NHS: Out-of-Hours Services

Baroness Masham of Ilton Excerpts

Monday 29th July 2013 Lords Chamber

[Earl Howe]

I am sure that I speak for all of us in saying how pleased I am that the service worked so well in the noble Lord’s case. The answer to his broader question is that the service is working well in the vast bulk of the country. Unfortunately, in two particular areas we have seen problems, which are being gripped, and I am confident that NHS England has taken these issues forward with the seriousness that they deserve. I am assured that, even in the areas where problems have arisen, the service is good.

[Baroness Masham of Ilton]

Would it not have been simpler to build on NHS Direct, which would have saved confusion?

[Earl Howe]

The difficulty there was that we were more ambitious than simply wanting a revamped advice service. This is a service that puts a patient directly in touch with a doctor if they need one, a nurse if they need a nurse, or an ambulance if they need an ambulance, without the need for call-back. It is also free of charge, which the old NHS Direct was not.

Care Bill [HL]

Baroness Masham of Ilton Excerpts

Monday 29th July 2013 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I, too, support these amendments. People in the community definitely need better facilities. There is no doubt that people should have choice. My husband would have liked to have died at home. Sadly, that option was not available because he needed an antibiotic in a drip. He died in an A&E department. I therefore greatly support these amendments.

[Baroness Wall of New Barnet]

My Lords, I, too, wish to support the amendment presented by the noble Lord, Lord Warner. I want to focus particularly on the first part of the amendment and I support completely the sentiments within that. One of the points made by the noble Baroness, Lady Jolly, was very important. It is important to try not to have the elderly patients in the hospital so that their right to die wherever they want to be is where they are before they have to come in. The context here is not just the money. The noble Lord, Lord Warner, is absolutely right to point out that it is hugely expensive. I think that it is more than £3,000 if an elderly person is in hospital and dies in hospital. It is very much evidenced by the fact that they very often feel quite degraded by the lack of privacy when they die in hospital. By definition, it is not the same as being at home or, even, I would suggest a hospice, where people have very good experiences. The evidence provided by the noble Baroness, Lady Jolly, and the noble Lord, Lord Warner, is absolutely crucial.

I can tell the Committee from first-hand experience that people also say this to us. I declare an interest in Barnet and Chase Farm Hospitals. If I or anyone else in the hospital goes around the wards, the patients tell us that they would love not to be there to die. Certainly, the nursing staff would love them to be in a better, more dignified place to die. It is a hugely important part of any of the social care we are looking at.

NHS: Accident and Emergency Services

Baroness Masham of Ilton Excerpts

Thursday 25th July 2013 Lords Chamber

[Earl Howe]

That is very much in the focus of Health Education England, which oversees workforce issues in the health service. There has been a shortage of A&E consultants for some time and Health Education England is looking at that area very carefully. A&E is a discipline that has not traditionally proved attractive to trainee doctors for a number of reasons. It is very stressful and the remuneration is perhaps less than in other areas of medicine. That needs to be addressed and is very much an area of scrutiny.

[Baroness Masham of Ilton]

My Lords, following on from that, is the Minister aware that half as many again emergency doctors are needed? What is he going to do about recruiting?

[Earl Howe]

As I have just said to the noble Baroness, there are no instant fixes to this but we want to ensure that recruitment over the medium term is addressed and Health Education England is doing that.

Antibiotic-Resistant Bacterial Infections

Baroness Masham of Ilton Excerpts

Wednesday 24th July 2013 Grand Committee

[Baroness Masham of Ilton]

My Lords, I thank my noble friend Lord Crisp for securing this most important debate. I declare an interest as, over the years, my life has been saved by the use of antibiotics, and I personally know how important they are for the correct infection.

Is there a problem of people sharing medication such as antibiotics, or stopping taking them when they feel better, thus causing drug resistance? After I brought up the subject of MRSA in your Lordships’ House in 1996, I was a member of the Science and Technology Select Committee’s sub-committee on resistance to antibiotics and other antimicrobial agents from 1997 to 1998, chaired by the noble Lord, Lord Soulsby of Swaffham Prior. We went to Washington, Atlanta and Boston. The amount of research being undertaken in America left a lasting impression. I am pleased that there is a vet speaking in this debate. It is most important that there is good co-operation between human and veterinary medicine.

