Gosport Independent Panel: Publication of Report

Baroness Jolly Excerpts

Wednesday 20th June 2018 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I thank the noble Lord for reading out the Statement. I was able to hear only a little of the media coverage in anticipation of the report this morning, but I heard one of the relatives speaking about what she had been through over the past 20 years. It was heartrending. Our thoughts, sympathies and condolences go out to the families of those 450 patients whose lives were shortened and who have campaigned for so many years to find out what happened.

We also pay tribute to the relatives for their determination, tenacity and persistence, and to the parliamentarians and others who have played their part in helping to get the panel established or supporting the relatives who have lost loved ones. I include in this the organisation, Action against Medical Accidents, which helped the families to get inquests and to press for a full inquiry, as it has done on so many of these very difficult, awful occasions.

I finally place on record our thanks to all who served on the inquiry panel and offer particular thanks for the extraordinary dedication and calm, compassionate, relentless and determined leadership yet again of the former Bishop of Liverpool, James Jones, in uncovering injustice and revealing the truth about a shameful episode in our nation’s recent history. In its own words, the panel finally,

“listened and heard the families’ concerns”.

The four key conclusions of the panel were that there was disregard for human life and a culture of shortening lives of a large number of patients; that there was an institutional regime of prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated or justified; that relatives were constantly let down by those in authority in the hospital when they complained; and that senior management, Hampshire Constabulary, local politicians, the coroners system, the Crown Prosecution Service, the GMC and NMC all failed to act in ways that would have better protected patients and relatives.

As the panel comments, patients’ and relatives’ interests were,

“subordinated to the reputation of the hospital and the professions involved … a large number of patients and their relatives understood that their admission to the hospital was for either rehabilitation or respite … they were, in effect, put on a terminal care pathway”.

The report is a substantial, 400-page document published only this morning and it will take some time for us all fully to absorb each detail. I welcome the Government’s commitment to coming back to the House with a full response as quickly as possible. I also welcome the setting up of a hotline and making available counselling provision to those affected and who have lost loved ones, as well as the Secretary of State’s commitment to meeting the families, with Bishop James continuing to act as a link.

Perhaps I may raise five key issues at this stage. First, can any further action be taken in respect of the 200 additional patients whose clinical notes or medical records were missing and who the panel considered to have been affected in a way similar to that of the 450 patients given opiates without appropriate clinical direction or as a result of the prescribing and administering opioids that became the norm at the hospital?

Secondly, on GMC and NMC failures in this matter, does the Minister accept that this underlines the urgent need for legislation to streamline their professional regulatory procedures and responses? In this instance, despite GMC disciplinary action against the doctor involved resulting in her being found guilty of serious professional misconduct, it did not have the authority to overturn the decision of its disciplinary panel not to strike the doctor off the register. I understand that a White Paper on regulatory matters issued by the GMC this week emphasises that, as matters stand, the GMC is operating under a legislative framework that is 35 years old and simply not fit for purpose. A Bill has been sought by this and the other professional bodies and promised by the Government, but we still have had no sight of it. Is it not now vital that such legislation is forthcoming?

Thirdly, on the key question of patient safety, in light of this inquiry, what changes have been made, or will be made, to the oversight of how medicines, particularly opiates, are dispensed in our hospitals? Is the Minister satisfied that oversight of medicines in the NHS is now tight enough to prevent incidents like this happening again? What are the wider lessons for patient safety and the need to build the safety culture in the NHS, and is additional legislation required to keep patients safe? Do the Government now regret the abolition of the patient safety agency? Do they consider that a new independent body is urgently required to pick up and take forward the PSA remit, and will the Minister promise to review this issue? Is there a need for the scope of the draft patient safety investigations Bill to be widened to reflect the learning from these tragic events?

Fourthly, there is the issue of how a proper inquiry in such appalling situations is actually started when there are ongoing police investigations and coroners’ inquests to be held. Delay is built into the system from the outset. It is a key issue that we need to find a way through.

Finally, we have all welcomed the learning from deaths programme set up to build organisational learning on the sorts of failures that we are discussing today. How will the programme assist in helping learn the lessons in this report?

We will rightly acknowledge 70 years of the NHS and the great efforts of our NHS workers every day. On this occasion, however, the system has let so many down and we must all ask why.

[Baroness Jolly (LD)]

My Lords, I shall crave the indulgence of the House for a moment while I read out the first two points in the summary and conclusions of the report:

“In waiting patiently for the Panel’s Report, the families of those who died at Gosport War Memorial Hospital … will be asking: ‘Have you listened and heard our concerns, and has the validity of those concerns been demonstrated?’ … It is over 27 years since nurses at the hospital first voiced their concerns. It is at least 20 years since the families sought answers through proper investigation. In that time, the families have pleaded that ‘the truth must now come out’. They have witnessed from the outside many investigative processes. Some they have come to regard as ‘farce’ or ‘cover-up’. Sometimes they have discovered that experts who had found reason for concern had been ignored or disparaged. Sometimes long-awaited reports were not published”.


I commend my right honourable friend Norman Lamb for having a quiet word with the Secretary of State to ensure that this was moved forward.

