Emergency Healthcare (Public Services Committee Report)
Baroness Merron Excerpts(1 year, 5 months ago)
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Baroness Merron (Lab)
My Lords, I join other noble Lords in paying tribute to my noble friend Lady Armstrong for her leadership on this very important report. I also thank members and staff of the House of Lords Public Services Committee for taking the initiative to launch this inquiry to investigate the barriers to accessing emergency services, which we have discussed numerous times in the Chamber and will I suspect, sadly, continue to debate. I am glad finally to have the opportunity to debate this important report. As my noble friend Lady Morris justified and reminded us—although she should not have needed to justify it—the committee used the word “crisis”.
Worryingly, the committee argued that there was no sign of an adequate plan or the necessary leadership to address the problems it had unearthed. I am sure that is a concern to the Minister. This is against a backdrop of dangerous waiting times which have meant some 5,500 more deaths in 2022 than we had in 2019. This debate is an opportunity to unpick the Government’s recovery plan, which I will come back to later. It is a step in the right direction, but it is not sufficiently ambitious to ensure that patients are not waiting longer than is safe and the ambition it does have is not sufficiently underpinned by substance.
Several noble Lords have referred to the workforce plan. It was indeed long overdue and still needs substance behind it to make the difference it promises. I highlight that it is not matched by a social care workforce plan, which will always cause a problem for the NHS workforce plan. The key findings of the committee’s report on social care referred to the finding that:
“Unmet need in primary and community care and low capacity in hospitals and social care has left the emergency health services gridlocked and overwhelmed”.
The committee also discovered that when patients are ready for discharge, as my noble friend Lady Armstrong highlighted, there are often waits for community or social care to become available, meaning that beds cannot be accessed by other patients. Demographic change means that this problem in social care is not going away and will get only worse.
We therefore have a problem of a lack of a joined-up approach. I particularly want to highlight that, because my noble friend Lady Morris rightly illustrated that the whole system, which needs to work together, does not work together to allow for positive change. She used a very good example of the Metropolitan Police not responding to mental health call-outs. She was extremely reasonable in how she described it and used one of the many connections that there are: the interface between the police and the NHS. There are so many more, such as the interfaces I have just referred to between social care and the NHS, and between rural and urban, as the right reverend Prelate referred to. I am sure we in this Room could come up with a whole list of interconnecting situations not being addressed in an interconnected fashion. Perhaps the Minister could tell the Committee what work is going on to address this. It seems to me that this is absolutely at the heart of it.
I am also struck that problems faced by the NHS are not exclusive to the NHS. The noble Lord, Lord Allan, referred to frequent callers. Frequent callers are an issue that many other parts of our services are trying to deal with—for example, social services and the DWP. My question to the Minister is: what work is going on across government to focus on dealing with this challenge, which does not recognise boundaries? Of course, people do not recognise boundaries when they make a call for help.
I am sure that the Minister will refer to a delivery plan for recovering urgent and emergency care services, so I have a few questions on that in anticipation of his reference to that point. The plan set out a number of ambitions and one was about patients being seen more quickly in the emergency departments. It gives a new target, which says that there will be further improvement in 2024-25, from the original target of 76% of patients being admitted, transferred or discharged within four hours by March 2024. Can the Minister give us something of a flavour of what further improvement we might expect?
Similarly, the same question applies to the ambition of ambulances getting to patients quicker. The Government have stated that their ambition is:
“Ambulance response times for category 2 incidents will decrease to 30 minutes on average over 2023-24, with further improvements in 2024-25”.
Again, what further improvements might we see?
Certain areas were focused on in the recovery plan. I have a few questions on that. First, in respect of improving discharge, what does the recovery plan’s reference to “strengthening discharge processes” mean in practice? Is this new metric in place currently? What is that new metric and what is its predicted impact?
On funding commitments, there is a commitment of £150 million to build 150 new facilities to support mental health urgent and emergency care services, which, with my simple mathematical approach, means £1 million per facility on average. Are these really new facilities—a question raised similarly in respect of so-called new hospitals? If they are being built anew, how much is the expected cost of running them and is there a commitment to that funding to do so?
NHS Providers made some interesting comments, including that funding needs to be available to deliver change. It also talked about rising demand and persistent workforce shortages, because they challenge targets. I absolutely agree with my noble friend Lady Armstrong that the key enabler for achieving targets is improved patient flow. That runs throughout the whole of this report.
On ambulance trusts, there is a reference to a number of ambulance services—this might fall into the category of good practice to be rolled out elsewhere—seeking to increase the proportion of calls that are closed as “hear and treat”, where there is an appropriately trained member of staff at the call centre to deal with things over the phone. What progress can we expect to see in order for this to increase, and does the Minister consider this a way of dealing with the many challenges?
Finally, my noble friend Lady Morris mentioned the NAO report, which was extremely timely. She referred to a number of concerns raised by the NAO. I will not repeat them, but they bore out the point about the need to improve patient flow. The NAO talked about considerable variation in service performance and access between regions and across different providers, thereby highlighting inequality. As the right reverend Prelate reminded us, a part of that is the challenges faced by rural areas. The NAO also made the point that these various challenges pre-date the pandemic. Will the Government look at the NAO report alongside the committee’s report?
We will see, of course, whether winter pressures are going to be dealt with adequately. This will be an indication of whether the Government’s current plan is going to be helpful. However, my final question to the Minister is, what is his assessment of how the winter will look? I do not want us to get to the stage the committee alerted us to: that when we get to winter, we will have the same problems, only worse. The committee has done an excellent job in giving advance warning, and I hope the Minister and his department will take heed.
