises, employee-owned organisations, provident industrial societies with “bencom” status and so on—want to provide choice, continuity and care for women both in the independent sector and for the NHS. They are based in their communities and many provide services for vulnerable women, asylum seekers, those with mental health problems and so on, on a pro bono basis, but like the rest of us they cannot live on fresh air. They are seeking commissions with clinical commissioning groups. They are working towards direct referrals from GPs who welcome the continuity of knowing the midwife responsible for a mother who needs advice and support. Can my noble friend suggest ways in which the Government could support independent midwives, who are the professionals who not only support the Government’s policy but are the professionals who actually carry it out?
The NHS mandate, which sets the agenda for NHS England and which my noble friend and his ministerial colleagues shape, is an opportunity to ensure that alternative choices are there for women and their partners. Will he encourage the ministerial team to focus on this issue and enable independent providers of services to thrive, thereby enhancing government policies, giving women choice and providing the continuity that they seek?
In closing, I pay tribute to the Nursing and Midwifery Council, which has taken a very measured view of this statutory instrument, has listened and has tried to meet the needs of all concerned, amending its guidance as necessary. I look forward to my noble friend’s reply, in writing if necessary.
Baroness Brinton (LD)
My Lords, I completely endorse all the points made by the noble Baroness, Lady Cumberlege, and I am glad that there has been some give from the council to try to move this difficult issue forward.
I want to make a slightly different point. In these febrile days, when everything in the EU is damned, it is most welcome that this regulation comes from a new directive that is going to give patients across the EU the security of knowing that there will be indemnity and insurance available in every state. It may not be directly comparable but there will be something there. I am pretty sure that this will not hit the headlines but I see it as a major benefit to those of us who travel in Europe, as well as those coming to the UK. It is the sort of thing that is completely hidden from the headlines; it should not be.
On the difficult issue of indemnity insurance for midwives, I have been wondering, having come late to this debate, whether or not there is scope for NHS England, the regulatory councils and the insurance councils to try to work better together. The financial services industry talks frequently about the problems of insuring a very small service. This clearly is that, and it does not fit into an ordinary framework. Yet the midwives have been through exactly the same training as their counterparts elsewhere in the NHS and I am sure that clinical commissioning groups will demand that they have insurance cover. That is absolutely right. Therefore, the problem is in looking at this small cohort of midwives rather than seeing them as part of the greater group who have qualified under the same professional regulation.
I ask the Minister whether discussions will continue to ensure that no one could be denied service simply because they may not fall neatly into one of the categories. Again, I congratulate the Nursing and Midwifery Council on at least trying to find a solution to this difficult problem but it should not be said, as it is in paragraph 8.3 of the Explanatory Memorandum, that there is a balance that has to be made here and, as it affects only a few people, we should perhaps be prepared to let it go. I do not believe that we should.
Earl Howe
My Lords, I am grateful to all noble Lords who have spoken. I shall endeavour to answer all questions that have been put to me as fully as I can. To the extent that I cannot, I shall of course write to noble Lords after this debate.
The centre of attention in noble Lords’ contributions has been independent midwives. Independent Midwives UK is the body which has expressed most concern about the regulations. I am the first to say to my noble friend Lady Cumberlege that continuity of care and service in the NHS is important, and that is part of the mandate to NHS England. We fully accept the value of independent midwives. NHS England will refresh the maternity commissioning guidance to CCGs over the summer to support the plurality of providers and to help social enterprises get NHS commissions.
However, as my noble friend is aware, we are dealing here with self-employed, independent midwives. It is therefore important to look at the factors which pertain to that group of people in particular. My noble friend suggested that the order effectively puts certain independent midwives, the self-employed practitioners, out of business. I do not see it in that way at all. We recognise that self-employed independent midwives may be required to change their governance and delivery practices to comply with an indemnity policy, and it is for the individual practitioner to determine a suitable operating model under which they are able to continue to practise. Social enterprises are the obvious route to that.
The suggestion that independent midwives have not received the fullest attention from officials in my department is seriously misplaced.
Baroness Cumberlege
I have never said that. The department has really helped independent midwives keep up to date with what has been going on. Nor am I opposed to the order. I said earlier that I start from the premise that every practitioner should have professional indemnity. Perhaps the noble Baroness, Lady Emerton, did not hear that.