This report makes for shocking reading. It hangs on a confusion of responsibilities between two organisations, the NHS and the police force, and there is a multitude of questions to be answered. I shall put only two questions to the Minister and hinge them on two points in the report. The first is paragraph 12.62. Health bodies felt prevented from taking action because police investigations were under way. The report points out:

“All concerned assumed not only that the police investigations took priority, but that they prevented any other investigations from proceeding”.


There is clearly a need to clarify lines of responsibility between the police and the NHS regulatory bodies when there are allegations of wrongdoing and systematic failings of this kind so that organisations simply do not pass the buck. Can the Minister assure me that this work will start?

Secondly, how will the Government take forward the call for action in paragraph 12.60? I welcome the Minister’s commitment to an independent inquiry in future in such circumstances to be carried out by the police force, but the report states that,

“the evidence … suggests that, faced with concerns amounting to allegations of unlawful killing in a hospital setting, there are clear difficulties for police investigation. It is not clear to the Panel how the police can best take forward such investigations, and how they are to know whose advice to seek from within the health service without compromising their enquiries. This is … significant if the problem concerns the practice on a ward where more than one member of a clinical team is involved. It is a need that calls for action across different authorities, rather than a matter for the police service in isolation”.

We cannot guarantee that something similar to this could not happen elsewhere—please God that it does not—but what action will be taken to ensure that there is not such a muddle and confusion in a resolution? What processes are either in place or being put in place within NHS settings and with police forces to make sure that this does not happen again?

[Lord O'Shaughnessy]

I thank the noble Baronesses, Lady Wheeler and Lady Jolly, for their very perceptive questions—as ever. First, I extend my personal sympathies to the families and join my right honourable friend in expressing our apologies on behalf of the Government and the NHS for what has happened to them and their relatives. Like the noble Baronesses have done, I pay tribute to those families and all the others who have fought so tirelessly in seeking justice. As has been acknowledged, we owe a huge debt of gratitude to Bishop Jones and his panel.

The story told in this report is of a litany of failure across many institutions, which often had very closed cultures. Unfortunately, those piled on to one another across many different agencies of government, which is what created that highly unacceptable cover-up for so long. It is about getting to the bottom of that culture. Let us face it: unfortunately these circumstances are not unique. We come across this in different parts of our society all the time, and we need to get to the heart of that closed culture to lead to a culture of accountability and transparency.

The noble Baroness, Lady Wheeler, asked some specific questions, including about the 200 additional patients without notes. Clearly, further investigation is warranted because we need to substantiate that claim. It is obviously one of the work streams that will be going forward. She asked about streamlining professional regulation, given the obvious inadequacies of the GMC and NMC regulators during this process. As my right honourable friend the Secretary of State said, every part of government needs to look to itself with great honesty about what we need to do to put in place the right environment to prevent this happening again. I think we all agree on the need to move forward to streamline professional regulation. It is not something we have yet been able to do, but the tragic news we have been discussing today gives that fresh impetus. It is clearly something we will be looking at.

Patient safety is a great passion of the Secretary of State. There were changes in the oversight of medicines, particularly opioids, after the Shipman inquiry. The noble Baroness raised some good questions about whether there is a need for an independent body, or whether in the Health Safety Investigation Branch we have that body but its remit needs to be reconsidered as part of the Bill going through. I am sure that we will be doing that.

The noble Baronesses, Lady Wheeler and Lady Jolly, asked about the issues around inquiries. One of the things that has been exposed here is that there were overlapping inquiries that were impeding each other or preventing one another moving forward. Making sure that there is a clear process for how that ought to take place when someone—a family member, a staff member, the police—has raised a concern is something we have to get to the bottom of because that bureaucratic muddle was clearly at the heart of the delay and, because of the delay, more people died unnecessarily. It is not just a case of clearing things up and making them neater; it has a massive impact on harm.

The learning from deaths programme is a big step forward. It has been taken into many bits of the health service already. It is now moving into the primary care area. Trusts are already obliged to publish deaths that ought to be in the scope of mortality reviews. From next April, all non-coronial deaths will be subject to investigation by medical examiners. That is yet another part of the patient safety environment that we need to put together.

Going beyond that, there are clearly some very challenging questions that the criminal justice authorities, coroners, the Home Office, the Department of Health and Social Care and all parts of government need to ask themselves to see whether they are really doing everything they need to do to provide a safety net to make sure that when things go wrong we find out about them quickly, we stop them and we learn from them. In the next few months, as we move towards publishing a plan for what we should do next, it is imperative that all Members of this House and the other place, who have great contributions to make in this area, feel free to engage with this process and make their recommendations to it, so that when we report we have done as thorough and comprehensive a job as we possibly can so that we can prevent these tragedies happening again in future.

Branded Health Service Medicines (Costs) Regulations 2018

Baroness Jolly Excerpts

Wednesday 20th June 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this slightly interesting regret Motion.

