Child and Adolescent Mental Health Services

Baroness Jolly Excerpts

Monday 30th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is right about variation, sadly. We had the CQC thematic review on mental health provision at the end of last week, which showed that 80% of specialist in-patient care is good or outstanding but that that is true of only two-thirds of community care provision, with around a third either requiring improvement or inadequate. That is clearly not good enough. Patchy provision is absolutely one of the things that we need to deal with. The best way of doing that is by expanding both the number of children being treated and the size and quality of the workforce, to help us to meet our targets.

[Baroness Jolly (LD)]

According to a Guardian article last month, English CAMHS is struggling to satisfy the rapidly growing demand of referrals. We all know this. Within the past decade, 68% of admissions into hospital because of self-harm were girls under the age of 17. What are the Government doing to decrease the number of young girls inflicting self-harm?

[Lord O'Shaughnessy]

Again, this is one of the most difficult issues. Two hundred thousand people a year are admitted into the health service with self-harming injuries. Twenty per cent of young women under the age of 24 have said that they have self-harmed at some point in their lives—that is one in five. There are now NICE guidelines on self-harm and its treatment and there will be a new care pathway by 2019. However, I do not underestimate how difficult it is to crack this problem.

National Health Service (Pharmaceutical and Local Pharmaceutical Services) (Amendment) Regulations 2017

Baroness Jolly Excerpts

Thursday 19th October 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to move the Motion standing in my name on the Order Paper. I so do because I am very concerned at the reduction in community pharmacy funding, at the very time when we need this precious profession to take on ever more responsibilities. In opening this debate, I take the opportunity to pay tribute to Mr William Darling CBE, the youngest ever president of the Royal Pharmaceutical Society, who died earlier this year. I had the pleasure of working with Mr Darling over many years in the NHS; it was he who brought home to me the hugely valuable role that community pharmacies play in the UK. I, the profession and the public will be ever grateful to him for his immense services.

I should also say by way of introduction that the Secretary of State, under current statutory requirements, was expected to initiate a review of the pharmaceutical and local pharmaceutical services regulations 2013 by 31 August this year. He has not done so because, according to the Explanatory Memorandum, the Pharmaceutical Services Negotiating Committee sought to judicially review the Secretary of State’s decision on pharmaceutical spending and the department decided to await the outcome of the review. Let me say at once that I do not object to that at all or, therefore, to the order. What I object to is the way the department has dealt with the profession over the whole question of funding.

I find it remarkable that a Conservative Government are effectively undermining both patient choice and the role of SMEs in their approach. On patient choice, it was clearly stated by Ministers at a meeting of the All-Party Pharmacy Group last year that the intention was to reduce the number of community pharmacies in this country. Remarkably, the department feels that there is too much choice for patients in our high streets. In effect, the change to funding they are making is reducing the number of pharmacies. The judicial review ruled in the department’s favour, but nevertheless established the legal principle that it is the duty of the Secretary of State to always bear in mind health inequalities when making judgments. The problem in relation to community pharmacy cuts is that the department has not done so; nor does it deliver the more clinical and effective approach that it said it wanted in its letter to the PSNC back in December 2015.

Community pharmacies are the most accessible of all healthcare services. Last year, they had, on average, 137 visitors a day, gave 281 medical reviews and dispensed approximately 87,000 prescribed products. My concern is that the cutbacks or reforms will have a painful impact on thousands of people and therefore need to be thwarted as soon as possible. By reducing the contribution that community pharmacies can make, there is a risk of an increased burden on already pressed GPs and A&E departments.

I remind the Minister of a PricewaterhouseCoopers analysis commissioned by the PSNC in England in 2015. It estimated that community pharmacies contributed £3 billion in value to the NHS, its patients, the public sector and the wider economy. This included £1.1 billion in cash savings for the NHS, £600 million in benefits to patients and £242 million saved in avoided NHS treatment costs. It is rather short-sighted to undermine a profession that can give so much to patients and relieve some of the pressure on a system that, overall, is really suffering at the moment.

The majority of community pharmacies’ funding comes, of course, from the NHS and is used to fund their premises, staff and all other operating costs. My understanding is that this funding was reduced by 4% in 2016-17, with a further reduction in 2017-18, making a total 7.5% drop from 2015-16. Some pharmaceutical contractors claim that the payments to them have been cut by as much as 20%. We know that the Government have brought in some reforms—combining dispensing fees into one, a special funding scheme for pharmacies in isolated areas, a scheme for high-performing pharmacies and a pharmacy integration fund—and I welcome those payments. The problem is, they will not ameliorate the impending crisis faced overall by many community pharmacies.

