Health: Neurological Conditions
Baroness Hollins Excerpts(13 years, 1 month ago)
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Baroness Hollins
My Lords, I am grateful for briefings from the Spinal Injuries Association, and from my daughter, who has tetraplegia, and to the Motor Neurone Disease Association. I am also glad to participate in this debate, which allows for deeper thought about the needs of people with neurological conditions than is possible in the lengthy debates around the Health and Social Care Bill, and indeed the Welfare Reform Bill.
I have learned, and am still learning, about the disabling barriers that people with different impairments encounter, both as a doctor working with disabled people over the last 30 years, and also as the mother of two adult disabled children. I am convinced that policy will not be effective if the social model is not fully embraced as part of the foundational principles underlying legislation. But some needs are medical, and require highly specialist expertise. I would like to draw attention to the fact that medical research into neurological conditions is grossly underfunded.
It would also be remiss of me not to mention the importance of attending to the emotional and mental health needs of patients with neurological conditions. I am thinking here particularly of newly spinal cord-injured patients. It is not just the obvious psychological adjustment to a new impairment, and all the learning required to keep well and to reintegrate into society. We should remember that many people acquire spinal cord injuries during a failed suicide attempt and there may be an underlying mental illness which also requires active treatment. It is the partnership between medical and social agencies working with the disabled person that will best meet that person’s needs, and the needs of their family, while recognising each person’s right to respect for their private and family life, as provided by Article 8 of the European Convention on Human Rights.
In 2009, the NHS published an updated National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, for use in England with revised eligibility criteria. In paragraph 79 of the framework, explicit mention is made of the Coughlan ruling under which a person with a high-level spinal cord injury or similar health need is entitled to continuing healthcare funded by the NHS. The purpose of the continuing healthcare assessment is to establish whether an individual’s care needs are primarily health related or social in nature. This is done by measuring the totality of their care needs according to their nature, intensity, complexity and/or unpredictability, and gives rise to the concept of a primary health need. These assessments are done at the time of initial diagnosis, they are reviewed regularly and there may be a reassessment when a person’s needs have changed.
For many people, securing continuing healthcare funding is fundamental to enhancing their prospects in rehabilitation and their prompt discharge, and thereafter in the community in reducing the likelihood of complications requiring hospital readmission. However, outcomes for individuals seeking continuing healthcare are very uneven and unpredictable across the country—a classic postcode lottery.
A primary cause for concern is the lack of quality clinical input into these assessments from professional practitioners with experience of spinal cord injury and of the patient in question. Often, no opinion is even sought when assessing patients in the community. A detailed and insightful clinical assessment from a spinal cord injuries centre consultant carries significant weight, but is all too often a key missing component. In the community, in particular, the patient is frequently left to persuade sceptical assessors, and when declared ineligible, to battle the bureaucracy of the primary care trust alone.
Unfortunately, there are an increasing number of appeals by people with tetraplegia who are being found ineligible for continuing healthcare funding, although those who appeal are often later found eligible. For people with some neurological conditions the award of continuing healthcare funding will be welcomed, but for others it will not. Consider someone with spinal muscular atrophy, which is a degenerative condition. For much of that person’s life, any support needs will be considered primarily social in nature and, appropriately, funded by the local authority. Increasingly, people are receiving direct payments to employ their own personal assistants. However. when a person’s condition leads to them needing more intensive support, such as being on a ventilator or needing a personal assistant 24 hours a day, some social services departments are asking the local PCT to pick up the funding under CHC rules.
Some people, including some with spinal cord injury, do not want to move on to continuing healthcare funding when their condition deteriorates because they will no longer be allowed to employ their own staff—personal health budgets allowing this are not yet available. The Secretary of State has announced that personal health budgets will be rolled out in 2014 subject to the evaluation of the pilots, and I think that will be welcomed.
There has been quite a lot of talk also about the need for a change in the law to allow people to take their support package with them if they move area, and indeed my noble friend Lady Campbell, who sadly cannot be here for the debate today, has had the first reading of a Private Member’s Bill to introduce a right to portability of support. However, I suggest that portability is not just a matter of geographic portability but should also apply to a change in the funder from social services to health, and vice versa.
Case law—and here I mean the Coughlan criteria—clearly indicates that if you have tetraplegia, you should be eligible for continuing healthcare funding. But many PCTs have been resisting their responsibilities and refusing to honour the Coughlan criteria. Some PCTs, such as Norfolk, have apparently sought to introduce a blanket requirement that anybody receiving complex medical care and considered to be at high risk will no longer receive continuing healthcare in their own home and will have to move into nursing home care, because it is thought to be cheaper.
Rehabilitating people with spinal cord injury in the community requires a positive and active engagement with friends, family and the wider community. It requires an integrated, collaborative, and joined-up approach by the NHS and the local authority, in which recovery is understood as being as much about removing social barriers as about medical treatments. It may require, for example, disabled facilities grants to adapt living accommodation, and the installation of environmental controls. It requires financial support to pay for the extra costs of living as a disabled person.
One of the biggest worries for someone with a spinal cord injury is the risk of pressure ulcers, and the absence of ulcers is usually down to good care. It does not require health professionals to deliver this care, but it does require specially trained personal assistants working under the direction of the spinal cord-injured person. The cost of treating pressure ulcers to the NHS and to the individual is very high.