Food: Two-For-One Offers
Baroness Merron Excerpts(1 year, 5 months ago)
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Lord Markham (Con)
As I mentioned in answer to a Question on ultra-processed food yesterday, as a definition that is not particularly helpful because wholemeal bread, baked beans and cereals are all examples of ultra-processed food. The real point is the content of the food, and that is what our regulations should look to.
Baroness Merron (Lab)
My Lords, when the anti-obesity strategy was published, this ban was said to be supporting food affordability, citing evidence that multi-buy offers such as “buy one, get one free” increase the amount that people spend on foods by around 20% but often on foods high in fat, sugar and salt. With the Government now making the opposite argument to support this postponement, do they no longer stand by the evidence? Would a ban on these deals make it easier or harder for those who are struggling to get by?
Lord Markham (Con)
As we have mentioned before, our general direction of travel is to educate, reformulate and give people the best chances through having choices, and a good start in life through the fresh fruit and vegetables that we have in schools. Those are the things that will really make the difference.
Ultra-processed Food
Baroness Merron Excerpts(1 year, 5 months ago)
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Lord Markham (Con)
I thank my noble friend; that was excellently put. Again, it is the content of the food that matters and not what it is called.
Baroness Merron (Lab)
My Lords, to follow on from the Minister’s comments about the definition of ultra-processed foods, can he confirm what work is taking place to nail down a definition and, upon this definition, will the Government carry out the research that scientists believe to be necessary?
Lord Markham (Con)
As I have said, the fact that something is processed is not a helpful definition. I would recommend that we focus all our activity on the contents of the foods—whether they are high in saturated fat, sugar or salt—and not on whether they are processed.
National Health Service (Performers Lists) (England) (Amendment) Regulations 2023
Baroness Merron Excerpts(1 year, 5 months ago)
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Lord Allan of Hallam (LD)
My Lords, we welcome the debate as an opportunity to look at some of the challenges around the number of GPs, dentists, optometrists and other primary care workers that we have available to us. I welcome the fact that the noble Lord, Lord Hunt, has given us that opportunity.
At the core of the statutory instrument, it seems sensible that we should accept registration from other parts of the United Kingdom where people are on the performers list in another part of the devolved system. To many of us, it is perhaps a surprise that it is not already the case that people on a list in one part of the UK are not automatically passported through to other parts. I am interested to hear from the Minister whether he has any information on how much of an issue this has been and whether there is quantitative or qualitative data around whether we have had significant numbers of practitioners in these fields finding that they had a problem as they moved from London to Edinburgh, Cardiff or Belfast and found that there was a barrier to them restarting their work as a professional because of this performers list issue. Any information he has on that would be helpful.
It would also be very interesting to know whether discussions are ongoing about reciprocal arrangements—whether the constituent parts of the United Kingdom will now plan to do something similar when a doctor on the performers list in England enters their system and whether there will be a similar arrangement for automatic entry to the performers list, subject to later checks, rather than having to apply from scratch.
My second point is to reflect on the user experience of trying to navigate the system, either as a practitioner who wants to work and is thinking about how to get on the performers list or as a member of the public. As the noble Lord, Lord Hunt, pointed out, part of the value—or intended value—of the performers list is that a member of the public can see if somebody who they are going to for treatment has been authorised effectively to offer treatment in their area. We want this to be very simple for everybody concerned, but it is quite confusing at the moment.
As part of my research for this debate, I went to a popular search engine and typed in “NHS performers list”. What I got back was a web page from digital.nhs.uk. The website had .uk at the end, so I assumed it was for the UK; the page was called “National Performers List”, and I assumed “national” meant it was for the United Kingdom. I clicked on that and then, on the next page, it told me that it is only for England. Nowhere in this does it explain to me that there are other performers lists for other parts of the United Kingdom. Nowhere am I given a link to say, “If you are interested in Scotland, go here”. The whole experience is a real confusion between the United Kingdom and England—I speak as a supporter of the devolved settlement, but if we are going to do it, let us do it properly. It seems to me that there is no excuse for not making it clear, given that the .uk bit of the service is not for the UK, that this relates to England and, if you do not want that, here is how to get to the other parts of the United Kingdom.
I note in passing that, if you have a problem with this system, the email address is for the Exeter helpdesk. As I think I have referred to before, I spent many happy years working on the Exeter system—the system for registering GPs—and I am pleased to see it still lives on in the helpdesk for people trying to find out about the performers list.
Equally, if you then come back and search for “performers list” for Wales, Scotland and Northern Ireland, you get a real mishmash of results. There is no consistency. Each of the constituent parts of the United Kingdom has some kind of thing that explains the performers list to you; none of them will link to the others or give you consistent information. In fact, the only place you can find it, if you are really lucky, is by stumbling across the website of the National Association of Sessional GPs, which I assume is intended for GPs looking for locum work. It has a really good explainer with links to all of them, but it seems to me that the Government should be at least as good as the National Association of Sessional GPs at signposting people to the right bit of the performers list.
The other significant area of the statutory instrument which is worth looking at is the question of the inclusion of overseas dentists, which I know the Minister is very familiar with and spends time on. Again, the Explanatory Memorandum tells us that this will improve the situation but is not very forthcoming on how. It tells us that one form of EU exemption will be removed and another system put in place. It would be helpful if the Minister could flesh out a bit about why he is confident—I assume—that it will be a genuine improvement. It would be interesting to hear a bit more detail about how he thinks it will be an improvement and how the new assessment process will help.