Earl Howe
I fully accept my noble friend’s statement on that score. It has been said that the Government have not been sufficiently supportive of the attempt by IMUK to overcome these obstacles, and I welcome my noble friend’s recognition of those efforts.
Independent Midwives UK made an application, as my noble friend knows, for government funding for its proposal. That was considered, but the conclusion reached after independent expert advice was that the proposed insurance model was not feasible and would not provide long-term protection to pregnant women.
Alongside that, we were mindful that the creation of any government scheme specifically for Independent Midwives UK would effectively position the Government as the underwriter of the independent sector. My noble friend is as aware as anyone of the sensitivity of that. That would have undermined any private sector solution, which in turn would reduce the onus on midwifery service providers to demonstrate financial responsibility in what is undoubtedly a high-risk area of clinical practice—that is, it would reduce the onus on them to be responsible for showing an underwriter the appropriate steps being taken to mitigate risks. So, for a number of reasons, we were not able to take those proposals forward.
However, we explored a number of routes. One was that a corporate body should be formed that would be eligible to join the clinical negligence scheme for trusts, although that would not cover non-NHS work. We made funds available via our Social Enterprise Investment Fund to support the development of social enterprise solutions where the market does not offer affordable indemnity to individuals. That was not seen as a viable route either, although a new social enterprise called Neighbourhood Midwives was set up through that route and is now offering maternity care in the private sector with appropriate indemnity cover in place. Its business model is a 100% employee-owned mutual providing management and support to small, community-based neighbourhood practices.
My noble friend Lady Brinton asked about the insurance sector. From the start of the discussion in 2010, dialogue has been in progress with the Association of British Insurers, individual insurers and insurance brokers, who have indicated that insurance would be available for corporate bodies employing midwives to deliver NHS or non-NHS services. It would be necessary for corporate bodies to demonstrate the robustness of their governance systems to provide adequate assurance to an indemnifier. Where providers can demonstrate safe outcomes as well as good risk management processes, this would affect the price that was quoted, making it more affordable. There are also other factors that can be varied, depending on the appetite for financial risk, and which can reduce the price, such as excess provisions. This concurs with the independent research commissioned by the NMC and the Royal College of Midwives that suggests that independent midwives would be able to obtain insurance as employees within a corporate structure. As I say, some independent midwifery providers have secured insurance by fulfilling the above principles.
I heard my noble friend Lady Cumberlege say that the order effectively deprives certain individuals of the right to work. I do not share that view. The right of an individual to practise their profession is not an absolute right; the state may impose certain conditions provided by law that an individual must satisfy in order to practise their profession. Those conditions should be both proportionate and justifiable.
The bottom line here is that we believe it is unacceptable, as the noble Baroness, Lady Emerton, emphasised, for individuals not to have recourse to compensation where they suffer harm through negligence on the part of a registered healthcare professional. The NHS constitution in England reinforces this by including,
“the right to compensation where you have been harmed by negligent treatment”.
In requiring all practising regulated healthcare professionals to hold an indemnity arrangement as a condition of registration, the order does not make the practice of independent midwifery illegal—far from it. Midwifery outside the NHS will still be accessible in the ways that I have already described. I note that Independent Midwives UK is advertising insurance as a benefit of its membership, so I wonder whether any self-employed midwives will in fact have to stop practising.
My noble friend Lady Brinton hit the nail on the head when she expressed her welcome for the EU directive and the principles that underlie it: that all patients across the EU should be treated by healthcare professionals who have insurance or indemnity cover.
The noble Baroness, Lady Emerton, touched on the issue of compensation. As she knows, compensation for negligence can be very high indeed. It is for this reason that the Royal College of Midwives no longer offers insurance. Its scheme was stopped after an issue involving an independent midwife.
If we distil the arguments to their most basic, the implication behind a number of criticisms of this order is that choice in natal care should trump other considerations. I am afraid that the Government take a different view. Our policy is that patients should have recourse to redress if they are harmed, and the most cost-effective and proportionate way of achieving that is by requiring all practising regulated health professionals to hold appropriate cover.