It is clear that the issue at stake is the appropriate treatment of hypothyroidism. We have to trust clinicians to prescribe based on what they consider is best for their patients, as the noble Lord, Lord Turnberg, said. I have done an awful lot of reading about this over the last few days, and, although it depends on which article you read, it seems that a significant number of women have this condition: one figure I was given was 10%. In fact, for the last 25 years I have been diagnosed as hypothyroid. I take T4— levothyroxine—which is cheap as chips and costs the NHS about £1.30 every month. But of course, not everybody responds to that, and the alternative is the very much more expensive T3. Some 10% to 20% of patients diagnosed with hypothyroidism come into this category. It is therefore important that the patient receives the right drug. We have heard completely unacceptable tales of patients, as a result of decisions made by clinical commissioning groups, surfing the internet to see what they can get. I did exactly the same last night—having a look to see what I could get—and, again, the T3 was ridiculously expensive, whereas T4 was hardly worth buying online as you could get it very much more cheaply.

What is to be done about this? I was going to explain what it is like when you develop hypothyroidism, before you are diagnosed, and so I thank the noble Lord, Lord Borwick, because his description was lovely: “pathetic, befuddled and exhausted”. I went to see a doctor because my brain was in a fog. I explained it to him and he said, “What do you expect? You work full time and you have two toddlers”. So I was sent away. Curiously enough, at a family event—a lot of my family are doctors or nurses—my mother-in-law asked me, “How long have you had a thyroid problem?” and I said, “I didn’t know I had a thyroid problem”. I went to see my GP, who said, “No, you haven’t got a thyroid problem at all. Who said you had one? Gosh—what does a paediatrician know about it?” Eventually, I had to leave my practice and go to another one to get a diagnosis. I am sure that that is not normal, but it was quite an interesting experience for me. Since then, I have been as fit as a flea. The medication works like a magic charm; very quickly you feel normal and well again. So I cannot overstate to Members of your Lordships’ House how important that prescription was.

I emphasise to the Minister what other noble Lords have said today. We must use the purchasing power of the NHS to drive down the costs of T3 in order to make the argument go away. That might be done by effective negotiation, as the noble Lord, Lord Lucas, said, or in another way, but it is completely scandalous that patients have to buy their own drugs online, and CCGs should therefore review or rework their guidelines as a matter of urgency. Drug companies must not hold the NHS to ransom over the cost of medication that will make patients feel absolutely well again.

On the issue of the costs of medication, one of the non-medical side-effects of having a diagnosis of hypothyroidism was that any other drug I had became free. It is on a list of conditions which, if you have them, mean that any other medication you need becomes free. At that time I was in my early 30s and working. It was very nice to have free prescriptions; I tried to pay for them but they would not let me. However, it means that for the NHS, an awful lot of money is spent inappropriately. Can the Minister give an indication of whether the department has any indication of how much this costs the NHS? I am happy for the NHS to pay for my levothyroxine, but it should not have paid for all other medication I was in receipt of—although, now that I am old, it comes free anyway. How sustainable is this in the current climate, and when was the principle last reviewed?

My takeaway issue for all this is that, whatever happens, we should ensure that the cost of T3 is driven down. However, I would also like the Minister to take this other issue away and—not as a matter of huge urgency—come back to me with some answers.

[Baroness Wheeler (Lab)]

My Lords, I thank my noble friend for tabling this Motion and for his excellent speech setting out the concerns we all share about NHS patients getting access to the drugs they need and how a number of CCGs are in effect placing a ban on expensive branded medicines—in this case ignoring NHS England’s advice concerning T3 in the treatment of hypothyroidism. I look forward to the Minister’s response to the key questions put forward by noble Lords on this issue.

The Motion has the full support from these Benches. I also commend the work of the British Thyroid Association and Thyroid UK in highlighting this issue, and the very helpful information on their websites, as well as the expert explanation from my noble friend Lord Turnberg on hypothyroidism. The websites include case studies of patient voices which clearly show the impact and suffering of patients who are either denied T3 or who are taken off it because of a decision made by their CCG. It is especially upsetting when patients who have successfully taken the drug for a number of years suddenly have to go back on to a drug, mainly T4, which they already know does not provide them with the treatment they need or will make them ill again. The case studies refer to both the T4 drug and the natural desiccated thyroid—NDT—drug, which I understand is the treatment given before T4 came on to the market but which is not now available in the NHS as it has to go through the Food and Drug Administration process, and it is not known when the branded NDT products will be licensed.

My noble friend and other speakers described their concerns over current CCG decisions that go against NICE guidelines and the advice of NHS England, and the increasing rationing of key services, so I will not repeat them and will await the Minister’s response. The NHS England recommendation and guidance on T3 needs to be clear and unambiguous. I hope that the Minister will acknowledge the confusion and concerns, and will ensure that NHS England informs CCGs that they must both comply with their guidance and amend it to end the scope for CCG misinterpretation. I hope that he will also acknowledge that access to T3 on the NHS is a matter of urgency for many patients and that he will give serious consideration to the call from Thyroid UK and ITT for the procurement of T3 from outside the UK for NHS prescriptions until its UK cost comes down.