Prevention must be the priority, but that requires that people with spinal cord injury are well trained and can train specialist PAs to support them. If they go into hospital for medical treatment, it is critically important that their personal assistants continue to support them in hospital, working alongside the clinical team whose job is to attend to the reason for the clinical admission. However, some people with spinal cord injury find that their personal assistants are not allowed to accompany them to hospital and so leave hospital in a worse condition. I would like an assurance from the Minister that the Government support the continuing involvement of personal assistants in the personal care of someone with a spinal cord injury who is in an NHS hospital.
The most obvious addition to a person's daily life is a wheelchair. We have already heard something about wheelchairs. An adequate, well fitting wheelchair is of critical importance in enabling somebody with spinal cord injury, motor neurone disease or another neurological condition to participate in their local community. The current wheelchair service is too slow to respond to the needs of someone with, for example, motor neurone disease. Some people wait as long as two years after the need for a chair has been agreed. Half of those with motor neurone disease die within 14 months of diagnosis. I have heard that some people do not receive a wheelchair in their lifetime because of the unresponsive nature of the wheelchair service. I know that the Motor Neurone Disease Association would like to become a provider of wheelchair services to get round this problem. I hope that the Minister will endorse that aspiration and that it will not be disadvantaged in competition with larger commercial providers.
Another issue of real concern is the lack of palliative care provision for people with motor neurone disease. This is entirely unacceptable. If there is any condition for which excellent palliative care is required, it is motor neurone disease. In Southampton, for example, there is no palliative care provision for people with motor neurone disease. The association is calling for widespread availability. Can the Minister confirm that palliative care services for people with motor neurone disease will be included in the pilot work associated with the current review of palliative care?
For all these conditions there are concerns about how services will be commissioned in future. Will the Government issue guidance on when services should be commissioned jointly for these complex but relatively rare conditions? I am talking about commissioning both at the acute stage and in the longer term for people with complex neurological conditions. The NHS Commissioning Board and clinical commissioning groups will of course need to recognise the difference in commissioning for people with spinal cord injury—normally a fairly static long-term condition, with the prospect of somebody in their 20s living to 70—and for people with a deteriorating condition such as spinal muscular atrophy. What is not clear in discussions on the Health and Social Care Bill is where responsibility for commissioning continuing healthcare will lie in the future. The Minister's response to this question would also be welcome. Certainly, risk sharing between several clinical commissioning groups will be needed to make locally funded continuing healthcare a viable prospect.
With respect to spinal cord injury, does the Minister agree that specialist treatment in spinal injury centres leads to the best chance of recovery and rehabilitation in both the medical and social meanings of the words; that the decline in the number of people with spinal cord injury being admitted to spinal injury centres is to be deplored; that people with spinal cord injury should be treated in such centres both acutely and over their lives, as they need to be readmitted for complications from their spinal cord injury to be managed and treated; and that the National Spinal Cord Injury Strategy Board, which is to be nationally commissioned in future, should also be involved in ensuring that continuing healthcare is appropriately commissioned?
Health and Social Care Bill
Baroness Hollins Excerpts(13 years, 2 months ago)
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Lord Turnberg
My Lords, I will speak to Amendments 103, 104A, 106, 135A, and several of the others in this group. Clause 20, new Section 13M, highlights integration of services as something the Commissioning Board should “exercise its functions” to secure,
“where it considers that this would—
(a) improve the quality of those services”.
That is all well and good, but by itself it seems insufficient. Integration is of course difficult to pin down. We have heard quite a bit about that this evening, and I will not repeat those remarks. I know what I mean by integration, so I will give you my particular understanding, for the purposes I want to talk about, using the term to mean a seamless service for those patients, usually elderly and with multiple diseases, who need both hospital and community care, and flit between the two.
It is unfortunately the case that the integration that is needed between health and social services has seen so many failures and been so elusive, despite many wasted words. We have an opportunity here to correct these failures, so I was somewhat disappointed when the Minister said in the debate on 2 November, when we were discussing the role of the Secretary of State, that the Government were,
“not in the business of dictating the processes”—
and that—
“integration is neither a necessary nor a sufficient condition of a good outcome”.—[Official Report, 2/11/11; col. 1334.]
Surely if integrated care is a good thing—and I think few will deny that—then we must give a lead on how it might be achieved. We cannot ignore the process, and must at least try to see what conditions are necessary for successful integration. We should not go around simply saying it is a good thing, without showing how it might be achieved.
There are many examples out there that we can build upon. We are not entirely in uncharted territory. The noble Baroness, Lady Cumberlege, mentioned Assura Cambridge and services in Torbay in our last debate, and other noble Lords spoke of Kaiser Permanente, Northern Ireland, personal health budgets and information sharing, as valuable means to an end.
We also have the excellent report from the Nuffield Trust, Integration in Action, that analyses successful integration being carried out in four places across the world, including in Scotland. We are not working in a vacuum, and we could and should take advantage of all this information, and incorporate some of those ideas in the Bill without waiting for yet further work.
Of course, not everything can or should be put in the Bill, but we should see where we can strengthen it, by including more pointers to how we can improve the present, very unsatisfactory, position. Let me give some examples, leaning heavily on the Nuffield Trust report. First, the Commissioning Board should point the way by developing commissioning for bundled payments, and local tariffs for key conditions. I think that is possible. At the moment, fees for service for episodes of hospital care, as we have heard, work against integration with community service. That is something that the board should seek to redress quickly.