Having said that, we lay great emphasis on choice, as my noble friend is aware. The policy set out in Maternity Matters: Choice, Access and Continuity of Care in a Safe Service, published in 2007 but endorsed by the current Government, aimed to introduce by the end of 2009 four main areas of choice in maternity. The choices are: how to access maternity care, whether via a GP or directly through a local midwifery service; the type of antenatal care—depending on the circumstances, midwifery care or team care with midwives and obstetricians; the place of birth, depending on the circumstances, supported by a midwife at home or in a free-standing midwife-led unit in a hospital, or supported by a maternity team including obstetricians in a hospital; and where to access postnatal care, at home or in a community setting.
I hope my noble friend will concede that maternity has been a major focus for the current Government. We have invested heavily in training additional midwives. There is a record number in training at the moment. We have invested large sums in improving and refurbishing birthing units, as well as introducing specialist mental health midwife training so that every birthing unit will have a specially trained clinician available by 2017. This is a major part of our agenda.
I think I have said as much as I can in answer to questions. I will, however, respond in writing to the points that I have not adequately covered, including my noble friend Lady Cumberlege’s question about how many home births might be on hold or suspended as a result of this order. I beg to move.
National Health Service: Nursing Staff
Baroness Cumberlege Excerpts(10 years, 5 months ago)
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Earl Howe
My Lords, the figure that I have is in fact a decrease of just over 3,000 nurses in senior positions at bands 7 and 8, but that is more than made up for by the increase of over 7,500 nurses at bands 5 and 6 on the front line. On the noble Baroness’s second point, the figures that I saw emanating from the Royal College of Nursing should be looked at with some caution; the RCN has included exit packages for executive directors but not for nurses. In fact, the latest independent evidence shows that for the third year running there was no increase in median executive board pay. It is important to compare like with like there, and the figure of 6.1% as a rise for executive directors is not one that we recognise.
Baroness Cumberlege (Con)
My Lords, does my noble friend agree that one of the most encouraging aspects of the nursing profession is the number of senior nurses who have gone on to be chief executives and board members in the NHS, bringing all the skills of nursing to the leadership of hospital trusts and clinical commissioning groups?
Elderly People: Abuse
Baroness Cumberlege Excerpts(10 years, 6 months ago)
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Baroness Cumberlege
To ask Her Majesty’s Government what assessment they have made of the incidence of elder abuse across the nation.
Baroness Cumberlege (Con)
My Lords, I start by declaring my interests which are in the Register of Lords’ Interests.
I am very grateful for the opportunity to have this debate to ask Her Majesty’s Government what assessment they have made of elder abuse across the nation, albeit I appreciate that we are in the sunset of this parliamentary Session.
According to the Office for National Statistics, there are 3 million people aged 80-plus in the United Kingdom. By 2050 this figure will rise to 8 million. The vast majority of these people are well and active and are a great source of strength in supporting their families and communities. Society would, of course, be so much poorer without them. However, the Alzheimer’s Society informs us that there are currently 800,000 people living with dementia. By 2050 the figure will be 1.7 million. They are the most vulnerable and their care is often a challenge for their families and society in general.
It was the wonderful Sir Alec Douglas-Home, a former Member of this House, who said:
“To my deafness I’m accustomed,
To my dentures I’m resigned,
I can manage my bifocals,
But oh how I miss my mind”.
I suspect that few of us here today have not had the responsibility of caring for others at the start of life in bringing up a family and then at the close of life when caring for someone who is increasingly frail. Whereas Patrick and I made a reasonable fist of bringing up our three sons—I do not believe that any of them has helped the police with their inquiries, but I could be wrong—we are now challenged by a close relative with dementia who has lived in residential care for eight and a half years. We acknowledge that we do not have the skills or patience to look after her. Fortunately, she lives in easy walking distance of our house. The staff, who are exemplary, are local, as are many of the residents, and the front door is never locked. We are always welcomed and never cease to admire the quality of the care that is given. Of course, I appreciate that this is not the case throughout the land. Through the media, the CQC and other organisations, we know that there is abuse in nursing and residential homes, hospitals, prisons and, sadly, within families, and this abuse is the most prevalent and the hardest to detect.
The Department of Health estimates that just under half a million elderly people are subject to abuse in the community. Action on Elder Abuse defines abuse as a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.