On the regulations, I note paragraph 4.7 of the Explanatory Memorandum, which deals with provisions of the Health Service Medical Supplies (Costs) Act 2017 that have been included. This includes the promise of the annual review of the operation and objectives of the statutory scheme which is to be published and put before Parliament. Can the Minister tell the House what the current thinking is in terms of the review process and timing, and say when he would expect the first review to be completed?

The impact assessment also states that the implementation of these regulations will generate a saving of £33 million to the NHS between April 2018 and March 2019. The Department of Health and Social Care says that this will enable the provision of additional treatments and services estimated to provide NHS patients with an additional 2,213 quality-adjusted life years, valued at £133 million. Can the Minister explain to the House exactly how the Government have calculated the savings, and can he give more details of how this money is to be spent in the NHS?

The Explanatory Memorandum also says that the regulations set out other instances when the Secretary of State can give a direction specifying the maximum price of drugs—for example, when there are supply issues with respect to a particular branded health service medicine and the Secretary of State is satisfied that a new temporary minimum price needs to be provided to help resolve the supply issue. Can the Minister explain to the House how the Secretary of State is to decide on the temporary minimum price?

Finally, in respect of the provisions in the regulations for manufacturers and suppliers to pay 7.8% of their net sales income to the Government, the impact assessment provides for those in the PPRS with annual NHS sales above £5 million to make percentage payments based on the difference between allowed percentage and actual percentage growth in NHS expenditure on branded medicines. Can the Minister provide more clarity on how this 7.8% figure has been reached?

Long-term Plan for the NHS

Baroness Jolly Excerpts

Tuesday 19th June 2018 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for repeating this Statement. I also declare an interest as a member of a local clinical commissioning group.

It would indeed be churlish to say that an injection of funding into our NHS is not welcome right now. However, the 70th birthday present is an uplift in funding of below the 60-year average—from 1948, the birth of the NHS, to 2010, it is just on 4%. Of course, we would all, not least the patients and staff, welcome not having to face another winter crisis like the one we have just had. After what, I suspect, were some serious tussles within the Government about quantum, timing and explanation of where the funding will come from, the Minister and his colleagues must be a little disappointed in the headlines that have been generated so far. The IFS said, with respect to the Brexit dividend that,

“over the period, there is literally zero available”.

Sky News has done a data poll which suggests a majority of people do not believe there will be a Brexit dividend to help to boost NHS funding, a reaction made more unpalatable to the Government because the same polls show that a majority of people, 54% to 38%, say that they would be happy to pay more tax to fund the NHS, which we in the Labour Party have known for quite some time. In 2002, when the then Prime Minister Tony Blair made a commitment to massively increased funding to the NHS, he also announced an increase in national insurance to pay for it. He and then Chancellor Gordon Brown had spent two years preparing for that announcement and preparing the plans for the investment in the NHS that was necessary to turn it round from the previous 18 years of Conservative neglect and underfunding and to deliver the waiting list targets, cancer treatment targets and A&E targets which then followed. So when Theresa May says, as she did over the weekend, that Labour spent only half of the increased expenditure on patient care, that is completely misleading and plain wrong. If she means that replacing falling-down buildings and worn-out equipment, paying staff decent wages, and investing in massively increasing the number of doctors and nurses available is in some way not spending money on patient care, one has to question the right honourable lady’s understanding of what the NHS is and what it does.

Leaving aside the issue of how the £20 billion will be raised, we do indeed need to address how it can best be spent. We recognise that it will take time and planning to work out how to make the best use of this funding over 10 years. The challenge is huge because the prevailing state created by a combination of cuts for both health and social care, and the overcomplex bureaucracy of the NHS as a result of the Health and Social Care Act, make this a serious challenge. Waiting lists of 4 million last winter in the NHS were so severe it was branded a humanitarian crisis. Some 26,000 cancer patients are waiting more than 60 days for treatment. There have been billions in cuts to local government and social care.

My questions to the Minister start with three basic ones about the legal obligations of the NHS. These were also asked by my honourable friend Jonathan Ashworth. Will the waiting list for NHS treatment be higher or lower this time next year than the 4 million it is today? This time next year, will there be more or fewer patients waiting more than 60 days for cancer treatment? This time next year, will there be more than 2.5 million people waiting beyond four hours in accident and emergency or fewer—a target not met since 2015?

If the Secretary of State wants, as he says he does, to transform the health and social care system, how will he do this when every economic expert, from the Institute for Fiscal Studies to the Health Foundation, tells us that with a growing ageing population—which the Minister mentioned—increasingly living with long-term conditions, this announcement will do nothing more than see the NHS stand still? As my honourable friend Liz Kendall put it yesterday:

“We cannot put the NHS on a steady financial footing without a proper funding settlement for social care, yet the Secretary of State now says that that will not happen until the spending review, which in reality means no substantial extra money for social care until 2020 at the earliest. We cannot transform care for older people or reduce pressure on the NHS until we look at the two together”.—[Official Report, Commons, 18/6/18; col. 63]


Why are the Government still ducking that vital integration issue?