Antibiotic-resistant bacterial infections are a worldwide problem, and given the economic situation we are in, there should be the greatest cohesion. In the community there is a dangerous toxic substance produced by some strains of staphylococcus aureus called Panton-Valentine leukocidin which can kill within 24 hours. The infection can be contracted from gorse bushes, in military camps, colleges and playgrounds—that is, places where young people often gather together. It seems to be more prevalent in the USA and therefore we should be learning from that country. It is vital that a quick and correct diagnosis is made, and GPs and hospital doctors must be aware of the symptoms that suggest an illness could be PVL-positive MRSA.

The overuse of antibiotics and thus the increasing resistance of bugs to them have led to fears that soon we may run out of effective treatments. Microbes are mutating faster than scientists can come up with new antibiotics. According to the World Health Organisation, some 440,000 new cases of multidrug-resistant tuberculosis are diagnosed every year, causing at least 150,000 deaths. A mutant strain of gonorrhoea, which has emerged in Asia, could be more devastating than AIDS. Antibiotic-resistant strains of e-coli are on the rise, particularly among the elderly, and there are risks from common infections such as pneumonia and urinary tract infections.

What can be done to give the pharmaceutical industry incentives to develop more antibiotics? The absence of rapid diagnostic tests for tuberculosis is further compounded by a widespread inability to screen for drug-resistant bacteria. An ideal diagnostic test for respiratory tract infections should be rapid, cheap, easy to use, sensitive and specific, and should screen for many micro-organisms and their antibiotic resistance. The diagnostic platform should be transportable and robust; ideally, it should also be able to be run on solar power for use in remote healthcare settings in developing countries. In Australia there is such a portable box, called the “lab without walls”, so progress is being made. To achieve this across the world, physicians, scientists, biotechnology companies, funding agencies and Governments need to work together to drive the development of improved diagnostic tests for both developed and developing countries.

Here in the UK we have seen the emergence of multidrug-resistant tuberculosis among homeless people. This should be a wake-up call for us all. I have great admiration for the Find&Treat service, which works with the most vulnerable and excluded people in our society to ensure that they can access diagnostic services and complete tuberculosis treatment. Homelessness is an independent risk factor for multidrug-resistant disease, as is birth in east Asia or eastern Europe or a history of previous tuberculosis treatment. Funding for the Find&Treat service is secure only until March next year, and it still has not been able to replace its only current mobile unit, which is on its last legs. The unit goes around hostels for the homeless and other places in order to test the vulnerable. I stress that the effective control of TB is important to wider public health, and interventions must be made in complex cases. I hope that Public Health England will take this on and work with NHS England.

A dual HIV/MDR TB infection complicates patient management, compromises treatment options and leads to poorer treatment outcomes and greater disease transmission. Basic and clinical research is needed to explore any possible causal relationship between HIV infection and MDR TB specifically.

Extensively drug-resistant TB, which is resistant to at least four of the core anti-TB drugs, and MDR TB both take substantially longer to treat than ordinary TB and require the use of second-line anti-TB drugs, which are more expensive and have more side effects than the first-line drugs. Very worryingly, in some countries extensively drug-resistant TB is on the increase. The modern world is now very accessible. There should be no complacency. All Governments across the world should realise the risk to their populations posed by antibiotic-resistant bacterial infection, and should work closely with the World Health Organisation.

NHS: Children’s Congenital Heart Services

Baroness Masham of Ilton Excerpts

Tuesday 23rd July 2013 Lords Chamber

[Earl Howe]

Yes, my Lords. The point that the noble Lord makes is extremely important. I think that there were a number of people who, for whatever reason when the Safe and Sustainable review was going on, felt left out of the picture. NHS England is clear that that should not happen again and that lessons have to be learnt so that this is a genuinely inclusive process.