I have a final couple of questions. One foundational question, which comes back to the point about the impact assessment, is whether anybody has looked at how much value this performers list system actually adds over and above the existing professional registration systems. I do not think we should just take things as read. We have done it like this previously, where we have people registering with a professional body which requires passing all kinds of tests to get on to the register as a practising dentist or doctor within the United Kingdom—then we have this performers list system. I am genuinely interested in whether we have ever thought to ask whether it is useful to have the performers list layer on top of the general registration layer; if so, how useful it is; and whether the cost of having these two layers of registration is justified. It seems to me that we should always ask those questions; otherwise, we will have bureaucracy on top of bureaucracy.
Finally, I cannot miss this opportunity: I noticed today that in the Prime Minister’s announcement about the funding settlement, which is a welcome increase for various public sector professionals, he said that the Government are going to fund it in part by raising visa fee rates. That is critical. Here we are debating a measure which will make registration on the performers list as an overseas professional a little easier—and we all know that we need a continued stream of overseas professionals in this area. However good we are at training people, we are not going to get there for a while. I am interested in and hopeful about the Minister’s views on whether we are not giving with one hand and taking back with the other. We are making registration a bit easier, but we are going to make it a lot more expensive for people to get here in the first place. As I say, I cannot miss the opportunity to flag that there may be some inconsistency in government policy across that piece.
Baroness Merron (Lab)
My Lords, I think this debate is all about whether these regulations will do the job they are intended to do. As my noble friend Lord Hunt said at the outset, it is difficult to see whether that is the case in the absence of, for example, an impact assessment. I start by thanking my noble friend for again bringing this issue before the House. NHS dentistry is so important to people’s health and well-being in this country, and it has deteriorated, sadly, over a number of years. This is not an issue with the regulations themselves but whether they assist primary care in the way that it is said they are going to and that we all seek to do.
In terms of the background, there is no doubt—we all know this from our own experience and that of the people we know—that finding an NHS dental practice in the UK which will accept new adult patients for treatment under the health service is something of a rarity. Only one in 10 practices is offering that at present. That situation remains unsustainable.
Community Health Services: Waiting Lists
Baroness Merron Excerpts(1 year, 5 months ago)
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Baroness Merron
To ask His Majesty’s Government what recent assessment they have made of current levels of waiting lists and times for community health services for (1) children and young people, and (2) adults.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
We regularly monitor community health services’ waiting lists and recognise the variability between the number of people waiting and the time on waiting lists across services in local areas. We are committed to reducing waiting lists; that is why the NHS Long Term Workforce Plan sets commitments to grow the community workforce, with increases in training places for district nurses and allied health professionals and a renewed focus on retaining our existing staff.
Baroness Merron (Lab)
My Lords, long waits have a more severe effect on children because delays in assessment and treatment have a knock-on effect on their communication skills, social and educational development and mental well-being. With over 37% of children and young people on waiting lists for community health services for more than 18 weeks, compared to under 16% of adults, when will the Government address this ever-widening gap and what steps are they taking to prevent a disproportionate impact on vulnerable families both now and in the long term?
Lord Markham (Con)
The noble Baroness is correct about the urgency for young people; I have personal experience of this as well. We are taking steps by piloting nine early language and support services for all children focused on exactly what the noble Baroness mentioned. There is £70 million behind that pilot, with the intention being that we learn lessons from that and roll it out quickly.
NHS: Doctors’ Strikes
Baroness Merron Excerpts(1 year, 5 months ago)
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Lord Markham (Con)
I think the morale of doctors is best approached by a number of measures. As I said yesterday, there is not one silver bullet. There are a number of things: clearly, pay is important; pensions are very important, and we have addressed those, and so are working conditions. I was at Whipps Cross Hospital, one of the new hospitals, last week. The morale boost to staff there, knowing they are getting a new hospital, is massive. All those features are vital to improving morale.
Baroness Merron (Lab)
My Lords, in celebrating the 75th anniversary of the NHS, I too pay tribute to all NHS staff. It is therefore highly regrettable that the Government are currently presiding over the largest amount of industrial unrest in the history of the National Health Service, with doctors’ leaders warning that the strike action could last until 2025. With that in mind, what is the Government’s assessment of the impact of their failures to resolve NHS disputes?
Lord Markham (Con)
As we have seen, it is having an impact, regrettably. We saw that from 14 to 17 June: almost 100,000 appointments were lost during that strike. We are now looking to cover that up. That is why we are firm in our conviction that we want to resolve this situation. These sorts of things are not good for anyone. We have a formula that worked; we have managed to do this with nurses and the Agenda for Change unions, which make up the vast majority of the health service. Our hope is that we can sit down and have sensible conversations and do the same with doctors and consultants.
NHS Long-term Workforce Plan
Baroness Merron Excerpts(1 year, 5 months ago)
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Baroness Merron (Lab)
My Lords, I am absolutely sure that the Minister is as relieved as anyone to see this Statement on the NHS workforce plan before your Lordships’ House today, after many years of waiting and promises of it being published shortly, imminently, or at some time in a very extended spring.
The plan promises much, but it is the delivery that will count and the difference it will make to the health and well-being of the nation. But at the heart of it, its effectiveness will stand or fall on how successfully it joins up with other key aspects of the NHS and social care. It is not just about delivery: the commitment to updating the plan every two years is essential in the hope that it will be a lasting way out of the continuing workforce shortages that have blighted the NHS for many years. Ministers have a lot at stake and are investing a lot of hope in this workforce plan, not least because the lurch from crisis to crisis has to come to an end, with proper consideration of the long-term challenges ahead.