Why is the social care Green Paper delayed yet again, and how can this funding be used to mitigate the £7 billion in cuts and 400,000 people losing care support? How will the Government bring together health, social care, parity in mental health and the essential preventive work of public health, when they are scattered across different delivery bodies, often with differing commissioning regimes and accountable sometimes to different regulatory regimes? How will that be done under the proposals for the 10-year plan? Will this injection of funding ensure that we have a service with new models of care fit for the 21st century? Finally, we have a £5 billion repair bill facing our NHS right now, and outdated equipment. When will the Government start investing in the fabric and equipment of the NHS?

[Baroness Jolly (LD)]

My Lords, I too thank the Minister for his Statement. I welcome any increase in funding. Should the Chancellor be wondering how to pay for it, we on these Benches would be quite happy to see a 1% increase on income tax, for starters. The IFS has said that increases of close to 4% are needed for social care, as well as a funding boost for the NHS. Yet the Statement had nothing to say on this vital issue. We all know that the NHS cannot function efficiently unless social care is working well too. Many local authority leaders are indignant that the Green Paper has been moved further down the track, so when the new funding does arrive there is already a sizeable deficit to claw back. They are extremely anxious about the situation with adult social care funding being insufficient for this financial year.

What conversations have been held with the LGA, local council leaders and the Ministry of Housing, Communities and Local Government in advance of these statements? We are also dismayed about the silence on mental health, public health and community health funding. One in four of us will be affected by mental illness, there is an obesity epidemic among our children, too few health visitors, and we are critically short of psychiatric social workers. Is the Minister confident that these issues can wait until the autumn NHS plan and the Budget?

[Lord O'Shaughnessy]

I thank the noble Baronesses, Lady Thornton and Lady Jolly, for their questions. I think that our debate on the report of the Lords Select Committee on the sustainability of the NHS and social care was revealing, in that we got a hint that, while the settlement would receive a broad welcome across the House, the party opposite might not be in quite the same positive mood, and, unfortunately, we have had that confirmed today. Perhaps that might generously be described as a cautious welcome.

The noble Baroness asked about the funding of this settlement. We were very clear yesterday that it will come, effectively, from three sources: from taxation, from economic growth, and from the fact that, as we are leaving the European Union, we will not be paying annual subscriptions any more. It will be a combination of those factors that determines the spending. Indeed, the Treasury is confident in that, and it would not have signed off this deal if it had not been.

On the noble Baroness’s specific questions about the legal obligations under the NHS constitution, actually the money that was given to the NHS at the Budget was to help it to get back on target—in the case of A&E, by the end of this financial year and, for elective procedures, to halt the growth in the expansion of the waiting list. Clearly, one of the reasons for this settlement, which is set out explicitly, is to get back to those key standards, which we know are the yardsticks by which people judge their everyday experience of the NHS.

On the point about there not being enough money, there can always be arguments for more, but it is instructive that two former Health Ministers, one from the Labour Party and one from the Conservative Party—my noble friend Lord Prior and the noble Lord, Lord Darzi—set out last week that they felt that 3.5% was the right figure, which we have got very close to. We should take the suggestion of those two very experienced and knowledgeable former Health Ministers as a good yardstick for our achievement.

The noble Baroness asked about social care funding, as did the noble Baroness, Lady Jolly. The intention behind the delay in the Green Paper—which I recognise is a source of regret for people in this House and elsewhere—is to make sure that integration, which we all agree has got to be at the heart of this 10-year plan, actually happens in planning terms and policy terms as well as in announcements and delivery. That is why there is that co-ordination between the two. Again, it is worth stating that, over the current three-year period, at previous Budgets an extra £2 billion was put into the social care budget, which is rising now for the first time in a number of years, and that is obviously important as we put together that long-term solution.

Finally, let me deal with two other points. On the repair bill and the capital settlement, again at previous Budgets the Chancellor has pledged £10 billion through a number of sources towards the capital settlement for the NHS, but we are expecting the NHS, through this process, to come forward with long-term, multi-year capital proposals, because clearly that underpins so much of the transformation.

In terms of the impact on other elements of the broader health budget, mental health is included in there, including a clear commitment to deliver on parity of esteem within this period. Public health and community health will be dealt with in the next spending review process, which will be happening in the next year. Again, there are clear commitments that there will not be additional pressures, if you like, created for the NHS by what happens to the public health and social care budgets in the future. Ahead of a spending review process, that is a clear indication that there is not a desire to create trouble, if you like, in those budgets that would land at the feet of the NHS.

Chronic Lymphocytic Leukaemia: Ibrutinib

Baroness Jolly Excerpts

Thursday 7th June 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, the NHS constitution states that patients have a legal right to,

“drugs and treatments that have been recommended by NICE for use in the NHS”.

At the moment, in England, there are many men and women who have cataracts that are deemed by NICE as being ready for operation and for replacement, but the CCGs are refusing to commission and they are having to wait longer and longer. Can the Minister shed any light on this?

[Lord O'Shaughnessy]

I am afraid I do not know—it is a slight handbrake turn on the topic. I would of course be happy to meet the noble Baroness to discuss this issue; I was not aware of it, but I will happy to investigate it for her.