Abuse of elderly people is a huge subject, but I shall this afternoon concentrate on only two areas. Before I do so, I want to pay tribute to successive Governments who have enhanced the lives of retired people through increasing the state pension and introducing other saving schemes. With the Better Care Fund, this Government have strengthened support for carers; and the Care Bill, which might have just been enacted, places safeguarding adults boards and safeguarding adults reviews on a statutory footing for the very first time. Therefore, much is to be commended but still more needs to be done.
There is no statutory code of conduct to hold care workers to account. The majority, with the right support and supervision, do an excellent job in challenging circumstances. However, there are too many reports of staff delivering poor care. There are individuals who, having abused elderly and vulnerable people, are dismissed from one employer and then employed by another. The Cavendish report advocated standardisation of training and supervision for support workers and greater responsibilities for employers. The CQC is strengthening its inspection regime and identifying poor care.
Those initiatives are very welcome but not enough. The Health and Care Professions Council suggests three ways forward: first, a statutory code that articulates the requirements for honesty, integrity and respect; secondly, an adjudication process that can hold individuals to account; and, thirdly, public access to a register of those not fit to work as carers—a barring system. These measures would make a real difference. They would be proportionate and cost effective, and strengthen the current system, but they need to be backed by legislation. The Law Commission spent three years undertaking a huge task in revising the regulation of professional bodies, and that is much needed. It produced a draft Bill incorporating these and many other ideas. I know that it is the wish of the regulatory bodies that the draft Bill be incorporated in the Queen’s Speech. If that is not possible, I ask my noble friend to use his considerable talents to urge his colleagues to set up a cross-party, pre-legislative scrutiny committee of both Houses to at least start the work to examine the proposed Bill so that we can protect elderly people who are in situations of vulnerability.
My second area of concern is financial abuse, which has a devastating effect on older people. Not only can a comfortable lifestyle disappear but older people do not have the time or opportunity to recover financially. Such a profoundly disturbing experience can be a life-threatening event. Cases are complex and often involve family members or others who have “befriended” an older person—first by giving them gifts, then winning their trust, and then demanding a disproportionate amount for services. These cases can be especially difficult where the older person has mental capacity but seems to be under undue influence from the family or friend and cannot resist their requests.
Age UK receives many cries for help on its advice line. For example: Helen is one of three children who all hold powers of attorney for their mother and is becoming increasingly concerned about the actions of her two sisters, who she feels are not acting in the best interests of her mother. One has moved into her mother’s house without paying rent and the other has set up direct debits from her mother’s account to pay personal bills. They have both pressured their mother into selling personal items and taking out loans in her name and giving them the money. Helen is not sure whether her mother is really aware of what is going on but is finding it difficult to talk to her because the sister who lives with her mother is stopping Helen from contacting her. What can she do? That is one example but there are countless others.
A recent study found that financial abuse was the second most common form of mistreatment for those living at home, nearly twice as common as psychological or physical abuse. It is estimated, that 57,000 people aged 66 and over have experienced financial abuse by a friend, relative or care worker. Indications are that 60% to 80% of financial abuse takes place in the person’s own home and 15% to 20% in residential care. The risk is likely to increase as the population ages, with more people living with dementia and increasing financial pressures on people caring for older relatives. As more bank branches close and services move online, a greater number of older people are likely to rely on family and friends to help to mange their finances, including accessing cash.
What should we do about this? I suggest there should be a national task force to tackle financial abuse. It should aim to ensure better co-ordination between banks and other agencies such as trading standards, the Financial Conduct Authority and the Association of Chief Police Officers. The task force should establish clear reporting lines where financial abuse is suspected. It should consider: how to prevent financial abuse, based on the principle that older people are citizens, not just users of care services; how to raise awareness in all sectors, among older people themselves and the public generally; how advice can be provided to older people on issues relating to lasting power of attorney; and how adult protection committees could work better to prevent financial abuse.
This is not a cheerful subject, but it needs to be addressed. One of the objections to the proposed Assisted Dying Bill is the fear of greedy relatives: where there is a will, there is a relation. I thank noble Lords for taking part in the debate and for their contributions. I look forward to what I hope will be my noble friend’s affirmative reply.