Secondly, we should design the national tariffs that we have heard about, which incorporate a full care pathway across the health and social service divide. Monitor and the board should work together to develop a pricing strategy that provides the incentives for integration. They should also develop ideas about how outcome measures, which are admittedly difficult to quantify when we are talking about a complex system like integrated care between hospital and social care, can be used to promote integration across the whole pathway of care. Contracts based on those measures can encourage providers to respond to the need to integrate. There is nothing here that obviates competition between providers, which I am sure will please my noble friend Lord Warner.
We will come later in the Bill to Monitor, but it too should link improvements in outcomes, including the patient’s experience, to the way it regulates integration. Then, there are several measures that clinical commissioning groups and local authorities should be encouraged to develop by the Commissioning Board. One huge area is of the improvements we desperately need in the flow of information between hospitals and community. Too often we rely on phone calls on the day of discharge, which is inefficient and fails most of the time. We should have an IT system which allows information to be shared across the divide. It only requires a competent programmer to produce the programme, and a safe system for preserving patient confidentiality and data protection. I am sure that that is not beyond our capacity.
There is also the need for joint funding and integrated governance arrangements, which we have had some discussion about. This is much easier said than done, but it can be done. We have seen it in action here and there and we must spread the good practice.
There is also the need for people to make the whole thing work on the ground: for example, liaison officers whose sole responsibility is to ensure that patients pass seamlessly across the divide, and nurses and doctors who move without constraint from one sphere to another. The example of specialist district nurses is a good one. They follow patients from hospital to the community and back, and are very much appreciated. Unfortunately, they are a threatened species and are disappearing, largely because neither the NHS nor local authorities will fund them. We must get around that problem.
Of course, much of what is needed depends on a change in the mindset of those working at the coalface in hospitals and the community. If through the Bill we can change the conditions from those that inhibit collaboration to those that encourage it, we can begin the process. The amendments bring a greater sense of the need to focus more strongly and urgently on the duties and responsibilities of the board in putting integration more firmly on the map as a way of improving outcomes. I support them strongly.
Baroness Hollins
My Lords, I will speak to Amendment 203A in my name and those of my noble friend Lady Finlay and the noble Lords, Lord Patel of Bradford and Lord Patel. I will speak also in support of Amendments 135C and 135D, tabled by my noble friend Lady Finlay.
The Bill seems to favour the commissioning of services through the any-qualified-provider model rather than being concerned primarily with commissioning an integrated model of care. Amendment 203A would introduce a duty on clinical commissioning groups to commission multiple providers of health services competing to deliver a section of the care pathway only where they can demonstrate to the NHS Commissioning Board that the approach is beneficial to patients. Integrated care pathways are particularly important in complex, long-term conditions such as serious mental illness or challenging behaviour, for example in someone with learning disabilities who is also on the autistic spectrum.
There have been attempts in the NHS to deliver integrated care pathways, with varying degrees of success. The introduction of a plurality of providers in mental health services in recent years is already showing signs of fragmenting complex care pathways in some instances. The disaster of Winterbourne View is just one example of how commissioning one provider to deliver part of a pathway without planning, commissioning and co-ordinating the whole of an integrated pathway can be an expensive and tragic mistake.
The further introduction of competition between providers has the aim of reducing the cost of provision while maintaining and improving the standard. This is a noble aim on which we may all be able to agree. However, commissioners must evaluate whether the aim is being achieved, recognising that care pathways vary hugely in different conditions and even for different patients. The variety of provision needed means that we cannot easily—if at all—prescribe a rule to cover all situations. Of course, the health service exists to serve patients, not providers. It is in this light that we must consider proposals to introduce competition between providers, and it is because of this that the burden of proof must be on those who favour increasing competition to show that doing so would benefit patients.
The risk is that many providers will compete to provide more profitable parts of a pathway, cherry-picking the parts they would like to offer, perhaps only to the least complex patients, thus leaving unmet the less easy to cost and define but still essential parts of the pathway. The importance of an integrated care pathway cannot be overestimated. The comfort patients take in knowing that their entire provision is being dealt with in a coherent, joined-up way may be put at risk under an any-qualified-provider system. As always, it is the most vulnerable patients whose needs may remain unmet.
Health and Social Care Bill
Baroness Hollins Excerpts(13 years, 2 months ago)
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Baroness Williams of Crosby
Perhaps I may add a few words on an aspect that was touched upon only a moment or two ago by the noble Lord, Lord Lucas—the role of people who act as whistleblowers, particularly regarding patients who, for one reason or another, are not capable of standing up for themselves, are perhaps in institutions where they get little attention paid to them, and are not much listened to. They would be heavily dependent on the willingness of NHS staff to blow the whistle when bad standards are being allowed to continue.
One thing has always worried me about the NHS. As a parliamentarian of many years’ standing, I have received many letters from junior members of NHS staff asking me to look into some aspect of a hospital or care home in which they work, and almost invariably saying at some point in the letter, “I dare not do this myself because my job would be at risk”. This is a very serious aspect of the amendment of the noble Baroness, Lady Masham, but we have not talked about it very much at all.
I tend to favour the idea proposed by my noble friend Lord Mawhinney for having an element of mediation, as well as an element of court behaviour, in the way in which we deal with such cases. However, it rests on us all to give high priority to thinking of the ways in which we can protect whistleblowers and distinguish the genuine whistleblowers from those who are complaining merely about their personal position. For example, if we included private as well as NHS hospitals and care homes, the kind of position that the noble Baroness, Lady Oppenheim-Barnes, talked about—she described a terrible case with regard to her daughter—would not arise so readily.