[Baroness Masham of Ilton]

My Lords, does the Minister agree that adult and children’s services for congenital heart disease should be located on the same site to ensure continuity of care? When young people reach the age of 16, they seem to be thrown out of children’s service provision.

NHS: Keogh Review

Baroness Masham of Ilton Excerpts

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

I can certainly use my best endeavours through the usual channels with regard to my noble friend’s latter question. On his first point, he is absolutely right. That is what led us to believe that aggregate hospital ratings, provided that they are produced in a sophisticated and careful way, will be very informative to the general public and to patients in a local area, and to professional staff within the health service. The Healthcare Commission, of old, used to produce aggregate ratings. They fell into disuse and, I have to say, into some disrepute, because they were so broad brush as to be meaningless. When we asked the Nuffield Trust to look at this area, it told us very clearly that, as long as we adopted a nuanced and sophisticated approach so that what was assessed was not just a hospital trust or an individual hospital within that trust but rather the performance of individual medical teams and units within a hospital, we would provide useful information to the public. However, that information needs to be accessible.

[Baroness Masham of Ilton]

If the chief inspector, when visiting failing hospitals, finds a lack of senior sisters on the wards and a shortage of doctors working in emergency medicine, what is he going to do about it? Does the Minister realise that there is a serious shortage of emergency medicine doctors?

Public Health England Advisory Board Membership

Baroness Masham of Ilton Excerpts

Thursday 4th July 2013 Lords Chamber

[Earl Howe]

My Lords, across the field of health it is difficult for me to give a generic answer, but the NHS Leadership Academy, which is now starting its work, will ensure that women with promise for leadership will be encouraged to come forward in a variety of roles, not just clinical but managerial. I hope that we will see the fruits of that work over the coming months.

[Baroness Masham of Ilton]

My Lords, does the Minister agree that Public Health England is responsible for campaigns for vaccinations, and that as vaccinations deal mostly with children and young people, mothers are involved, so it is essential to have women on the advisory board?

Care Bill [HL]

Baroness Masham of Ilton Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Lord Black of Brentwood]

My Lords, I shall speak to Amendments 78E, 87K and 88J, which are in my name. They raise the issue of companion animals—mostly cats, but dogs as well—and the positive role that they can play in the care of elderly, vulnerable and sick people, whose welfare is at the heart of the Bill. I should declare an interest as president of the Printing Charity, as it runs two homes providing sheltered accommodation and financial support and care for people from the printing industry.

Amendment 78E includes the positive contribution of a companion animal to an individual’s well-being in the list of factors to which a local authority must have particular regard in exercising its functions under Part 1. Amendment 87K includes identifying the role of companion animals in the care and support of an individual when a local authority is assessing their needs and those outcomes that an individual wishes to achieve in day-to-day life. Finally, Amendment 88J deals with the issue of companion animals in regulations under Clauses 9 and 10. Taken together, their purpose is to ensure that the benefit which companion animals can provide to well-being, a subject not currently covered in the Bill, is not overlooked by those implementing and interpreting it.

It is estimated that 25% of people over retirement age own one or more pets. For the elderly and vulnerable, the companionship that cats and dogs can bring cannot be overstated. Academic research over many years has documented this. One study by Brooks, Rogers and others, published just last year, highlighted the emotional and practical impact that companion animals offer. Noting that they provide unconditional support and love, as we all know, the study concluded that,

“the policy implications of this study suggest that pets might usefully feature alongside consideration of the usual support systems associated with the management of long-term conditions and in planning how needs might be ... creatively met”.

That, of course, is precisely what this Bill is designed for and what these amendments are crafted to deliver.

Cats in particular can help those who are vulnerable, through age or health, in three ways. First, there is a powerful body of evidence about the contribution of cats to physical health. According to one study published recently in the Journal of Vascular & Interventional Neurology—not a magazine I look at frequently, but it is there—they contribute to a reduction of fatal cardiovascular disease by around 30%.