Health: Liver Disease
Baroness Cumberlege Excerpts(10 years, 6 months ago)
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Lord McConnell of Glenscorrodale (Lab)
My Lords, Elena Baltacha had a remarkable career—
Health: Midwives
Baroness Cumberlege Excerpts(10 years, 8 months ago)
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Baroness Cumberlege
To ask Her Majesty’s Government what is their strategy to ensure that independent midwives can continue to practise with clinical indemnity.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Department of Health has been working closely with Independent Midwives UK, which represents self-employed sole-practitioner midwives, to explore possible options to secure insurance for its members. Independent Midwives UK has presented a business plan to the department seeking government funding, which has been carefully assessed. As any solution must be applicable across the UK, discussions have also taken place with the UK devolved Administrations. A decision regarding Independent Midwives UK’s proposal is imminent.
Baroness Cumberlege (Con)
My Lords, I thank my noble friend for that Answer and declare my interests as listed in the register. It has occurred to me that the first person to see your Lordships in the nude is a midwife. Midwives are very special people, and independent midwives are equally so. It is a travesty that independent midwives will not be able to practise if they cannot get clinical indemnity. As my noble friend said, Independent Midwives UK has worked very closely with the department but, unfortunately, there is still a gap of £1 million, the initial pot required to get midwives clinical indemnity. Will my noble friend work very hard to ensure that he and his colleagues fund that £1 million? I have to say that, in the context of the NHS budget, which is £110 billion, it is simply short change.
Earl Howe
My Lords, I hesitate to correct my noble friend but Independent Midwives UK submitted a business proposal to the department which would require the Government to provide a £10 million grant to support the inception of an insurance scheme for its members to provide full maternity care. We have considered two options, either of which would deliver that result. The creation of any government scheme specifically for Independent Midwives UK would effectively position the Government as the underwriter of the independent sector. That is something that we have hitherto found difficult to consider.
Health and Social Care (Amendment) (Food Standards) Bill [HL]
Baroness Cumberlege Excerpts(11 years ago)
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Baroness Cumberlege (Con)
My Lords, I declare my interests, which are in the register. I am the executive director of two companies, Cumberlege Connections Ltd and Cumberlege Eden & Partners Ltd. I thank noble Lords who are taking part in this debate, in particular my noble friend the Minister, who I know is sympathetic to the cause. I hope that I will not be too disappointed. He may be interested to know that many other noble Lords very much wanted to take part in this debate. However, Friday is a difficult day for your Lordships as we are a voluntary Chamber, and many noble Lords have commitments that they fulfil on Friday when the House does not usually sit.
I thank the hospitals I visited, which generously, and perhaps with some courage, allowed me to see and taste the hospital food and to talk to patients. On the whole, I was disappointed. When the food is frozen and has to travel from Wales to hospitals in England and is then reconstructed by steam, is it surprising that fish and chips are soggy and that other food is not quite what you anticipate it will be? Finally, I thank the excellent briefings I have had from the Campaign for Better Hospital Food, whose supporters exceed 5,000 individuals and many other organisations.
At the age of eight I was sent to boarding school, and the most precious item in my trunk was my ration book. School food in post-war Britain was not good. Fish on Fridays was no surprise, because you could smell it at 10 in the morning. Jam was either red or yellow, and made with mangels, and resurrection pudding lived up to its name. After decades of prosperity, however, British food has now changed enormously and beyond all recognition. For instance, whatever happened to gravy? Gravy now masquerades as jus, and leek and potato soup is now vichyssoise.
Virginia Woolf said,
“One cannot think well, love well, sleep well, if one has not dined well”.
When in hospital we do not expect to dine well, but expect to have delicious, appetising and nutritious food—food that aids recovery. In the past 20 years successive Governments have spent more than £50 million of taxpayers’ money issuing guidance to hospitals about how to improve patient meals. When I was a junior Minister I was one of those who tried. I was responsible for food—that was before the Food Standards Agency was established—and introduced the nutrition task force, which in turn set up a hospital catering project team that produced nutrition guidelines for hospital food. Those were launched by the celebrity chef Albert Roux. In the foreword he wrote:
“Food should be regarded as an integral part of hospital service and treatment … Food provides us with the nutrients essential to our existence and general health … In providing comfort, food can also help to make patients feel more at home, reduce stress, and actively contribute to an ambience that can enhance the quality of medical treatment”.