I ask the Minister to say something about the view that mediation is one way forward, as well as court cases. At least as importantly, perhaps he can say whether the General Medical Council or others would now seriously consider protection for whistleblowers within NHS staff, who are often the most effective inspectors that we can find—much more effective than people with no clear knowledge of the way in which medical and health services work.
Baroness Hollins
Perhaps I may raise a couple of issues that have been touched upon. The first is that I do not know how far the consultation that is looking at the duty of candour will tease out the role played by whistleblowing. I should like some clarification about that.
The General Medical Council’s document, Good Medical Practice, in paragraph 31, makes it clear that doctors must be honest and open and act with integrity. I mention that because my noble friend Lord Walton spoke about the GMC’s role and said that he was not sure how far the medical defence unions currently adopt the same approach to encourage doctors, when they are aware of an error, to be open and honest. I decided to telephone my medical defence union before this debate and ask it for its current advice. It said that it refers doctors to Good Medical Practice and reminds them of paragraph 31, which states that they must be honest and open and act with integrity. I hope that the House will be reassured to hear that.
In my experience, a culture of openness and honesty leads to a culture of learning. That point has been made by a number of noble Lords. We should not be afraid of the idea that apologising will in some way lead to a greater culture of litigation. It is certainly my experience that being open and apologising does not necessarily imply negligence; it reflects the fact that something harmful has happened and that the lessons from mistakes must be learnt from in order that other people will not be harmed by the same mistakes in the future. That is what this is really about.
Lord Winston
Does the noble Baroness not agree with me, however, that this is not what this is about? The problem is that any persons providing healthcare—someone who is seeing a patient but is not concerned with the original treatment—would be required to be open and candid. The problem with that is that it is likely to be highly dangerous and damaging to patients in that situation, as extensive medical experience over many years has shown to the many people trying to do an honest and open job within the health service. The matters of each case have to be looked at on an individual basis.
Baroness Hollins
I absolutely agree with the comment of the noble Lord, Lord Winston. Commenting on another practitioner’s practice and making judgments is fraught with error. That is why it is important when looking at the duty of candour to understand the role that whistleblowing plays. A great deal more could be said but it is extremely dangerous to make assumptions about another person’s practice.
Lord Warner
My Lords, I was not intending to intervene in this debate, but after listening to the discussion I want to remind the Minister of the many happy hours that we spent taking the NHS Redress Bill through this House six or seven years ago. Can he tell us the extent to which some of the measures in that Act may or may not have helped to deal with some of the concerns that have been expressed in this debate, because that legislation was an attempt to give patients more satisfaction without going to court and to encourage a greater culture of openness and apology on the part of the NHS when it made mistakes?
Baroness Armstrong of Hill Top
My Lords, I seek only to intervene briefly on this. The whole issue of how to tackle inequalities in health is an extremely complex and difficult one. When I was a Member of Parliament, I looked forward to receiving from the department reports on a regular basis on how inequalities had been addressed and how health had improved throughout the constituency. What was clear was that the more effective our public health interventions were, such as on reducing smoking, the more difficult it was to tackle inequalities. The people who automatically responded best to those interventions were those on higher wages, with better qualifications and who were likely to be in higher class groups than those in the poorest parts of the constituency. That could always be seen clearly in those reports. The amendments that support better information are very important because clinical commissioning groups in particular are not well placed instinctively to tackle inequalities. It is generally not part of the training of GPs to look at these issues and work out how to address them.
We have already discussed the second issue today, and it is important—the issue of access. Unless we open up access much more sharply to the disadvantaged we will not have a chance of addressing inequalities. The noble Baroness opposite talked about homelessness. I have discussed this issue with the Minister on a number of occasions, and I am not content that the Bill deals with it adequately. It is not fair to ask clinical commissioning groups to address this issue. Sometimes they will simply be too small to do so. Also, homeless people tend to be fairly mobile, so in London they will cross authority areas. From my experience in the north-east of England, a single PCT—or what will now be the smaller clinical commissioning groups—does not have the people available properly to offer the sort of services that are needed to open up access effectively to those who are not normally registered on a GP list.
I am also concerned that clinical commissioning groups may be responsible for areas with poor GP coverage and there will be a need to bring in salaried GPs. It will need someone other than a clinical commissioning group to address the issue of GP shortages—and it is always the poorest areas which have the poorest access to GPs. It is an issue that continues to have to be addressed time and time again. I was pleased when the last Government introduced many more salaried GPs, but we have to keep on top of that agenda.
I also support the amendments that look to the responsibilities of the NHS Commissioning Board. There will be occasions when the board has to come in specifically to address inequalities in a range of ways. I am not sure that it is really geared up to do that at the moment. But because I certainly do think that clinical commissioning groups are not going to be able to do this on their own, and indeed it would not be appropriate for them to address some areas of clinical commissioning, it is very important that the department, the Secretary of State and the Commissioning Board think about how they are going to do this effectively.
Baroness Hollins
My Lords, I particularly welcome the amendments which are designed to strengthen the duty to reduce health inequalities between people and communities, the emphasis here being on inequalities not between “the people of England”, but between individuals as well as groups. I draw attention to this because in 2008 the Department of Health drew up a policy on health inequalities, and I sat on the group which developed it. I was pleased when the document was published in June 2008 because it talked about the group that I am interested in, which is people with learning disabilities. I shall read out a short paragraph from the executive summary because it makes my point very nicely:
“Progress on health inequalities will be judged against how public services treat especially vulnerable groups. The recent Disability Rights Commission report made it clear that people with learning disabilities often receive a poorer level and quality of service from the NHS. If services and health outcomes are improving for people with learning disabilities, they are likely to be improving for other groups at risk of health inequalities”.