Secondly, the ownership of a cat brings positive benefits to an individual’s mental health. Research conducted in 2011 for Cats Protection and the Mental Health Foundation among people with a mental health problem found that 76% of people who owned a cat felt they could cope with everyday life much better as a result, and that 87% said it had a positive impact on their well-being. Cats can be especially helpful for depression during the winter period—a particularly important point since, as we now know, this goes on for about nine months of the year. As the Cinnamon Trust, which works tirelessly to support the elderly and their pets, summarises it:

“Pets have the ability to bring happiness and laughter and lift depression. Communication with other people is often easier when a pet is present for reassurance”.

Thirdly, cats make particularly suitable companion animals for those with chronic health problems, including those who are immobile or disabled. I know that this is a charge always made against cat lovers, so I am not forgetting our canine friends. I highlight, for instance, the excellent work of the innovative Dementia Dog Project, which helps to keep people in the early stages of dementia active and engaged with their local community, as well as providing a constant companion to reassure those suffering from dementia in new or unusual situations. This project in particular shows that a dog may aid a sufferer to stay on longer in his or her home—an important ambition that many noble Lords have highlighted in this debate—and may even slow the onset of this terrible disease.

Real-life examples of how cats promote well-being and play a vital role in an individual’s care appear regularly in the excellent magazine, The Cat, which is a publication I do look at regularly and is published by Cats Protection. In recent months, there have been stories about how their cats helped an owner to cope with epileptic seizures, helped a seven year-old boy to deal with the debilitating problem of selective mutism, and comforted a 17 year-old girl confined to bed with the life-long incurable condition of Behçet’s syndrome. One particularly moving story related to how a visit from a cat to an elderly lady who was in a hospital ward and suffering from severe dementia got her to speak for the first time in three months.

There are many other examples. Indeed, I think of the experience of my own mother. In the last year of her life, she was widowed, immobile and more or less housebound. Her faithful cat, Toby, was her constant companion. She talked to him, laughed with him and moaned and shouted at him; he cared for her in return. Indeed, he lay on her bed as she died. That companionship is a priceless gift, which this legislation should protect. Let me explain briefly how these amendments might help, as I ask my noble friend the Minister to consider these three issues.

First, one of the many problems that those who are elderly with a pet can face is how to care for it when they go into a care home. There are some amazing care and retirement homes which welcome pets but others do not have a policy on them, which can cause anxiety and distress to those who need to enter one. For a person to have to give up what might be their sole companion is a tragedy for an owner and for the pet. It also adds to the growing burden on many animal charities, which are having to take increasing numbers of abandoned pets as economic problems have bitten hard in so many families.

Secondly, it would encourage those at the front line of care—GPs, in other words—to become aware of the role of a pet in an individual’s life. Many GP surgeries include in their information about the over-75s whether a companion animal forms part of the client’s household. The signal sent from amending the Bill would encourage many more GPs and clinical commissioning groups to ensure that this important information is routinely collected for all age groups, including the elderly.

Finally, the Bill needs to be drafted widely enough in its definitions of well-being and needs assessments to allow for money, whether budgets or direct payments, to be used where necessary to support an individual who perhaps wishes to retain a pet but is having problems due to health. Professional pet-sitting or feeding may be needed when an individual is hospitalised and where there are no friends or family to help. Knowing that a pet is being cared for can help encourage otherwise reluctant individuals to go into hospital for treatment and relieve anxiety. Equally, in cases where a care assessment shows that a companion animal would bring individual health benefits, money may be needed to help an individual obtain a companion animal. There are many examples of such budget programmes in other countries—most notably, I think, in Australia—where health and local authority budgets are pooled to provide companion animal support programmes. This principle should be embedded in regulation and statutory guidance for all relevant implementing bodies.

Most importantly of all, these amendments would ensure that the role of companion animals is given proper recognition and protection through an individual’s care journey. Some may be too vulnerable or frail to request that their beloved pet is taken into account when their care is planned. Others may need help or assistance in retaining their companion. Others still may not be aware of how a cat or a dog could improve their quality of life, ease their loneliness or help tackle a chronic disease. The amendments I have tabled would ensure that this happens as a matter of routine and is not left to chance in the way that, tragically, too often happens now.