This long overdue plan started and continues its life against a backdrop of chronic NHS understaffing. It is long overdue. If it had been launched eight years ago, it would have been enough to fill the NHS vacancy levels—yet we have had to wait. Instead, the NHS is short of 150,000 staff, and this announcement will take years to have an impact, while patients continue to wait longer than ever before for operations, in A&E, or for an ambulance. While the plan is a positive step, it is only the first step. Much more detail is needed on how the plan will be implemented and what measures will be used to judge its success. What attention is being given to training staff and key leaders in what quality management looks like?
Retention is key, and the plan has little to say about that. The overall staff leaving rate increased from 9.6% in 2020 to 12.5% in 2022. The plan acknowledges the importance of retaining workers, offering more flexibility and improving the culture in the NHS, but it is light on detail about how it might do that. We know that more NHS strikes are planned—and that work culture, bullying and harassment continue to be a real issue, and nearly one in 10 staff experience discrimination. When will there be details on retention, pay and working conditions, such that they can add some detail on how retention might be improved in the NHS?
It is a missed opportunity that there is no social care workforce plan, especially as the NHS workforce plan identifies the impact that delayed discharge due to difficulties securing a social care package is having on patients and staff alike. Without such a plan, it will not be possible to enhance the quality of care and support provided by the NHS—they are inextricably linked. There are currently 165,000 vacancies in social care, an increase of 52% and the highest rate on record. Average vacancy rates across the sector are at nearly 11%, which is twice the national average. What assessment has the Minister made of the impact that having an NHS-only plan will have on the social care workforce? Social care workers already seek jobs in the NHS, where pay and conditions are better. Does the Minister share my concern that an NHS-only plan is likely to exacerbate this situation and the number of vacancies in the social care workforce? Does the Minister consider that this will undermine the ambitions of the NHS plan?
As the King’s Fund rightly observed, the projections are likely to be based on ambitious assumptions. Yet there needs to be realism about the investment in buildings, technology and equipment that is needed to realise productivity gains. Can the Minister say whether and when we can expect plans relating to the various and absolutely crucial aspects of investment? Page 121 of the plan sets out a labour productivity rate of 1.5% to 2% per year. That was never achieved by the NHS or any other comparable health system, so what assumptions are being made in relation to achieving that?
The focus of the plan is crucial. It appears on reading to have been seen through a rather hospital-focused lens, so will the Minister ensure that the lens includes healthcare in the community? At the centre of this plan has to be the patient in all their different facets. In the consultations that took place in the lead-up to the development of this plan, could the Minister advise your Lordships’ House on how patient organisations were involved and which ones were consulted?
It appears that the plan seeks to look to the longer term. As happened in 2000, when the Labour Government of the time produced a 10-year plan of investment and reform which included seeking frequent staff increases, we will look to this workforce plan to make a difference to patients and care and the health and well-being of the nation in the same way as we saw come out of the plan in the year 2000. I look forward to the Minister’s response.
Lord Allan of Hallam (LD)
My Lords, I shall try not to be too grudging, as we have been calling for this plan for so long. I start by recognising the enormous amount of work that has gone into this from people working in the NHS and the department over a very long period, but the reality is that the plan is too late for those who are waiting for treatment today and are unable to get it, because the investment was not made in the workforce years ago for it to be available now on the front line. However, the plan certainly is substantive and there is much to welcome in it, looking forward. There are several areas where I hope the Minister can explain the Government’s thinking further.
First and perhaps most importantly, we need a similar, sister plan for the social care workforce. As we have discussed many times across these Benches, health and care work in symbiosis and both have seen too little supply to meet demand in recent years. Can the Minister confirm that the Government have no plans to further reduce capacity in social care by acceding to some of the requests from his political colleagues to limit visas being made available for essential social care staff? Can he say when the Government intend to release a sister plan to the NHS plan dealing with the social care workforce?
The plan also depends on ambitious productivity gains, and these will require certain things to be put in place. First, we need technology that will make life easier rather than more difficult for staff. Will the Minister explain what work is being done to understand how front-line staff in the NHS actually experience the technology they are being provided with, to ensure that we are not setting them back? Technology, when implemented well, leads to productivity increases, but technology poorly implemented can simply add to the frustrations of staff and make their jobs more difficult.
Another key factor in productivity is good management. This is a much less fashionable area to comment on than additional doctors and nurses, but the evidence seems to suggest that the National Health Service is actually quite lean in terms of its management. Will the Minister comment on what is in the plan to boost management capacity so that we can make savings on that other kind of consultant, the management consultant? Far too much is still being spent on externalising management expertise rather than building capacity within the service.
The final area I want to comment on is retention. The plan has hard numbers and new targets for getting new people into training but is much less precise on how we can improve staff retention over the long term. This is of course, quite importantly, a matter of pay and working conditions across all grades of staff. I invite the Minister to comment on some of the press stories we have seen saying that there seems to be some reluctance on the part of the Prime Minister to implement pay review body recommendations in full, something that he himself has said we should rely on to resolve issues particularly around junior doctors. Certainly, understanding that pay is important and that review body recommendations are going to be respected is critical for retention.
We can see that the Government have looked very closely at the specific factors that discourage senior doctors, in particular, from staying on as they approach retirement age. I suggest to the Minister that similarly detailed work needs to be done to understand the precise factors that are leading more junior staff at earlier stages in their career to leave the profession. Similar attention must be paid to resolving those specific issues if we are to address the retention problem.