The report goes into some detail about the importance of measuring the improvement in health inequalities for particularly vulnerable groups. That is a good measure to measure progress in the NHS.
Health and Social Care Bill
Baroness Hollins Excerpts(13 years, 2 months ago)
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Baroness Hollins
My Lords, I support the amendments of my noble friend Lord Rix. He made reference to people with learning disabilities and in particular expressed concern about people with complex needs. I should like to say a little more about people with learning disabilities who have challenging behaviour. It is estimated that as many as 40 per cent of people with learning disabilities may present behaviours that are challenging to family and other carers. These behaviours can be so intense and frequent as to have a major impact on the quality of life of the individual and their families.
People who present severe behavioural challenges are among the most disadvantaged and marginalised individuals in our society and are at much greater risk of exclusion, institutionalisation, deprivation, physical harm, abuse, misdiagnosis and exposure to ineffective interventions. Their carers are subject to physical harm, psychological ill-health, physical ill-health and to an increased burden of care and financial consequences. It can also have an impact on their employment prospects and quality of life.
Commissioners, policymakers and providers all face escalating costs and risk undermining national policy. Providers face high staff sickness and turnover, service breakdown, scandals and exposés such as the recent “Panorama” programme about Winterbourne View in Bristol and previous scandals in recent years in Cornwall and Merton and Sutton.
Back in 1993, Professor Jim Mansell emphasised the need for commissioners of health and social care to work together to provide good support and services for this group of individuals. He recommended locally based, individualised packages of care. He suggested that the environments where people are cared for should be skilled and capable of maintaining support for the long term. He revised his report in 2007 for the Department of Health and made the same points because insufficient progress had been made. He and others, such as the Challenging Behaviour Foundation, have made it very clear that large institutional provision is not the answer, yet many people with learning disabilities have care packages commissioned within such institutional care, mainly in the independent sector, funded by the NHS and by social services. These placements are often far from home. They have little guarantee of high-quality, skilled care and are vulnerable to the kind of restrictive practices that have been revealed time and again in a variety of high profile exposés. This care is often very high cost, as well as not delivering good outcomes for people.
A recent publication entitled There Is an Alternative, published by the Association for Supported Living, makes a strong argument for local, community-based support, saying that it is more successful and cheaper than specialist in-patient provision. However, for that to happen requires vision, commitment and a will to make it happen. It cannot be achieved without the will of effective local commissioners, a will that must be expressed in decisions to invest in local community-based services, rather than to farm out problem cases to expensive out-of-area placements—what in the world of learning disability we know as the “crisis Friday afternoon very expensive mistaken placement”. Most successful supported living services have their roots in commissioners' decisions to invest in that service model, acting on sound demographic knowledge of the communities they serve and the needs and wishes of the people with learning disabilities who live within them.
I am sure that health and well-being boards will have an important role in thinking about the needs of their population with learning disabilities in that way. However, it is clear that there need to be good lines of accountability in future. There is a worry that local clinical commissioning groups will not be able to commission adequately when specialist services are needed. They will have to be able to address a comprehensive local strategy that can deliver early intervention, timely and skilled professional expertise and support, competent and high-quality providers of individualised support and services, flexible crisis intervention services, such as psychological therapies, which are very underdeveloped for that group of people, and psychiatry, which can build the support required for each individual—real individualised care. The numbers of individuals are relatively small but they can be very high cost if the services are not planned well.
It is essential that the needs of this group of individuals are specifically considered within the new commissioning arrangements. I always say that if we can get it right for people with learning disabilities and complex needs, we can get it right for everybody else. There may be an argument for looking to the National Commissioning Board to take this overall responsibility without compromising the need to find ways to ensure local responsibility—the delivery of creative, flexible and local solutions to meet the needs of individuals and families within their own communities. This is quite a challenge, which is why I have gone to such lengths to explain the problem faced by this complex group of people. I ask the Minister to comment on how such services might be commissioned in the future.
Lord Newton of Braintree
My Lords, perhaps I may intervene briefly in support of the general thrust of the amendments without necessarily saying that I agree with every dot and comma. I also agree, not least, with the remarks of the noble Baroness, Lady Hollins. The noble Lord, Lord Rix, and I have known each other for quite a long while in the field of learning disabilities and, indeed, through my role many years ago as Minister with responsibility for disabled people, so I am happy to lend a sympathetic word on this point.
I ought to declare an interest in that several times I have told the House that I am the chair of a mental health trust. Of course, mental health trusts often deal with learning disabilities as well, as indeed does the health trust that I chair, although happily last year it transferred most of its residents on old-style campuses to Suffolk County Council for a more complete version of genuine living in the community and community care, and I am rather pleased that we did that.
We need to recognise that, although there are overlaps—the word “co-morbidities” is used in one of the amendments—between mental illness and learning disability, they are not the same, and we need to make sure that we take particular and appropriate account of the needs of learning disabilities in all this. I hope that the Minister will be able to assure us that that will be the case.
Health and Social Care Bill
Baroness Hollins Excerpts(13 years, 3 months ago)
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Baroness Hollins
Baroness Hollins
My Lords, in moving this amendment I shall speak also to Amendments 105 and 180. I am pleased that they are supported by my noble friends Lord Patel and Lord Alderdice, and the noble Lord, Lord Patel of Bradford. The amendments concern the duty of the Secretary of State set out in Clause 2, in Clause 20 in respect of the National Health Service Commissioning Board, and in Clause 23 in respect of the responsibility of clinical commissioning groups. I speak as a psychiatrist and as a former president of the Royal College of Psychiatrists.