Despite my efforts and those of successive Governments, in many hospitals the food is unappetising, non-nutritious and does nothing to aid recovery. Six out of 10 patients say that they rely on family and friends to bring them food because the food is of such poor quality, and sometimes barely edible. At many hospitals patient meals are viewed as a bureaucratic necessity and not as an integral part of care. Hospital life is boring. When in hospital, patients want three things. They want to go home, they want visitors and they want good nourishing food, because it is food which punctuates the day. That should be something to look forward to, but many patients dread it. The Francis inquiry into Mid-Staffordshire was deeply concerned about the attitude by staff towards meals, mealtimes, nutrition and dehydration. The witnesses’ comments are heartbreaking. I could quote many but will quote only one:
“On examining the food and fluid intake chart, mum had only had half a cup of tea over the last 20 plus hours. Some days nothing was marked as being taken, today there were three cups of fluid on the table, all of which were full. She couldn’t have drunk them if she tried because all three of the cups were placed way outside her reach”.
I do not underestimate how difficult it is to serve meals to large numbers of sick people three times a day. People who choose a meal one day are discharged the next, so that an incoming patient is welcomed by a meal they may detest. Some people may have uncompromising diets or have an appetite which changes from day to day due to the medication they receive. Hospital food is complicated, but there are hospitals where they really think through these issues, have a love of food and organise it well—while in similar hospitals in the same city, of the same size, almost in the same catchment area, the food is simply appalling. I am sure that noble Lords will agree with me, and I know that the majority of people in this country find it unacceptable for hospital food to be unhealthy. However, much of the food served to patients is of a poor nutritional standard.
In 2012, a nutritional analysis of commonly served hospital meals showed that they often contain more saturated fat and salt than meals served at fast-food restaurants, including McDonald’s and Burger King. Hospital food which is high in fat, sugar and salt, is not helping to nourish patients, and much of it is wasted. Government figures suggest that as many as 50,000 people a year could be dying with malnutrition in NHS hospitals in England, and at least one in every 10 meals is thrown into the bin uneaten.
The British Association for Parenteral and Enteral Nutrition estimates that three out of four patients are not eating enough during their hospital stay, and that the majority of them lose weight while in hospital. This problem is particularly rife among elderly patients. Only today, the Campaign for Better Hospital Food published new data showing that hospitals in England spend more on nutritional supplements for patients than on the meals served to them during their stay. While of course I recognise that nutritional supplements are vital in the cases of some patients, should they have become the routine prescription given to patients who are unwilling to eat hospital meals, or failing to gain nourishment from them? Patients should be nourished with enjoyable food rather than by nutrient and vitamin pills administered as medicine.
We look forward to hearing later in this debate from my noble friend Lady Miller of Chilthorne Dormer, who has expertise in this area and chairs the All-Party Parliamentary Food and Health Forum, the noble Lord, Lord Rea, the previous chairman, and other noble Lords who have experience or knowledge of this issue. I suspect that my noble friend might be tempted to address in his reply the subject of foundation trusts in the context of mandatory standards for hospital food, which is the purpose of this Bill. Both Scotland and Wales now benefit from mandatory standards for hospital food.
The Government have given hospital trusts greater control over how they manage and care for patients and have given them the opportunity to influence the shape and direction of the NHS. That is absolutely right, and I strongly support it. However, it is no less important to have a safety net to ensure that the NHS does not fall below acceptable levels and that standards of care are regularly monitored and enforced. Standards are not goals; they do not restrict a hospital’s freedom. They provide basic levels of assurance for organisations commissioned to provide healthcare. So we are not setting a precedent; there is an abundance of standards already in place in the NHS, which reflects the important role that they play, including employment standards; care standards for patients with specific ailments, such as diabetes; and standards for financial auditing, to name but a few. Standards for hospital food should be no exception.
The Bill requires the Secretary of State to appoint a body of experts to draft hospital food standards and make it mandatory for all patient meals to meet those standards. The Care Quality Commission and the Chief Inspector of Hospitals will be required to check that the standards have been adopted and are met. If they are not, it gives the CQC power to act, ultimately by withdrawing a hospital’s registration. The CQC is working hard to increase the regularity and effectiveness of its monitoring exercises, and is ensuring that patients participate in them. The CQC already evaluates patient satisfaction with meals, so this Bill would require only that monitoring is carried out to assess adherence to more specific standards. This solution does not in any way necessitate burdensome regulation, and does not require the Government to take greater administrative control over the provision of hospital meals. In fact, patients themselves are likely to take a leading role in monitoring hospital food, as more and more of them sign up to join inspection teams, as encouraged by the Care Quality Commission’s new Chief Inspector of Hospitals, Professor Sir Mike Richards.