One way we can motivate staff to stay on is through continuous professional development and retraining into more highly skilled roles, yet training opportunities can be constrained by the capacity of those delivering it. Can the Minister assure us that training opportunities will be provided for existing staff as well as new staff, so that we do not end up holding back Peter in order to train Paul? It will be net negative if we lose staff from the existing workforce through missed training opportunities as we bring in new staff. More generally, is there an understanding of how we are going to build up that capacity for training existing and new staff?
When I was younger, I had a teacher who would often write on my essays, “Okay as far as it goes”. This would annoy me, but with the benefit of wisdom and age I have to concede that it was often fair and accurate. Today, we might say that this plan, into which I know a huge amount of work has gone, is okay as far as it goes. We can be confident that it will really make a difference only if it is delivered in full, and in particular if there is a sister plan for the social care workforce and a real effort made on staff retention. I hope the Minister will comment on some of those aspects.
Mental Health In-patient Services: Improving Safety
Baroness Merron Excerpts(1 year, 5 months ago)
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Baroness Merron (Lab)
My Lords, I welcome the announcement in this Statement that the inquiry to investigate the deaths of mental health in-patients across Essex between 2000 and 2020, chaired by Dr Strathdee, will now be given vital statutory powers. This is an important and long overdue development. Not only have the grieving families suffered the pain and anguish of bereavement, and how they have felt in their fight for answers over so many years, but all of this has been compounded by an inquiry that lacked the necessary powers to seek the truth. It would be helpful for your Lordships’ House if the Minister could shed some light on why it has taken so long to allow the inquiry to do its job thoroughly.
More broadly, and connected with this issue, are repeated scandals in in-patient mental health settings involving abuse, dehumanising behaviour and needless loss of life, such that more than one in three people say they do not have faith that a loved one would be safe if they needed mental health care in a hospital. How will the Government seek to restore essential public confidence?
The situation set out in the Statement is against a backdrop of some 1.6 million people on waiting lists for mental health treatment. Their condition is deteriorating and can reach crisis point. At the same time, the incidence of poor mental health continues to rise. Those in poverty or financial difficulty are particularly at risk, to mention just one group. With the cost of living crisis continuing unabated and children from the poorest 20% of households four times more likely to develop serious mental health difficulties by the age of 11 when compared with the wealthiest 20%, this is an upward and unequal trend that the Government have to tackle. I hope the Minister can comment on how this will be properly dealt with.
I will pick up some particular aspects. Families of patients in Essex will welcome the news that this inquiry will be put on a statutory footing, but across the country those failed by inadequate mental health services are in desperate need of answers and need change. In March 2022 the CQC released its Out of Sight report to identify what progress the Government have made in addressing the culture, behaviour and design of services for patients in mental health in-patient settings. Will the Minister tell your Lordships’ House what progress has been made in implementing the recommendations in full?
If we are to bring about change, it is very important that the rapid review of data in mental health in-patient settings translates into action and the report does not simply sit on a shelf in the department. Can the Minister tell your Lordships’ House when the Government’s response to the review will be published and whether he will set out a timetable for when the recommendations are to be implemented?
Over the past year there has been a flurry of reports, as we know only too well in this House, of patients being failed in the care of mental health trusts around the country. Have Ministers actually met the leaders of those trusts to find out what has gone wrong? If not, do they plan to meet and when?
The Government have shelved the 10-year mental health strategy and, despite promises first made in 2018 to reform the outdated Mental Health Act, legislation has repeatedly been delayed. The Joint Committee on the Draft Mental Health Bill published recommendations for improving legislation in January, but thus far Ministers have still not responded to the report and the Bill is yet to be introduced to the House of Commons. Will the Minister please update the House on when it can be expected?
When it comes to mental health, taking a preventive approach would mean fewer patients needing to use in-patient services in future. Have the Government considered shifting the system towards prevention by providing mental health support in every school, for example, and a mental health hub for young people in every community? Ensuring that there are enough staff to provide adequate services is vital to improving patient outcomes, so can the Minister say some more about what plans the Government have to retain staff, to recruit new staff and to expand access to mental health treatment? I look forward to hearing from the Minister on these points.
Lord Allan of Hallam (LD)
My Lords, I am grateful to have an opportunity to discuss mental health provision, and my comments will very much follow on from those of the noble Baroness, Lady Merron. We are also interested in the Government’s latest thinking about the draft mental health Bill. Now that the workforce plan is out—we will discuss it tomorrow—our new refrain may be, “When will the Government get on with the mental health Bill?”. It is long overdue, and a huge amount of work has gone in that is clearly fundamental to trying to deal with some of the structural issues.
Turning to some of the issues raised in the Statement, I first want to ask about people’s journeys when they are in need of mental health support. The Statement said that 111 will now provide mental health advice, which is very welcome, but can I ask the Minister for his thoughts on what is happening in primary care? My understanding is that at the moment mental health nursing provision is not a requirement of all general practices—some offer it and others do not. Can the Minister, who I know cares about joined-up, seamless services, give us some insights into the Government’s thinking on ensuring that people who present with mental health problems to general practice—which is the first port of call for many of them, before they even get to 111 or 999—see more consistency of support available at that level?
Thinking about the review—a major part of what is in the Statement—a significant proportion of providers of mental health in-patient services are private sector, which has been the case for some time. Can the Minister confirm that they will be included in the review and comment on whether the inspectorate’s powers will be applied equally to the private and public sectors? That is critical to understanding what is happening in all settings.