It is time for a paradigm shift in the way we think about the health of the people of this country. When the word “illness” is mentioned, I suspect that in most people’s minds there are images of physical illnesses such as heart disease, stroke, kidney failure and so on. The current wording in the Bill places a duty on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups to promote comprehensive services in respect of both the physical and the mental health of the people of England. The Bill makes no specific mention of mental illness in respect of their duty as regards the improvement of the quality of services. I suggest that the word “illness” should be changed to “physical and mental illness” so that there can be no question about the Government’s commitment to ensure parity between services for physical illness and services for mental illness. The amendments would also be in keeping with the Government’s mental health strategy, No Health Without Mental Health, which states:
“We are clear that we expect parity of esteem between mental and physical health services”.
Noble Lords might think that there are some pros and cons to these amendments. I have discussed their purposes with mental health charities, service users, practising psychiatrists and other noble Lords. I believe that the pros strongly outweigh any possible cons, but I will deal with the suggested cons first. It has been suggested that there is no need to emphasise that illness encompasses both mental and physical aspects because of course it does; it is so obvious that emphasis is unnecessary. But the stigma associated with mental illness is still such that, on the whole, people do not self-disclose when they have a mental illness in the same way that they might talk about diabetes or cancer. I am sure that noble Lords can remember a time when cancer was a taboo subject, largely because of fear and ignorance. Unfortunately, a lot of the manifestations of mental health problems still evoke fear in the minds of the public. Until we start to name mental health and mental illness much more explicitly, I believe that we will allow mental illness to remain something which is not discussed in polite company, something that is kept out of sight and out of mind in spite of the fact that in each of our lifetimes, one in four of us will have mental health problems. Probably everyone in this House has someone in their family or among their friends or colleagues who is experiencing the symptoms of mental illness at this time.
It is not the same as including children or older people in the definition; nor to including a discrete group of conditions. Mental illness is relevant to every age and social group in the community. We all of us experience either good or less good mental health, just as we all experience good or less good physical health. Our physical health varies according to the presence of specific disorders, as does our mental health, and this applies just as much to children as it does to adults. Imagine a child with a complex neurological disorder who also has a mental illness. The child needs to be treated as a whole person with co-ordinated care by people who understand that the child’s mental and physical illnesses have equal priority.
The second possible con is that in labelling mental health in this way, specifically mentioning mental and physical illness, we might exacerbate the split between the two. Perhaps in 100 years’ time we will have adopted a sufficiently sophisticated understanding of health that defining health and illness as being about both physical and mental aspects will no longer be necessary. However, at this point in time, clarity is more important than any disadvantage that may come from naming both.
Another comment has been that mental illness is simply just another condition, similar to diabetes or stroke, perhaps, but this is not a 21st-century way of thinking about mental illness and mental health. The Government very helpfully earlier this year published their mental health strategy and called it No Health Without Mental Health. That is the point of these amendments: there is no health without mental health and there is no public health without mental health.
Given the scale of the changes the Bill introduces, the financial climate within which they will be implemented and the current underfunding of mental health services and care, I am keen to ensure that the Bill enshrines such a principle in law so that commissioning bodies can be under no illusion that they have an equal responsibility to commission high-quality and continuously improving mental health services as they have for services for physical illnesses. It would be extremely regrettable if the importance of mental health commissioning was overlooked because adequate reference to the parity that mental illness should enjoy with physical illness was omitted from the text of the Bill.
Mental health is part of the continuum of health, both for individuals and populations, and it cannot be thought about as if it was a discrete disorder or set of disorders. Medical science today is demonstrating what it should have taught us many generations ago: that physical and mental illnesses are inextricably linked. Do not misunderstand me: I am not suggesting that mental health problems are all down to biology and genetics; environment and relationships play an enormous part in supporting our mental health. This point was made very well on the “Today” programme yesterday, when a service user, a patient who had lived with schizophrenia, spoke about his experience of his illness. Professor Robin Murray from the Institute of Psychiatry, spoke about genetic imaging and other research into schizophrenia which so clearly shows that it is a brain illness, albeit strongly influenced by social and environmental factors.
The mind/body split has unhelpfully been set in concrete within the NHS, which uses different NHS trusts to treat mental and physical illnesses. This unfortunately fails to recognise the fact that depression, for example, is a very common co-morbid condition associated with diabetes, stroke and heart disease. It is not surprising, really, given that the brain is just one organ among many.
Mental illness in someone with a recognised physical illness is often overlooked, delaying that person’s physical recovery. As noble Lords will be aware, people who have severe mental illnesses are at an increased risk from a range of physical illnesses, as well as greater levels of obesity, and they have a shorter life expectancy. This is in part because, just as mental illness in those with physical illness is overlooked, so is physical illness overlooked in people with mental illness. We need to do more in all health services, including public health, to ensure that the connections between mental and physical illnesses are better understood; that service responses are co-ordinated; and that diagnostic overshadowing of one by the other is avoided.
We also need to recognise the part that education, training and research will play in achieving parity of esteem for mental and physical illness. Many factors contribute to the poor physical health of people with mental illness and, for many people with severe mental illness, social stigma, poverty, limited housing options and reduced social networks contribute to the problem, as do difficulties in accessing physical healthcare. I hope noble Lords will support me in inviting the Minister to agree to these small but significant additions to the Bill about which I feel so strongly. I beg to move.