One of the reasons given by the Government is that they think there are simply too many community pharmacies in some parts of the country. It often seems to me that the Department of Health lives in a world of isolation, ignoring general government policy. I had rather thought that the Government were in favour of consumer choice and therefore having more community pharmacy premises on the high street would be a good thing, not a bad thing. No doubt the Minister can enlighten me on the Government’s view on that matter.

One has to be clear that although Ministers have said they are worried about the number of community pharmacies, the reality is that those cuts will actually affect mainly the smaller pharmacies, which tend to be in the deprived areas. This is the real concern here. The fact is that there is financial instability in the sector. The reduction in NHS funding has led to pharmacies having to face worryingly high and unexpected wholesale bills if they want to maintain an adequate level of stock, which clearly they need to do. They face the potential prospect of banks withdrawing credit because income covenants have not been reached, due to the inability to find a source of credit to cover the aforementioned bills.

In a desperate attempt to keep the business viable, community pharmacies are reducing their services to patients. Because they are having to reduce their staff costs and make staff redundant, they are reducing opening hours and apparently cutting some free services, such as delivering prescriptions to the home, which particularly benefit older people and those with long-term degenerative conditions. We know that community pharmacies were under significant financial strain this summer. We are concerned that as we move into the winter, that financial strain will grow. Of course, it is mirrored by the pressure on the NHS at the moment.

Last year community pharmacies provided 950,000 flu vaccinations. There is a reason for this: it is very convenient. You do not have to wait until the surgery tells you that you can come in one Friday when it is able to give you a vaccination. You can go into a pharmacy and have it immediately. Already this year, community pharmacies have given out 500,000 flu vaccinations—a figure that could double by December. It is just one example of community pharmacies’ huge potential. They could do more—much more—if they were fully engaged in the kind of planning we need to see at local level.

Last night in your Lordships’ House we debated sustainability and transformation programmes. I do not think many STPs have mentioned the contribution that community pharmacies could make to providing services which, otherwise, other bits of the health service will have to. It is a pity because I believe this profession could provide much more support for the system and for patients in the future. I am worried about the impact of the financial reductions that have been made. I hope through this debate to at least encourage the Government to think again. I beg to move.

[Baroness Jolly (LD)]

My Lords, I am happy to lend my support to this regret Motion. For many years, pharmacies have been the lynchpin of our health service. Before the NHS was formed, the pharmacist was the expert who those without means went to for advice and medicine. With the advent of the NHS and a free general practice service backed up by free prescriptions, the role of the pharmacist began to change. The last couple of decades have seen further change. Pharmacists began to reassert their role of offering advice to customers, being commissioned locally and nationally for public health and medicines support.

In 2015 the Government proposed 6% cuts to the pharmacy service and suggested the ways in which this might be achieved, including a reduction in the number of pharmacies and the adoption of internet supply. This was solely a budgeting exercise and lacked any evidence base or indeed impact assessment. The Chief Pharmaceutical Officer suggested that we have 3,000 too many pharmacies without offering supporting evidence.

Apart from the pharmacy being a place where we collect our prescriptions and buy over-the-counter painkillers and cough medicines, the public ask advice from the pharmacist on things they would not trouble a doctor with. Women access emergency hormonal contraception, while needle and syringe programmes are managed, as is the supervised consumption of medicines.

Pharmacies offer specific public health services, support with self-care and medicines support, including checking prescriptions and the New Medicine Service. In addition, they arrange deliveries of prescriptions to patients. That might be stopping in some parts of the country but in Cornwall it is ongoing. In 2015, there were nearly 12,000 community pharmacists dispensing a billion prescription items to the value of £9.3 billion. They are funded by both local and central government to provide essential, advanced and local services.

The PSNC was so concerned at the lack of evidence base for the Government’s decision that it commissioned PwC to look at 12 specific services and determine their net value. In 2015, more than 150 million interventions were made, along with 75 million minor ailment consultations and 74 million medicine support interventions. They also served more than 800,000 public health users, for example with supervised interventions and emergency hormonal contraception. PwC determined that patient benefits totalled £612 million, that the wider societal benefits were £575 million, and that the NHS benefits to the tune of £1,352 million. There are other benefits to the public sector of £452 million. That is a total just shy of £3 billion of benefit which, in one way or the other, comes to us all from having community pharmacists. That is just the financial benefit and does not include the benefit of Joe Bloggs or Mary-Jane being able to walk in and ask their pharmacist a quiet, discreet question and get support, help and advice.

I suggest that when not only our GPs but our A&E services are under immense pressure from patients presenting with conditions that do not require prescriptions or that level of advice, this is not the time to take away from the high street the welcome and expertise of the neighbourhood pharmacist. Will the Minister persuade his colleague to stop, look at the evidence and protect these services which are so vital to the communities they serve?