Will the Minister also talk a little about the input the review may get from related services? Again, we know that the police, local authorities and accident and emergency departments often pick up the pieces where mental health provision has not been made available. Can the Minister assure us that the review will also look at all those other parties to this journey of care that people require? Can he also comment on the data questions? I have seen evidence from freedom of information requests to the Office for National Statistics asking about deaths of people in mental health in-patient settings. My understanding is that the data is not recorded consistently. If we are to have a review and to understand what is happening in the mental health sector, it would be helpful to know what measures the Government will take to improve the consistency of data collection so that, when someone unfortunately suffers a tragic incident, we know where they were at the time and have the data available to build up the national pattern.
The final issue I want to ask for the Minister’s comments on is out-of-area placements. Will he acknowledge that it remains a serious issue that many people with serious mental health conditions are able to get treatment only in places that are far from home and therefore far from their families and support networks? I note from the Statement that the Government are providing three new hospitals. This is of course welcome, but I hope the Minister will also be able to confirm that there is a locality-based strategy, with the Government thinking hard about matching local facilities to local need so that we can end the situation in which people at a time of extreme distress are sent very far away from home, which can only add to the crisis they are facing.
Lung Cancer: Screening
Baroness Merron Excerpts(1 year, 5 months ago)
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Baroness Merron (Lab)
My Lords, I thank the National Screening Committee for its work and welcome this Statement, which outlines the only response that makes any sense: the establishment of a national targeted lung cancer screening programme. I also pay tribute to the many individuals and organisations that have worked over many years for this, in particular the Roy Castle Lung Cancer Foundation, which, in addition to campaigning, has been delivering its own scans since 2016.
I very much wish to associate these Benches with the thoughts of the late and much-missed MP for Old Bexley and Sidcup, James Brokenshire. I acknowledge the work he did in bringing this cancer screening programme about, which was continued by his wife Cathy. This is a very fitting Statement with which to honour his memory.
There is no doubt that diagnosing more people earlier is absolutely crucial. This programme will certainly improve that, but it does have to go hand in hand with treatment that is available rather quicker than is currently the case. The UK currently lags behind the European average for five-year survival rates for lung cancer. More broadly, since 2010, ever more cancer patients have waited longer than is safe to see a specialist. The target of 85% of patients to start treatment from initial GP referral within 62 days has not been met since 2015.
Can the Minister tell your Lordships’ House whether this extension of screening will be matched by the necessary improvements in access to treatment? If the treatment programme is to be improved—as surely it must be—how will this be done, and when? Will it be new money or a diversion from existing resources that funds the programme and any associated improvements in treatment?
Turning to the areas where lung disease is most prevalent, notably those with the greatest deprivation and health inequality, can the Minister give an assurance that resources for the screening programme will continue to be targeted at the areas that need it most? With existing health structures already worse in these areas, how will they be improved to support the delivery of the lung cancer screening programme?
Despite the Government’s support today, it has taken nearly nine months to act on the recommendation of the National Screening Committee, and there is now a timeline to reach 40% of the eligible population by March 2025, with full coverage by March 2030. Can the Minister say whether work is going on to hasten the timeline of this rollout?
The Health and Social Care Select Committee’s report last year into cancer services concluded that a lack of serious effort on cancer workforce shortages risks a reversal in cancer survival rates. While we have been promised the NHS workforce plan this week, after many years of waiting, I note that the Government’s press release had just one line on the workforce necessary to make the screening programme a reality, saying that additional radiographers are due to be appointed. Can the Minister assure the House that when we do get the workforce plan, it will address the major shortages that were outlined by the British Thoracic Society, whose report identifies workforce shortages as the main challenge in the provision of healthcare to those with lung conditions?
As the Minister rightly pointed out in the Statement, smoking is indeed the leading cause of cancer, causing 150 cancer cases every day and one person’s death every five minutes due to smoking-related ill health. It is therefore important that alongside diagnosis, we work to stop people smoking in the first place and support those who do smoke to quit. Yet the number of people quitting has slumped since 2010 and smoking cessation services have been cut. Can the Minister confirm when we will get the awaited Government response to the review of tobacco control policies, led by Dr Javed Khan?
It is not only smokers who have lung cancer and other lung conditions. The context in which all of this takes place is a range of other factors in addition to smoke and smoking, and that includes air quality. It would be helpful if the Minister indicated what is being done to tackle these broader challenges. Furthermore, it is not the diagnosis of lung cancer only that will improve through the screening programme, but also that of conditions such as cystic fibrosis. What expectation does the Minister have in this regard?
My Lords, I am sure we all want to see this national, targeted lung cancer screening programme save lives, and I hope the Minister can give the reassurances I seek today.
Lord Allan of Hallam (LD)
My Lords, I would like to follow the noble Baroness, Lady Merron, in welcoming the Government’s acceptance of the National Screening Committee’s recommendation to introduce a targeted lung cancer screening programme, and echo her tribute to the late James Brokenshire, whom I dealt with in a previous capacity when he was a Minister advocating for child safety online. I found him to be very effective; a firm Minister who was also very pleasant to deal with—the most effective model for all of us.
The new programme is especially welcome as a step towards addressing the glaring health inequalities we face in the United Kingdom. I hope the Minister will reassure us that sufficient data will be collected in order to understand whether it is having the kind of impact the Government intend, as he outlined in the Statement.
I hope the Minister can also provide more information about how it can be delivered, given that we already have dire shortages in capacity to deliver diagnostic tests. This shortfall is reflected in today’s report from the King’s Fund, which shows a serious gap in CT and MRI scanner capacity between the UK and comparable countries. When can we expect to see investment from the Government in additional scanners, to bring us up to something more like the international mean? As well as the lack of machines, we do not have sufficient people to operate them or to assess the test results. I invite the Minister to refresh his formula for when we may see the long-awaited NHS workforce plan, including the element that relates to radiologists, perhaps updating it from “shortly” to “in the next week”, as it surely has to come before the 75thanniversary of the NHS on 5 July.