Baroness Hollins
My Lords, I thank the noble Earl for his answer and indeed for the sustained interest and commitment that he has always shown to mental health services. I have been heartened by the enormous support across the House for my amendments and was impressed by the breadth of interest shown in mental illness.
There is wide recognition of the need to try to bring mental illness more into view, particularly perhaps to make it more explicit in the Bill. The indicators of better outcomes, about which the Minister spoke, are indeed welcome. We have heard how much they are needed. I hear every day of how mental health services are being disproportionately cut. We are still a long way from the kind of holistic service that we would all like to see. That is the difficulty and why I still feel quite strongly that we need to name mental and physical health. This may not be the right place in the Bill to do it, but I still think that when they hear the word “illness”, people think about physical illness. It may be defined but I do not think that it is what people hear. I have heard Ministers of Health and Secretaries of State speaking about health and illness over many years and nearly always when they do so we know that everybody is hearing “physical illness” and not hearing or thinking “mental illness”. We know that mental illness includes addiction and a wide range of different disorders and conditions.
I take note of what the noble and learned Lord, Lord Mackay of Clashfern, said and his question about where the amendment would best fit. I am willing to withdraw the amendment but I hope to hear more discussion and thought about how to show more explicitly in the Bill that there is a real intention in a 21st century Bill to have parity for mental and physical illness. In 100 years’ time somebody could be standing here arguing to take away the words “mental illness” because they are no longer needed, but we are such a long way from being able to do that. I am not arguing that mental illness is just a medical condition—not at all. It is a condition, as the noble Lord, Lord Alderdice, reminded us, which affects the very essence of our being. It requires integrated services and integrated approaches; it requires medical attention. But it also requires an awareness of the social recovery models of support and help. I will bring back the amendment at the next stage. I beg leave to withdraw the amendment.
Health and Social Care Bill
Baroness Hollins Excerpts(13 years, 3 months ago)
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Lord Newton of Braintree
Monitor has extended responsibilities—and, importantly, a much clearer remit to be concerned with the quality of patient services—beyond what it had when its overwhelming focus was on financial matters. I regard that as an improvement. The Secretary of State under the Bill has more powers over Monitor than it had under the original proposals introduced and passed by the Labour Government. I see that the noble Lord, Lord Warner, is nodding his head.
This is a difficult and complex area. We could argue for ever about the best way to deal with it. I say to my noble friend on the Front Bench that I hope that we can find a way forward. I also hope that many noble Lords will recognise that some things said about the Bill are simply not true.
Baroness Hollins
My Lords, I seek clarification. I am very sympathetic to the amendment tabled by the noble Baroness, Lady Williams. To remove a key word without good reason causes anxiety and I am not convinced by the reason given for removing it. Perhaps I could ask the noble and learned Lord, Lord Mackay, to clarify whether his amendment would ensure that the obligations required as a result of the Coughlan case would still be protected.
Lord Mackay of Clashfern
Yes, precisely; I tried to say that when I referred to the 2006 Act. The passage in the 1946 Act on which my noble and learned friend Lord Woolf relied as Master of the Rolls in Coughlan was the first part—that is, the duty to promote a comprehensive health service, free at the point of need. That was its function. It was in the nature of a preamble: the first part of the first provision of the Act. That was what my noble and learned friend Lord Woolf regarded as enforceable. In relation to Amendment 1, I said that that section had been demonstrated to be enforceable in law, which one could not say for sure about the amendment that the noble Baroness, Lady Thornton, promoted as the first clause of this Bill. Of course, the provision referred to by my noble and learned friend Lord Woolf is maintained in the Bill.
NHS: Future Forum
Baroness Hollins Excerpts(13 years, 7 months ago)
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Earl Howe
The noble Lord, Lord Hunt, raises an important issue. I agree with him that the quality of general practice has been extremely variable. We saw a report the other day, published by one of the think tanks, which said exactly that. We have some very good GPs, but we have some who, frankly, are less than the standard that we would want and expect in primary care.
We are doing a lot of work to roll out leadership programmes for general practitioners. The National Leadership Council is working with GPs to agree the skills required for commissioning and will assist GPs in developing these skills as appropriate. The NHS institute is also doing some good work in this area and we will shortly be able to provide a bit more detail on how we can develop leadership, regionally and nationwide.
The noble Lord’s question runs rather wider than that, being about the quality of care delivered by GPs. In rolling out the outcomes framework and the commissioning outcomes framework, and the transparency that goes with that, it will become rapidly apparent which GPs require more support. I have no doubt that the consortia or, as we are now calling them, clinical commissioning groups will see it as being in their interests to ensure that the poorer performers are brought up to the standard of the best.
Baroness Hollins
My Lords, I commend the Government on the depth and breadth of the consultation that has taken place. I particularly welcome the new focus for Monitor on integration and the proposed coterminosity of the clinical commissioning groups with local authorities, which is particularly important in the case of commissioning integrated mental health and learning disability services. Does the Minister agree that the changes now proposed can be expected to meet better the needs of people with serious mental illness, learning disabilities and other complex needs than the Bill as originally published, and that the focus on health inequalities will allow the Secretary of State to monitor reductions in them for those vulnerable groups?