Psychiatrists: Referral Fees

Baroness Jolly Excerpts

Thursday 7th June 2018 Lords Chamber

[Lord O'Shaughnessy]

If these allegations are substantiated, there must obviously be serious consequences for the doctors concerned and clearly it is right that the GMC investigates that. In terms of the noble Baroness’s overall question, there is of course local authority-commissioned alcohol and drug treatment available; it does not need to be purchased privately. More generally, in terms of mental health support, she will know that there is a commitment to recruit 21,000 more mental health staff and that, through the new mental health investment standard, CCGs have to continue increasing their mental health spending year on year.

[Baroness Jolly (LD)]

My Lords, is there any evidence to suggest that these are isolated cases or more common practice?

[Lord O'Shaughnessy]

We do not have any detail on further cases at this point. Of course we would always welcome any evidence, as would the GMC, in order to investigate that. It is important to point out that doctors are revalidated medically every year and fully revalidated every five years. In that process, they are asked to demonstrate that they have stuck by the ethical guidelines in the GMC practice and, if any evidence alights contrary to that, it would put their registration at risk.

Health Inequality: Autism and Learning Disabilities

Baroness Jolly Excerpts

Thursday 10th May 2018 Grand Committee

[Baroness Jolly (LD)]

My Lords, I too thank the noble Lord, Lord Touhig, for introducing this debate. I declare my interest as listed in the register.

People who have never been involved with learning disabilities are unclear about what they really mean. People with a learning disability will have the emotions of an adult—they can fall in love, worry, get cross and be jealous—but it is the reduced intellectual ability that affects them for their whole life. They are subject to mental health problems and early-onset dementia.

Learning disability is subject to the Equality Act and the United Nations Convention on the Rights of Persons with Disabilities. Somebody with a learning disability should be able to expect good NHS treatment. They should also expect clinicians caring for them to make reasonable adjustments. In the questions after yesterday’s Statement, I raised the issues of funding, clinician training and the provision of suitable written material, and I will not revisit them now. However, I should like to raise the issue mentioned by the noble Lord, Lord Crisp—access to NHS sight tests.

People with a learning disability are at high risk of sight problems. Adults are 10 times more likely to be visually impaired and six in 10 will need glasses. Most people think that sight tests are easy to access, but for many people with more complex needs they are not. No targeted scheme is run by the NHS or NHS England, unlike GP health checks or special dental care. For years, the same tariff of around £20 has been paid by NHS England to deliver these sight tests. This covers about half the cost of a standard high-street test, let alone the service that someone with more complex needs requires.

The outcome is that many people with learning disabilities are instead sent to use the sight-testing services at hospital eye clinics. Without any national scheme, parents are at a loss as to where to go. Half of the children in special schools have a vision problem. Around 45% of children of the age of 11 in a special school will not have had a sight test. This makes for a poorer quality of life than would otherwise be the case. Therefore, will the Minister look at whether an NHS England scheme in the community and in special schools, which four in five children with more severe learning disabilities attend, is a possibility?

As I mentioned, people with learning disabilities have rights, and this lack of appropriate treatment is an unacceptable face of discrimination. Therefore, will the Minister please investigate this and get back to us? I might also suggest that perhaps a much longer debate than this one is required on this well-ignored group.

Learning Disabilities Mortality Review

Baroness Jolly Excerpts

Wednesday 9th May 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Baroness for her questions and agree with her that it is a troubling report; it paints a troubling picture of the shockingly poor outcomes that people with learning disabilities have in terms of their mortality and morbidity. I would not disagree with her about that picture and I will come to the actions we are taking to try and address it.

On the publication, I agree with her that the timing was less than ideal. The department did not have sight of it; it was an independent report commissioned by NHS England. We are investigating that, but I agree it was not done as it should have been and we will endeavour to ensure that this does not happen again. On the areas of policy that she referred to, on out-of-area placements there is a programme called Building the Right Support, which is trying to increase the amount of care delivered in community settings, bringing people with learning difficulties, disabilities and autism out of in-patient care to more suitable care in the community. The intention is to reduce the use of in-patient beds for people in mental health hospitals by 35% to 50% between March 2015 and March 2019. It is an attempt to locate much more of that care in the community.

The noble Baroness also asked about other actions we are taking to improve outcomes. I want to focus on the annual health checks that are now available for adults and young people from 14-plus years. That is happening every year. We know the use of these checks is increasing; it has increased by 17% year on year up to 2017-18. There is a real ambition to raise that further by 64% in 2018-19 compared to 2016-17. We know this group does not always feel equipped to come forward and bring health issues to the notice of the health system. It needs extra support; it needs people to be on their side, checking in with them to make sure their issues are addressed. I think this is one way in which we will make some difference.

[Baroness Jolly (LD)]

My Lords, I declare my interest as chairman of a learning disability charity that provides services for 2,500 adults in England. This report makes for uncomfortable reading for anyone involved in the sector and it should shock the general public. We are judged by how well we as a society care for those who are weak and vulnerable. On this count, we have failed. Each year, the deaths of 1,200 people with learning disabilities are avoidable. The standard of their care is not fit for purpose. There are not enough learning disability specialist nurses in the NHS and support staff are no longer being funded to support people with a learning disability in a healthcare setting.