[Baroness Redfern (Con)]

My Lords, in debating this regret Motion I listened intently to the noble Lord, Lord Hunt. He agrees that more pharmacies should be more engaged and that people should have more choice. I agree with him, but in today lies an opportunity to acknowledge the unique contribution that community pharmacists make to the health and care sector by providing easy access to clinical advice. I refer at this point to my entry as listed in the register of interests.

We should acknowledge that the Government are spending over £150 million a year more on pharmacies than the last Labour Government did, with over 11,500 community pharmacies—up by 18% over the last 10 years—together with the growth in the service budget of 40% over the last decade, to £2.8 billion in 2015-16. We now see over 40% of pharmacies in clusters of three or four, which means that in some cases two-fifths of pharmacists are within 10 minutes’ walk of two or more others. So it is right and proper that the Government are having this review to make absolutely sure that no community, whether in urban or rural settings, will be left without a pharmacy.

I want to pay tribute to the people who work in those pharmacies. In many cases, they are located at the heart of our communities with trusted professionals on-site who reflect the social and ethnic backgrounds of their residents. They are not only a valuable health asset but an important social asset, because they are often the only healthcare facility located in an area of deprivation and play a critical role in improving healthcare. Maintaining community pharmacies is crucial to keeping older and frail people independent. Going forward, we certainly do not want to see those people forced to travel, potentially over long distances, to pick up vital medicines and receive health advice. I very much hope that many rural communities, where travel distances can be a lot longer, can receive some sort of protection to ensure that patients can still access those services.

In 2017, it is right and proper to support a better payment structure and to be more efficient in the allocation of precious NHS resources—particularly by payment for the quality of service, not just for the volume of prescriptions dispensed—and to support the continuous improvement of those services to patients. That in turn will relieve pressure on many other parts of the NHS, particularly with a commitment to a national minor ailments service delivered through pharmacies so that patients who need urgent repeat-prescription medicines will be referred from NHS 111 directly to community pharmacies, rather than a GP out-of-hours service. We need to move from clusters of pharmacies to protect access for patients through a new pharmacy access scheme where there is a higher health need in a particular community.

The NHS has to be much more integrated. Pharmacists can make opportunistic public health interventions and provide advice on healthy lifestyles, thereby preventing or delaying the onset of long-term conditions and fulfilling a commitment to support people to keep healthy outside hospitals within the wider health system and a more integrated approach.

Finally, with the NHS asking for a £10 billion budget increase, there is an overriding need to see reforms to make sure that every pound spent goes as far as it can for patients and for the taxpayer as well. This package of reforms will ensure much greater use of community pharmacies as a first port of call by more fully integrating working with the rest of the NHS so that more people benefit from the skills of pharmacists and their teams. I am pleased that the Government are investing £112 million to deliver a further 1,500 pharmacists in general practice by 2020. I hope this review of the regulations, although delayed, will bring about the beginning of a longer-term transformation of the sector, expanding it to provide public health services such as health checks and immunisations as well as dispensing and selling medicines. There is no doubt that we all want to see a strong future for community pharmacy, but only if we can move with the times, because any delay brings uncertainty.

Medical Examiners and Death Certification

Baroness Jolly Excerpts

Wednesday 18th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is quite right to highlight the pilots; indeed, early adopters have followed in their wake and have provided a much better service. The intention from April 2019 is for the service to cover the entire country, but it is most likely to start in secondary care and then move out into primary and community care.

[Baroness Jolly (LD)]

Changes to death certification are welcome and will impact on bereaved families. How were the general public involved in the consultation?

[Lord O'Shaughnessy]

I think I missed the critical word in the noble Baroness’s question. Did she ask whether the public were involved?

[Baroness Jolly]

I asked how they were consulted.

[Lord O'Shaughnessy]

There was full consultation on the proposals. We have been considering that and will respond to it.

Health: Medically Unexplained Symptoms

Baroness Jolly Excerpts

Tuesday 4th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I am certainly happy to investigate CCG practice and commit to write to the joint panel to make sure it understands both the nature of the classification of the illness and the fact of the NICE guidelines. Of course, those are guidelines for clinicians; they are not mandatory in themselves.

[Baroness Jolly (LD)]

My Lords, the commissioning of mental health services has a chequered past at best, particularly when involving many agencies such as in this case. However, good commissioning practice exists. What training is available for commissioners of such complex services and what opportunities are there for sharing innovative practice?

[Lord O'Shaughnessy]

Of course, a suite of training is available for those treating illnesses such as this one, which affects about 220,000 people in England. It is not a rare disease; unfortunately, it is far too common. That treatment is there and also a number of networks exist, such as the Academic Health Science Networks, to spread innovation and best practice for treatments around the NHS.