Finally, I address the issue of cost. At the moment, taxpayers are being doubly charged for poor hospital food. Not only are they paying for the cost of patient meals but they are funding the associated costs that bad hospital food incurs, such as food waste, malnutrition and longer recovery times. I frequently hear people say that good hospital food is expensive and costs too much for hospitals to afford, but the facts do not bear this out. It has been shown that there is no correlation between the cost of patient food and its popularity with patients. Many of those hospitals serving the best food, produced and prepared to very high standards, are actually paying less for it than are hospitals where patients are dissatisfied with what they are being served and where food is wasted. For example, according to data from NHS Estates, Ipswich Hospital NHS Trust spent an average of £13.59 on food for each patient per day in 2012, yet less than half of patients at the hospital surveyed by the Care Quality Commission rated the food as good. In contrast, the Royal Marsden NHS Foundation Trust in London spent £5 on food for each patient per day in the same period, and more than seven out of 10 patients surveyed by the Care Quality Commission described the food as good. So those public sector organisations that have set standards for their food have done so without incurring extra cost.
In 2010, the Department for Environment, Food and Rural Affairs carried out an extensive evaluation of the costs of introducing government buying standards for food served in central government, including prisons and government departments. The standards mandate was that organisations buy more organic food, more fresh fruit and vegetables, and sustainable fish. The evaluation concluded that the organisations would not pay more—and, indeed, they do not now pay more—for higher quality food. If patient meals contain high-quality ingredients and are cooked by highly skilled caterers, they are more popular with patients, more likely to be eaten and therefore less likely to be wasted.
In conclusion, this Bill has widespread support from the public and from 97 national organisations, including Age UK, the British Heart Foundation, the Hospital Caterers Association, the Royal College of Physicians and thousands of members of the public. I contend that hospital food standards must be made mandatory if all patient meals are to be of a sufficient high quality, are to be nutritious and made to minimum standards of production.
This is a modest but sensible Bill with widespread support, and I urge my fellow Peers, as well as my noble friend as the Minister responsible on behalf of the Government, to support it. I look forward to my noble friend’s sympathetic response. I beg to move.
Baroness Cumberlege
My Lords, I thank my noble friend Lord Howe for his comprehensive reply. What the Government are doing is extremely encouraging, but I am still not convinced that all this voluntary work and the emphasis on guidelines will achieve what we want. We will need to press for some mandatory standards. I want briefly to comment on some of the very knowledgeable contributions that have been made by noble Lords.
The noble Baroness, Lady Gibson of Market Rasen, started by saying that she is not an expert, but in her contribution she showed real clarity about her expertise as an expert patient. There is nothing more compelling than personal testimony. She did say that this is not asking for the moon, and I agree with that. It is a simple Bill and, indeed, a modest one.
It has been clear throughout the debate that noble Lords have been diligent about reading their briefing, and pretty well everyone described the 21 initiatives that Governments have put in place over 20 years as being extraordinary. In no way do I underestimate the concern and commitment of successive Governments, and we have heard about that again today. All Governments want to improve hospital food, but it is a question of how that is done: how do we make it happen? We know that the NHS is very good on policy, on discussions and on—what do they say?—paralysis by analysis, but it is the implementation that it is weak on, and that is what particularly concerns me about hospital food. I have a quote from one of those years: “It is good food, not fine words, that keeps me alive”.
My noble friend Lady Miller and the noble Baroness, Lady Thornton, gave us some shining examples of the good food being produced in hospitals. I am pleased to see that because it is very good for patients, and I would bet that it raises the morale of the staff as well. The Royal Cornwall Hospital was highlighted. I have not had time to visit that hospital, but I know that my noble friend Lady Jolly speaks of it often. I understand also that the Royal Brompton Hospital and others are good. However, my noble friend Lady Miller said that what really makes a difference within a hospital is the will to do well and good leadership; that is very important. Today, I am asking the Government for a bit of strong will and the leadership to bring in this legislation.