I have three questions for the Minister. Do either the Department of Health and Social Care or Health Education England collect figures on how many health professionals attend training in dealing with people with a learning disability? What guidance is given to staff about the provision of written material in an accessible format? Finally, once admitted, learning disabled patients lose their funding from the local authority so they have no one who knows or understands them and they are left frightened and alone. Does the Minister believe this should be the case?

[Lord O'Shaughnessy]

I thank the noble Baroness for raising excellent questions. We know that there is a need for more specialist nurses, and indeed that is one reason for the expansion of the number of nurse training places. The education and training of staff is a focus of the recommendations of this report and, equally, of the Mencap report. If noble Lords have not read that, I commend it too. Because it is a very good point, I will look into whether we are tracking the number of people who access training. Certainly there is now, and has been since 2016, an education and training framework for the care of people with learning disabilities. I believe that there is also one to follow for adults with autism, and that is welcome. However, as the noble Baroness says, it is about making sure that the staff use that training.

On the noble Baroness’s point about advocacy, I did not realise the funding issue that she raised existed. I will take that back and investigate it. I know that NHS England, the LGA and the Association of Directors of Adult Social Services have put out joint guidance on advocacy for this group of people, but I will investigate the funding point and write to her.

Health: Cancer Nurses

Baroness Jolly Excerpts

Wednesday 2nd May 2018 Lords Chamber

[Lord O'Shaughnessy]

I do not believe that nurses would have fallen into that category as nursing is named as a shortage profession in the immigration system, but I would have to check those figures and I will write to the noble Baroness.

[Baroness Jolly (LD)]

My Lords, the failure to screen nearly half a million women for breast cancer is a scandal. When it is coupled with the report of Macmillan Cancer Support, it has really been a bad few days for cancer. Immediate action is required on both counts. Is it the Government’s view that this shortage of cancer nurses is due to local budget constraints or to workforce planners’ failure to act on the demographic trend of the ageing workforce?

[Lord O'Shaughnessy]

My Lords, regarding the Statement made by my right honourable friend the Secretary of State earlier today about the errors in the breast cancer screening programme, I take this opportunity to apologise wholeheartedly and unreservedly on behalf of the Government, Public Health England and the NHS for the suffering and distress that has been caused to women by this flaw in the screening service. We will have an opportunity to discuss this at greater length tomorrow, when I will repeat the Statement.

The shortage that has been described is based on an analysis of vacancy rates. The number of cancer nurse specialists has actually increased by 1,000—that is 30%—in the last three years alone. That is a huge increase. Of course we know that we need to do more, but it is worth recognising the great steps forward that we have made in cancer treatment in this country.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Jolly Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I join all Members in the House today in congratulating the noble Lord, Lord Patel, and his committee on an excellent report, which came with a list of three dozen recommendations. I also share the anxiety expressed by some Members of the House about the quality of the government response. To wind up this debate is difficult because it has been so rich. People have brought to it their personal experiences as clinicians, as experts and even as patients. That has made the debate very broad so I shall try to narrow my remarks to just a few areas.

When the NHS was formed, in 1948, no one could foresee a world in which people were living longer and much care was taking place outside of hospitals. To tackle the demands facing our health and social care sectors today we need still to innovate and change and to develop a patient-centred model of care. In recent years, the NHS has halved the number of hospital beds, and it is estimated that with more efficient care half of patients currently in hospital could be treated at home or within their community.

Much has been said about joint working and integrated care, and here technology can really help. I think the noble Baroness, Lady Redfern, was the first person to mention data. Having common datasets by which NHS computers can talk to social care computers was seen as part of the solution to this very problem of integration when I first became involved in the NHS, 20 years ago. As an aside, my noble friend Lord Rennard might wonder why the NHS uses a fax machine to talk to itself but apparently security is the issue: it is the most secure way of communicating between NHS establishments and regular telecoms are not up to the task. We need systems that work together to smooth the transition from primary care to hospital to social care services, and reduce cross-referrals and delays—the bumpy departures and landings to which the noble Lord, Lord Carter of Coles, referred. I hope the Minister will be able to give us some indication in his summing up of where we are with this particular piece of the integration jigsaw and other ground-breaking digital innovations.

To do all this, we need money. To have care that is oriented towards the future, we must have a properly funded and integrated framework for health and social care. This is to be seen not as government expenditure but as investment. There will be payback: in increased efficiency, better care and improved patient satisfaction. Both health and social care have suffered from ebbs and flows of funding depending on the direction of the political wind, and we must endeavour to change that. In the social care sector alone, real budgets have fallen by nearly a quarter and brought the sector to near collapse, while in the NHS hospitals are overstretched and underprepared to combat the annual winter crisis, which seems to be all year round. The noble Baroness, Lady Watkins of Tavistock, reminded us that social care involves not just old people. It includes people with a disability, whether it is a learning disability or a physical disability, and, as she mentioned, children. Both systems are in need of rescue and reform in order to serve future generations. Without proper funding levels, we cannot expect to effectively implement cost savings that would arise from the integration of care services, and we run the risk of seeing money targeted for innovation and changes to our services go towards merely keeping our NHS afloat.