[Baroness Masham of Ilton]

My Lords, today is bowel awareness day. I have been chairing a reception for bowel care this afternoon. Two of the speakers had disabilities: one with multiple sclerosis and one a tetraplegic, paralysed from the neck down. Both needed bowel care and they both said that dignity and respect were so important. Amendment 78ZA should therefore be a must for the Bill. There are many important amendments in this group, including those on well-being and companion animals, which I support. Happiness is something we should all aim for.

[Baroness Tyler of Enfield]

My Lords, I add my support to Amendment 78ZA, to which my name is also attached. The noble Lord, Lord Bichard, has already spoken very eloquently of the reasons behind the amendment. Dignity and respect are absolutely fundamental pillars of well-being, which is why I would like to see these words spelt out in the Bill. Well-being is unattainable without dignity and respect as central components. In saying this, I am conscious that the public’s opinion on this matter is one of pessimism and distrust of the current social care system. In a recent survey, only 26% of the public felt confident that older people receiving social care are being treated with dignity. If the public do not trust their loved ones in the hands of the social care sector, what hope is there that well-being is being promoted?

We have recently seen and heard of shocking failures in the care of older people in both the health and social care sectors. These very harrowing examples serve to illustrate the importance of enshrining dignity and respect as a critical part of well-being in order to try to change the culture among care workers in the health and care sectors, to ensure the transformation of services that this Bill is intended to bring about and to have the sort of compassionate care that we all like to see. Dignity will also be very important when it comes to secondary legislation and specifically to the eligibility criteria. It is vital that these criteria have regard to the well-being principle. I am happy to be corrected about this if I am mistaken, but the draft feels very health-and-safety-oriented and does not mention dignity at all.

I would have liked to add my name to Amendment 79 about including well-being as part of the Secretary of State’s duty, the reasons for which have already been set out very clearly. The very wide-ranging definition of well-being, set out in The Care Bill Explained, makes it absolutely clear that for the well-being principle to be made a reality it would need to be the joint responsibility of a wide range of partner agencies, nationally and locally. Government action on key issues such as welfare, transport and housing are likely to have a very distinct impact on well-being at an individual level.

We rightly hear a lot about the importance of joining up health, social care and wider services: horizontal integration, if you like. For any system to work as it is intended and to be fully aligned it must be, as I said at Second Reading, vertically integrated as well to make sure that everyone, from the Secretary of State downwards, has the same objectives and is pulling in the same direction.

--- Later in debate ---

[Baroness Masham of Ilton]

Before the Minister sits down, I would just like to ask him: does he not really want to get things right? When there were problems at Mid Staffordshire, people were desperately thirsty, drinking out of flower vases, and were lying in their own refuse in their beds. Surely dignity must be written in all over the Bill.

[Earl Howe]

I agree that dignity is a very important concept, which is why we expressly amended the Bill to include that word right at the beginning. Clause 1, which defines the well-being principle, is the foundation for everything that follows. While one could pepper the Bill with references to the word “dignity”, I am not sure that that would add very much in practice.

NHS: Accident and Emergency Units

Baroness Masham of Ilton Excerpts

Wednesday 19th June 2013 Lords Chamber

[Earl Howe]

My Lords, Ministers are responsible to Parliament for the provision of the health service so I do not duck that responsibility for a second. Nevertheless, Ministers do not manage the health service day-to-day and have never done so. We are involved day-to-day in the plans to ensure that we have a health service that is properly configured to meet the needs of patients. My right honourable friend the Secretary of State could not be more assiduous in the work that he is doing to make sure that that happens. Responsibilities are not being ducked; nobody is being blamed. The fact is that demand is going up considerably, and has been for a number of years. We need to address that and we need to do it cleverly. It is not always a question of piling more money in; it is looking at how the services are configured and delivering care in the right place.

[Baroness Masham of Ilton]

My Lords, does the Minister agree that drunken and aggressive people are putting great pressure on A&E departments across the country, especially at weekends? Can he do something about it?