Catering staff are, of course, key to this. One of the things I have noticed when visiting hospitals is that different institutions approach this differently. That is great and I am all for them using their initiative and seeking their own ways of doing things. Some places have integrated nursing and catering staff, while in others there are dedicated catering staff who have an absolute love of food, and you can see the difference. There are merits in each of the different ways of approaching this, and that is right. Having talked to nurses and to catering staff, I am interested in the following question: where are the doctors? I am delighted that the doctors are here today and I thank them both, the noble Lords, Lord Rea and Lord Turnberg, for their contributions.
It is very interesting to look at the obesity plan that the Royal College of Physicians has produced; hospital food does not seem to enter into it. Bariatric surgery does, and the need for more nurses to be trained in bariatric surgery—all those things—but surely doctors should be looking much more closely at the whole condition of their patients, what they are receiving and how they are getting better.
The noble Lord, Lord Rea, said that sanctions are missing and the lack of progress has been shameful—I so agree. This is an opportunity to improve, as he was saying, not only the quantity and quality of food in hospitals but the education so that people can better understand food in general. I was asked whether the Bill includes private hospitals. No, it does not; it applies to the NHS.
I thank the noble Baroness, Lady Masham, very much. I know that Stoke Mandeville is seared on her heart. I am very pleased that I have escaped on my visits there but she certainly told us a great deal about how disappointing the food is. I was interested in what she said about having kitchens on the wards and in hospitals generally, and not food brought from Wales. The noble Lord, Lord Turnberg, also made that point.
There is a very nice quote from Elizabeth David, that great pioneer of good cooking:
“Good food is always a trouble and its preparation should be regarded as a labour of love”.
When the food is produced on an assembly line in Wales, frozen and then reheated on the ward, how can the people who are producing that food love it? They never see a patient. Whereas if hospitals have their own kitchens, you see chefs going round and asking the patients what they like, what they do not want, what size of portion they want—all the rest of it. That is the labour of love.
I was very distressed to hear the noble Lord, Lord Turnberg, say that many patients lose weight in hospital. He also went on to say that celebrity chefs are not the answer. I agree: that is another thing we have tried and tried and it does not work.
I was interested to think about how patients can use their power to improve hospital food. We have tried and tried. Age UK tried the “Hungry to be Heard” campaign, which was all about food in hospital. As nothing happened, it revamped it as “Still Hungry to be Heard”. I really do not think that across the country the food has improved that much, despite some of the good examples we have been given. It is interesting that two-thirds of staff would not eat the food given to patients. That says everything, as far as I am concerned.
I thank the noble Baroness, Lady Thornton, for volunteering for this debate. I had no idea she had such a long-standing interest in this subject. Her contribution was outstanding. I agree with her: I am afraid we have reached the end of the road on volunteering and now we need to really grip this subject. She asked me about the consistency of government policy. I fear it is not consistent and I fear that will be our struggle. I am trying to think of other ways in which we can perhaps introduce something if this Bill does not get through the House of Commons. The noble Baroness also mentioned care homes. I was very conscious that in the NHS you really need to focus on the subject to get it done and I thought that if we went much more widely, we would certainly fail.
Finally, I am delighted that I and my noble friend the Minister are at one in that we want to support high standards and we agree that more needs to be done. The Government are certainly not inactive and I have been impressed by the response he has given us today, starting with this new panel he has set up. It has a huge task ahead. He highlighted the remit of the panel and what it will do. It looks very ambitious. I hope it succeeds. When will it report? How can we monitor progress? We need to see that this is not the 22nd initiative that the Government have produced in 20 years. We really want it to succeed.
On the question of staff and visitor food, I appreciate that less than half the food in hospital is served to patients: it goes to visitors and staff. I visited a hospital and asked to see the kitchens. They said, “Why do you want to see the kitchens? The food is brought in from miles away”. I said, “I still want to see how you are going to regenerate it”. As I went into the kitchen area, I met two chefs. One chef was cooking for private patients. I thought, “That’s fine, they’re paying for it; fair enough”. The other chef was cooking for the staff. I went into the staff restaurant, which was superb. You could have chosen anything; the food looked lovely. Then I tasted the hospital food given to patients—I say no more.
It has been a very interesting debate. Again, I thank my noble friend for his summing up. I understand that there are a lot of initiatives; it is how they work in practice that concerns me. I will certainly keep an eye on this Bill. I am not totally persuaded. I want to continue. I commend the Bill to the House.