Queen’s Speech

Baroness Jolly Excerpts

Thursday 29th June 2017 Lords Chamber

[Baroness Jolly (LD)]

My Lords, as the Liberal Democrat defence spokesperson, I would usually have spoken in response to the Queen’s Speech last week. However, I have a social care issue of which I have given the Minister prior warning and would be grateful for a response, so I am speaking now and understand that I will get no feedback on the defence element.

Last week’s defence debate revisited issues that we have raised again and again these past two years: the 2% of GNP spend; concerns about our shrinking fleet; insufficient equipment to maintain capabilities in the face of growing threats; and all this against a backdrop of concerns over Britain’s diminishing position on the global stage.

Whenever our fleet is reduced, whenever a key military capability is lost, there are howls of indignation from all sides of the House. However, the gradual hollowing out of the Armed Forces through reductions in the numbers of personnel must also be of great concern. Last year, there was a deficit of full-time, trained personnel of about 6,400 individuals, a trend which has seen little sign of abating under the current Government. This means more pinch-points in operational capabilities. This pinch is already felt in specialties requiring key skills such as engineering, but it will be felt right across the Armed Forces should the decline continue. This week, HMS “Queen Elizabeth”, our magnificent new £3 billion pound aircraft carrier, put to sea for the first time. But how valuable an investment will she be if we cannot crew her or her supporting fleet?

For the service men and women still serving, the cuts have been felt acutely. The results of the Regular Armed Forces continuous attitude survey published last month painted a picture of low morale, both personal and within units, which, along with the impact on family and personal life, were the key reasons cited for leaving the service.

The recent report of the Armed Forces Pay Review Body noted that this is due to a “perfect storm”—those are its words, not mine—of pay below the private sector, increasing national insurance, changes in tax credits and increases in rental charges under the new combined accommodation assessment system. Beyond that, service personnel feel the pressure of having to perform difficult jobs without sufficient capacity, which leaves them feeling undervalued and undersupported by the establishment. It is small wonder, then, that there has been a deterioration in perceptions of the Armed Forces offer, as compared with that of the private sector.

The Government’s solution, announced in the Queen’s Speech, is the proposed Armed Forces (Flexible Working) Bill, which would enable flexible working arrangements for regular service personnel. This includes part-time service and limited geographic employment within the Regular Armed Forces. The Bill might go some way to stem the loss of service personnel and it might provide measures that would make the Armed Forces a more attractive prospect for some, but the proposals will not necessarily allow the Armed Forces to maintain current levels of functionality.

I would be interested in seeing the evidence that suggests that the measures in this Bill will be effective. Do any NATO members have similar schemes? Is there a great call for this from families? Furthermore, the Bill does not address the major causes of the lack of manpower. As such, it provides measures only to treat the symptoms of Britain’s ailing defence capabilities but fails to address their causes. Failure to address these deficiencies puts more and more pressure on our service men and women, who make sacrifices for our defence, risking their health and well-being. This truly threatens the security of the nation.

In the Queen’s Speech there is a commitment to improve social care and bring forward proposals for consultations. I am sure many noble Lords here today await these eagerly. I declare my interests as set out in the register. For the last 18 months I have been chair of Hft, a long-established charity which provides services to over 2,000 adults with learning disabilities and employs over 3,000 staff. We pride ourselves on our quality service provision and quality approach to staff. To put this in context, I remind noble Lords that one-third of social care expenditure is on adults with a learning disability—a significant number.

That sector is under threat due to the unintended consequences of a series of employment tribunal rulings, coupled with HMRC enforcement activity, relating to the treatment of sleep in shifts for the purposes of the national living wage. This is forcing employers to fund back-payments for a number of years when everyone involved funded on the understanding that sleep-ins are not covered by national minimum wage legislation.

Many in the sector, including charities and personal budgetholders, do not have the money to fund these payments. The total cost to the sector will be around £400 million. My charity is the first to be called to pay, going back six years, and it has a deadline of 1 September this year. The payment will exceed £5 million. Once this has happened, the issue will go past the point of no return and any solution will be very complex and difficult to achieve. As other providers are required to pay, many will be forced into insolvency and have to return contracts to local authorities. Unlike Southern Cross contracts, these will be unattractive to other providers, as they will contain the six-year back-pay liability.

The key issue is timing and the urgent need to seek a suspension of current enforcement action to allow space for a considered solution. This would prevent the failure of a significant part of the social care sector but requires swift action from government. It cannot wait until the promised November Green Paper on funding social care or the Government’s proposals for consultation. Can the Minister give the sector some assurance that this issue is very high on the list of urgent actions for each of the four ministries involved, and that there is an understanding that this cannot wait until after the Summer Recess?