The concern we continually have with announcements of new services by the NHS in the current context is that they will come at the expense of existing services; the noble Baroness, Lady Merron, also referred to this. I believe this is a rational and reasonable concern to have, given the evidence of missed targets and unacceptable wait times that is all around us. I hope the Minister can give us further assurances that, as the Government will the end of catching more cancers earlier, they will also be willing to will the means to deliver on this promise.
Anyone with eyes in their head can see that vaping is being cynically promoted to young teenagers; it is all around us in high street shops and in the evidence from the litter around schools. The Statement refers to the role of vaping as a tool to help existing smokers give up their harmful habit, but there is increasing evidence that vaping is creating new nicotine addicts, with associated risks. The Australian Government have found that young people who vape are three times as likely to take up smoking, and they have plans to bring in a range of measures to suppress vaping among young non-smokers. Can the Minister explain what assessment the UK Government have made of the Australian evidence of vaping leading to higher smoking prevalence among young people, and are the UK Government considering similar measures to reduce vaping use here? It took us five years to follow Australia in introducing plain packaging for cigarettes. I hope we can follow faster here, on vaping.
The new screening programme is welcome, but it must be properly resourced with both machines and people. I hope the Minister can give us some insights into how that will happen, and at the same time explain what action the Government intend to take to reduce vaping among non-smokers, so that we do not end up creating a new wave of people who are at risk of lung cancer.
Lord Markham (Con)
I thank the noble Lord, Lord Kennedy, and I am sorry for the loss of his brother. I agree with his sentiment that while this is good news today and is welcomed by all, it shows that this is a journey and that we need to do more in lots more areas. I take on that point and say, from our point of view, that we agree that we must work together to make further progress.
Baroness Merron (Lab)
Could I give the Minister another opportunity to pick up on the key point I raised? We very much welcome the improved diagnosis rates—and my noble friend Lord Kennedy makes a very pertinent point that, of course, we are talking not just about one cancer. I thank him for sharing his views and feelings with your Lordships’ House. That takes me to my reminder to the Minister: I asked about matching improvements in diagnosis with improved access to treatment; otherwise, we are leaving people diagnosed but not matching it by giving them the treatment they need in a timely manner. Could the Minister assist with that point?
Lord Markham (Con)
I am sorry; I was answering in a generic format in terms of the new CDCs. The noble Baroness is quite right that diagnosis is one thing—and we all know that the early stages are key—but you then have to follow that up with treatment. Of course, the good news is that if you can detect cancer in people at the earlier stages, they need less treatment. The resources I mentioned, in terms of what is being spent on the programme, take into account the treatment required as well.
Of the people being identified at this stage, only 1.4% from the pilot were then positive and needed treatment, thankfully. Obviously, those resources are in place. There is a second interesting category of people—about 17% or so—who are fine but we want to make sure that what has been noticed is in an okay state.
I am going to grab my notes to make sure I am referring exactly to the right term at this stage. I apologise; about 1.7% have nodules, which is not a problem per se, but it is a problem if those are growing. The idea is that we will be getting those people back in for frequent scans on a three- to six-monthly basis and using AI technology to see whether or not the nodules are growing. If they are not growing, it is not a problem, but we then keep up the frequency of scans. Obviously, if they are growing, that would be a concern at the early stages, and that would then move them into the treatment category.
The other 80% or so of people fortunately will not have any concerns from the scan at all. At that stage, they will be put into this continual programme, where they will be reviewed every couple of years to make sure that we keep on top of it. I hope that this shows that this is a well thought-out, entwined service, with the idea being that for the 1.4% who are identified as needing cancer treatment, the treatment is there to back them up.
NHS: Performance and Innovation
Baroness Merron Excerpts(1 year, 6 months ago)
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Baroness Merron (Lab)
My Lords, I am most grateful to the noble Lord, Lord Scriven, for securing this debate and giving us the opportunity to think about the link between current performance and innovation. I am also grateful for his introduction of the subject before us.
The noble Lord, Lord Crisp, and other noble Lords were absolutely right to remind us that innovation is about not just technology, important though that is—I will come back to that—but people, their practice, their professionalism and the way they work together. I hope the Minister will bear that in mind, because we are going to come to the issue of the workforce plan, which we still await.
A number of noble Lords have made the point that they have resisted talking about the difficulties faced by the NHS, but I am not going to resist. While the Minister has had a break, we must return to that subject because the fact is that the NHS has just not been able to meet many of its pledges—for example, on maximum waiting times—in recent years. The noble Lord, Lord Allan, made reference to the gap between the expectation that people have of the NHS and the delivery that they experience. We have raised that many times in this Chamber, and it is not just about expectation; it is also about people’s absolute need. It is more than disappointing that so many legitimate targets—which were set for a very good reason, which was to provide the best kind of healthcare—have just fallen by the wayside.
At the beginning of the year, the number of people on a waiting list for hospital treatment rose to a record 7.2 million. That number consistently rose between 2012 and 2019, and has risen more quickly since early 2021. I hope the Minister will resist constantly blaming the pandemic. It is of course true that the pandemic exacerbated waiting lists and has created many new challenges, but these problems existed before the pandemic and it would not be right to hide behind it, particularly when, for example, the 18-week treatment target has not been met since 2016.