Earl Howe
I am very glad that the noble Baroness, with her considerable expertise, raised the important subject of serious mental illness and the needs of those who are particularly disadvantaged. She is right: we now have a much better way forward in commissioning services for those particularly difficult-to-care-for groups, if I may put it that way. How services will be commissioned for those with special needs and serious mental illness will, I think, emerge as we go forward. However, in my own mind I can see that local authorities and consortia may well decide to commission services jointly. There will be the means to do that through pooled budgets and shared arrangements. We will ensure that the quality premium, the details of which are still being worked through, genuinely rewards the ironing-out of health inequalities. We are absolutely clear that one of our goals is to address health inequalities at every level, and that includes in mental health.
Winterbourne View
Baroness Hollins Excerpts(13 years, 7 months ago)
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Baroness Hollins
To ask Her Majesty’s Government, further to yesterday’s Written Ministerial Statement, whether they will ensure that the terms of reference of the serious case review into the abuse at Winterbourne View encompass the question of the appropriateness of placing people with learning disabilities in private hospitals.
Baroness Hollins
My Lords, I declare an interest as a psychiatrist who has spent much of the last 30 years working with people with learning disabilities who have similar needs to those of the subjects of the shocking “Panorama” programme. I am also the carer of an adult man who has a learning disability and whose behaviour at times challenges those who support him. I have also been a policy adviser on learning disability to the Department of Health on two occasions.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the safety and quality of care of those with learning disabilities are of the highest importance. We will discuss the terms of reference for the serious case review with South Gloucestershire Council. We want to ensure that the terms of reference for all of the reviews by the local authority, the strategic health authorities and the Care Quality Commission will give us the evidence that we need to answer the serious questions raised by the events at Winterbourne View. We have asked Mark Goldring, the chief executive of Mencap, to work closely with us in reviewing the evidence.
Baroness Hollins
My Lords, I thank the Minister for his response. The national picture needs to be thought about. This matter is not happening just in south Gloucestershire. I understand that there may be as many as 150 private hospitals. I consider that to be unacceptable given the three decades of work to close NHS long-stay hospitals, which was finally achieved just two years ago. Will the Minister consider reversing the decision to end the employment of the national director for learning disabilities, who, as a policy adviser to the department, could have responsibility for overseeing the implementation of government guidance? The Mansell report gives guidance on how to manage and support people with learning disabilities and challenging behaviour in the community, rather than exporting them a long way from home to private hospitals.
Earl Howe
My Lords, I am grateful to the noble Baroness. She raises some important issues. I am aware that the chief executive designate of the National Health Service commissioning board and the current chief executive of the National Health Service, David Nicholson, will be looking at the whole question of national clinical directors and leadership in clinical care in the coming months.
The noble Baroness is right about care in the community. That has been the direction of travel under the previous Government, as it is now. She will know that many Winterbourne View residents were sectioned under the Mental Health Act and had challenging behaviour, an area I know she has experience of. I believe that privately provided care can be trusted; if the commissioning is right, if regulation is right and if the arrangements for oversight are right, it is not intrinsically less likely that privately provided care will be delivered at the right levels of quality.
Care Homes
Baroness Hollins Excerpts(13 years, 7 months ago)
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Earl Howe
My Lords, that is a rather harsh suggestion regarding Southern Cross. The noble Lord will know that care providers must demonstrate to the CQC that they have the financial resources needed to continue to provide services of the required quality. Clearly, there are lessons to be learnt from this episode with Southern Cross, which we all hope will resolve itself successfully. I am sure the CQC will take on board the lessons. From the briefing that I have had on the financial model that Southern Cross adopted, it is extraordinarily complex even for an expert to understand. We need to get that right. I know that my right honourable and honourable colleagues in the Department for Business, Innovation and Skills will be looking in general at business ownership and the issues surrounding that to see whether there are actions that we can take to prevent this kind of thing happening again.
Baroness Hollins
My Lords, with respect to Winterbourne View, could the Minister comment on why so much public money is being spent on placing people with learning disabilities in private hospitals, when government policy is to support such people in the community?
Earl Howe
My Lords, that falls a little way outside the Question on care homes and Southern Cross. I am sure the noble Baroness knows that Winterbourne View is a private hospital with completely different commissioning arrangements. However, I should be happy to write to her. A Written Ministerial Statement that sets out the full position on Winterbourne View is being put down in Hansard today.
Mental Health: Children in Local Authority Care
Baroness Hollins Excerpts(13 years, 8 months ago)
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Earl Howe
My Lords, with his experience in this area, the noble Earl hits upon some extremely important points. As he will be aware, support for the mental health needs of looked-after children is at its most effective when child and adolescent mental health services, CAMHS, provide dedicated resources to work with looked-after children and their carers with trained and experienced staff. It is up to local authorities to decide the level at which staff should be appropriately deployed. Targeted CAMHS for looked-after children should work closely alongside the child’s social worker, carers and other professionals such as nurses and paediatricians. It is reassuring that data collected over past years for the CAMHS mapping survey by Durham University show an increase from 2003 to 2009 in the number of social services teams and teams with a focus on looked-after children, although those data carry a slight health warning in that participation in the survey, I understand, was voluntary.
Baroness Hollins
My Lords, how much research are the Government funding into the mental health and social outcomes for looked-after children and for adults who were looked after as children?
Earl Howe
My Lords, the noble Baroness may know that NICE and the Social Care Institute for Excellence prepared guidance recently on promoting the quality of life of looked-after children and young people. In doing so, they considered evidence including research reviews, a practice survey, a consultation with young people who have been in care, field work with practitioners and the testimony of expert witnesses. The evidence demonstrated that the health and well-being of looked-after children and young people are affected by nearly all aspects of their lives and care. The noble Baroness may like to know that a detailed list of that evidence is contained in appendix C to the guidance.