At the local government level, council taxes are at the highest levels that could realistically be sustained, and the opportunity to add a discretionary amount for social care is now widely acknowledged as a flawed policy. The challenge at local government level is commissioning. A move to outcomes-based commissioning is slow to be embedded but would bring transformational change to service delivery. An example of that came in the debate today from the noble Lord, Lord Colwyn, who is a dentist. I did not expect such an example to come from the area of dentistry, but he made the point perfectly that if you commission for outcomes, you will get a better service.

Sustainability and transformation plans should prepare our system for the future and should be given the financial investment needed to see services change with the times and produce quality results for patients.

We on these Benches believe that proper NHS funding can be accomplished through bringing our health expenditure in line with other nations and by providing a ring-fenced integrated budget for health and social care that would be kept separate and defined for a 10-year period. This would allow the NHS, care providers and local communities to prepare for long-term needs, together with a plan that they can implement. It would remove short-term thinking on health and social care budgets and create a sector that is looking forward to the future instead of being occupied with daily crises.

The noble Lords, Lord Kakkar, Lord Willis, and Lord Carter, and the noble Baroness, Lady Finlay, and many others, mentioned the acute workforce shortage, which must be the single greatest threat to our health sector. To begin solving this we need to train new workers while protecting the immigration status of foreign-trained staff already here. As we come up to 70 years, we must also acknowledge our debt to the Windrush generation—the people who came from across the Commonwealth to help us set up the NHS to become what it is now.

In order to have a functional health and care service we must continue to support health and care workers, who will be absolutely critical to the way we work in any future model of care. I welcome the Government’s shift on nursing pay, but in the current climate perhaps the Chancellor might consider a further uplift.

Health and care workers feel the pressure of caring for an ageing population and have remained committed to giving their services, even in the face of long hours and stagnant wages. In the long run, however, this will not be sustainable. The health and social care workforce is facing a tremendous gap in the number of workers, which we urgently need to address.

The noble Lord, Lord Willis, mentioned nursing associates. Before this debate I was speaking to members of a delegation from Kent. They were anxious about the nursing crisis in Kent. They mentioned nursing apprenticeships and asked me whether I was aware that there were no nursing apprenticeships at all in Kent. I confessed that I was not aware of that. Can the Minister give some indication of the uptake of nursing apprenticeships, and of the number of nursing associates, in England?

It is time to consider care work as a profession, which may well include regulation. For the most part, care workers work on the basic minimum wage. They often train in their own time and at their own expense and work unsocial hours with a difficult client group. They can always go to the supermarket and work for the same number of hours with less hassle—but they do not. They have a commitment and a love of the job and, as a society, we take advantage of that. So I hope that the Green Paper, in addressing the cost of care, will look at a model where their commitment and professionalism are recognised. We can then work to attract new care workers through providing regular performance-related pay rises and flexible working conditions to those who need them. Will the Minister tell the House how his department is involving partners in the preparation of this Green Paper and who represents the voice of the care workers? I would be grateful if he told me it is not care providers.

The picture with doctors is not hugely better than that for nurses. Yesterday, many of us received information from the Royal College of Paediatricians expressing alarm at the number of doctors on duty at any time. Nearly three-quarters of all medical specialties had unfilled training posts in 2016, with the number of applications to our British medical schools decreasing for the third year in a row, and by more than 13% since 2013. Fewer trainees are moving directly into speciality training, instead choosing to take a career break. Will the Minister give an indication of the attrition rate at this stage? What remedies are being considered to keep these hugely expensive to train professionals in the UK at the early stage of their careers?

This has been an excellent debate on an excellent report. I hope that as a House we will continue—I am sure we shall—through questions and debates to understand the Government’s thinking and to influence their direction in this area.

Domiciliary Home Care Support

Baroness Jolly Excerpts

Wednesday 25th April 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend is right to bring up that issue. They should of course be paid. If she has any specific examples to share with me, I shall be glad to investigate.

[Baroness Jolly (LD)]

My Lords, everyone knows that the social care sector, particularly in domiciliary and care homes, is under great stress at the moment—I declare my interests as in the register—and we look forward to the Green Paper coming up some time in the summer. I hope it takes into consideration that such homes need to pay not only wages and pensions but, for larger ones, an apprenticeship levy. Normally there would be a market for mergers but at the moment the sector is anxious about inheriting sleep-in liabilities. Can the Minister give any guidance about when these issues within the department and the Treasury will be remedied?

[Lord O'Shaughnessy]

We know that the issue of back-dated pay for sleep-ins has had an impact on this and other sectors. Two aspects of this are, first, that the Government have waived penalties for non-payment prior to July 2017; and, secondly, that there now exists an HMRC scheme that allows providers to work with HMRC and the business department to understand their liabilities and gives them a further year to pay them. That is the support we offer to any organisation affected by the changes to the taxation arrangements of sleep-ins.