The percentage of patients who have waited more than four hours in hospital A&E also rose consistently between 2015 and 2020, with a new record high reached in December 2022. We have discussed ambulance response times in this Chamber many times. These too have risen, with the average response time to a category 2 call in December 2022 standing at over one hour and 30 minutes, when the target was 18 minutes.
On cancer waiting times, targets are repeatedly missed and performances in April were among the worst on record. To give just one example, in April the 62-day target of 85% was not met, as only 61% of people started their treatment for cancer within 62 days of an urgent referral. This means that some 5,200 people who started treatment for cancer in April waited longer than 62 days after an urgent referral, when we all know that speed is of the essence.
In all this, my noble friend Lord Parekh and other noble Lords were right to say that there is much concentration on hospital care. Hospitals are of course a key part of the infrastructure, but we need to have more focus on primary care and to see joining-up—not just across government but, as noble Lords have said, across the whole NHS, along with social care. Noble Lords also spoke rightly today about the importance of prevention. The noble Lord, Lord Addington, and others raised this; we have to put far greater emphasis on prevention.
It is true that there has been a number of innovations and they are very welcome, but they are small fish when we compare them with the big picture. When we look at the revolution taking place in medical science, technology, working practices and data, we are missing out on the potential to transform our healthcare. There is absolutely no reason why this country should not be leading the rest of the world in this field, but it so often feels as if the NHS is stuck in something of an analogue age and that it has been allowed to happen under the watch of this Government. The future of the health service has to see, as noble Lords have said, more care taking place in the community. That would reduce the burden on hospitals; it would also allow patients to receive healthcare in their own home or close to home. But a slow adoption of technology has worked against this, as has the lack of joining-up within the system.
In his welcome intervention, my noble friend Lord Turnberg gave examples of both existing and previous practices that could be called upon. He also referred to the importance of having higher standards and a higher regard, and reward, for social care workers. If we are to support the development of social care and the healthcare system, those workers are absolutely essential.
The noble Lord, Lord Crisp, drew on examples of the network of community health workers in other countries, including Brazil. When I was an International Development Minister, prior to being a Health Minister, I also saw such networks growing and flourishing across African countries. They were built on trust, on locality and on harnessing people’s abilities and their links with communities. As the noble Lord asked, is it not interesting that that has inspired innovation in places such as Westminster and Calderdale? Who would have thought that?
I must say to the Minister that throughout the debate, I have been left reflecting that innovation, while it does exist, is patchy, and that is part of the problem. The IPPR estimates that, for example, the introduction of automation could be worth some £12.5 billion to the National Health Service by freeing up, among other things, staff time and by creating better productivity. Why are we not drawing on that?
I will refer to some missed opportunities, and then perhaps the Minister can explain why we find ourselves in this position. There are now tools which can map radiation therapy on to cancer cells and avoid organs more precisely than can an oncologist working alone. They do that in seconds, rather than the hour it takes a doctor. This is standard technology, used across the United States. However, just one in three radiotherapy planning centres in England uses this technology.
Between 1 million and 2 million mammograms are done across the UK every year. Although 96% will not find cancer, women are currently left in the dark for weeks, and even months, waiting for their results. The noble Lord, Lord Allan, suggested something quite obvious: why is there not a better technological means to notify people of their results? Why is there a hold up on mammograms? Because two clinicians are required to check them, and there is a workforce crisis. However, AI could rule out cancer-free screens in seconds, giving patients their results faster and freeing up clinicians to focus on the tests that display abnormalities. It has been rolled out across Hungary since 2021, but not across the National Health Service.
AI can also help to interpret chest X-rays, saving 15% of a radiologist’s workload. When combined with interpretation by a consultant radiologist, it could reduce missed lung cancer cases by 60%, but it has yet to be fully adopted by the NHS. Can the Minister tell us why?
We all know that staff shortages across the NHS workforce are not only a barrier to meeting important waiting times but also limit the NHS’s ability to adopt and develop innovation, in both a technical and technological sense, and a people sense. We have recently been told that the NHS workforce plan will arrive shortly—after many years of it not arriving shortly. Perhaps the Minister could again answer the question of when we will see it, whether it will be fully funded, whether it will ensure a look to the future and how it will deal with the immediate.
The NHS should not be lagging behind. It is a universal, single-payer service and it ought to be the best-placed healthcare system in the world to take advantage of changing technology and medicines. After all, what other health service can offer innovators a market of some 50 million patients and give the life sciences industry access to a diverse and large population sufficient to develop new medicines, in the way that our NHS can?
In drawing my comments to a close, I want to offer some solutions from these Benches to add to the points raised by noble Lords in this debate. On procurement, the NHS should identify the goods and services that should be purchased at scale and buy them at a discount. This would also cut out unnecessary bureaucracy and stop new technology being re-evaluated for years, while the world moves on and beyond. In clinical trials, I suggest that every trust could operate through a standard system so that the number of contracts needed is minimised and the administrative burden is eased across the system.
While I accept the point made by the noble Lord, Lord Allan, that apps are not everything, they are important and proper use of the NHS app could be made and extended. It currently has some 30 million users—that is a tremendous reach—but every patient should be able to see their medical records through it. They should be able to use it easily to book appointments, order repeat prescriptions and link to appropriate self-referral routes. When patients reach an age at which they should be screened or need a check-up, the app should alert them, just as we are constantly alerted by apps in other areas. If people are eligible for a clinical trial, the app should tell us.
For the NHS to be fit for the future, it has to make fundamental change and there has to be a different way of doing things. I hope the Minister will reflect on the debate today and take heart from the fact that we all want to see change, but that he has the responsibility to deliver it at present.