[Earl Howe]

The noble Baroness is right. Quite a considerable proportion of people who attend A&E do so at weekends after heavy drinking, and in some areas, that has overloaded the system. I am aware of many hospitals that are working with the local police force and others to keep such people out of hospital if they do not need to go, but to make sure that they do not disrupt the work of an A&E department if they do go.

Care Bill [HL]

Baroness Masham of Ilton Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Sutherland of Houndwood]

My Lords, as has been claimed in the course of this short debate, this amendment should be seen in the same context as Amendments 23 and 23A. However, together they have one common difficulty, which I think has been highlighted. The first point they make is that there should be proper training and education in this area, which is absolutely right; it should be a matter for Health Education England. Secondly, there is still a residual concern, which is very real, that the presence of training does not always guarantee that the care will be of the level and quality that we reasonably expect. So there may be a separate question about imposing some degree of regulation on employers. It is hinted at in Amendments 23 and 23A that employers could suffer a liability were they to put into the field, be they agencies or statutory employers, someone who evidently is unable to provide a decent quality of care. So the separation of these two issues is what I propose.

[Baroness Masham of Ilton]

I would like to ask the Minister a question. I do so agree with the noble Baroness, Lady Browning, over Winterbourne; we do not want any more Winterbourne Views—and they can happen in any part of the country.

My question to the Minister is whether he would agree with me that, when it comes to crisis intervention and physical restraint techniques, all front-line staff should receive a national standard of training to deliver the best possible quality care and health services. Undermining best practice in this area is driven by three elements: a fragmented, unregulated training provider sector; procurement pressures, and commissioners’ and regulators’ roles in quality monitoring; and practice application. The people who have to be restrained are very vulnerable and, usually, mentally ill in some way. Is it really suitable for untrained people to do this job?

[Lord Hunt of Kings Heath]

My Lords, the noble Baroness takes us back to our debates last year on the regulation of health and social care support workers. We had some excellent discussions but, as the noble Baroness, Lady Browning, said, the Government set their face against the statutory approach without convincingly explaining to the House why they did not favour such a move. As far as I can see, the Government’s main objection appears to be cost; they are relying on better training and a voluntary register. But as the noble Baroness, Lady Greengross, pointed out, this may not be sufficient. As she says, unqualified care assistants are looking after very vulnerable people without the necessary training and support, and are being placed in a very vulnerable position. This is probably not the time to debate the loss of state-enrolled nurses, but my noble friend Lord Turnberg is absolutely right to say that the essential removal of the SEN grade has left a gap which needs to be filled.

My noble friend Lord Campbell-Savours points out that we are absolutely reliant on support workers to provide care. Many or most of them are actually very dedicated, but they are not being given sufficient tools to do the job effectively. One has to have great sympathy with the noble Baroness in her amendment.

Some noble Lords have said that it is not readily apparent why Health Education England ought to be the regulator. I certainly sympathise with that point, but no doubt the noble Baroness could easily substitute either the NMC or the HPC. We could no doubt come back to the question of which regulator it should be. The HPC has been somewhat acquisitive in past years in adding professions to its register, and would no doubt be keen to add healthcare and social care support workers to the large number of people whom it registers at the moment. As for the NMC, we understand that it has been through some difficulties in leadership and has a backlog of cases to be heard by its regulatory committees. But it has new leadership, and I am confident that it will be able to get through those problems—and, if it was chosen, it could also register health and support care assistants if that were to be required. So I do not think that there is an organisational issue in terms of difficulty in organising the regulation of support workers.

The Francis report has been mentioned by a number of noble Lords. This compelling report says:

“A voluntary register has little or no advantage for the public. Employers will not be compelled to employ only those on the register although they could be incentivised to do so”.

It concludes:

“It is not generally those who would seek voluntary registration who are the concern. It is those who will or would not seek voluntary registration but are still able to obtain employment who will be in contact with vulnerable patients”,

and those patients may not be appropriately protected. The Francis report says that this,

“need not be costly and can be self-financing”.

Amendments 23 and 23A, which we are going to come to, are very helpful but they do not do the job of regulation. Does the noble Earl think that the Government should reconsider their position in the light of the Francis report and of today’s debate?