NHS: Long-term Sustainability

Baroness Murphy Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Murphy (CB)]

My Lords, like the noble Baroness, Lady Pitkeathley, this morning I was reminiscing about the number of NHS debates I have taken part in since I came here 20 years ago. It is at least one a year—I gave up counting when I got to 20—and the tenor of those debates has got more and more depressing. We have had words of wisdom that I have heard several times before—I mention in particular the noble Lord, Lord Hunt of Kings Heath, who always gives a characteristic, brilliant overview of what needs to be done. I disagree with him and the noble Lord, Lord Reid, about the Blair years’ injection of money and reforms. They certainly improved things for a short while but they were never continued, neither during the Blair years themselves nor afterwards. One of the problems with central government control, which we have had, is that you have no history. Nobody remembers. The next Department of Health enthusiasms come along, and no history is remembered by one set of Ministers after another.

I find it utterly heartbreaking to witness what has happened over the last 20 to 30 years, having been first employed in the NHS when I was 17 as a healthcare assistant, having been through the whole gamut of levels of interest and having worked alongside the NHS. No amount of money thrown at the NHS will do anything to improve productivity, generate a workforce proud to belong to the NHS, or produce a quality of care to rival the best in the world that we aspire to, nor change the chronic defensive culture, which is disastrous. We have the skills and the talented people, and we waste them by profoundly inefficient human and capital infrastructure.

The NHS is dying. Dentistry has died in the NHS, more or less, and the NHS is also dying, bit by bit. I was shocked when I was admitted as an emergency last year to a district general hospital in East Anglia. The quality of care and the ongoing support provided were appalling, and that is not a badly rated hospital. I understand that now up to a quarter of young people in London aged 19 to 24 cannot bear to be treated as they are by trying to get a GP appointment, so they go online and pay £39 for an online GP appointment. They are seen on video instantly and they get a prescription the same day. That will happen more and more unless we do something.

Of course, the last 13 years of organisational muddle, with no one able to make any serious decisions and endless time-wasting, has made things a lot worse. We still have this centralised system, which has not changed since 1948 and which gets worse from time to time.

In March there was a Question—I think the noble Lord, Lord Markham, answered it—about the decision to concentrate children’s cancer services at the Evelina rather than the Royal Marsden. I have no axe to grind—I do not know either of those institutions—but my overwhelming sense was that the noble Lord, Lord Markham, should not have called that in for another decision or looked at it again. He should have said, “Let the NHS managers who have made this decision get on with it”. The sooner we get our hospital providers out from under central control, the better. The model where we have everybody in the provider system and everybody in the funding system controlled by central government works only in very small countries. Luxembourg and Iceland both have our system, and it works quite well. After many years of having a more sensible system, the Canadians adopted our system and their health service has gone steadily downhill, with increased waiting lists and people not getting the central funding from federal government that they need. It does not work. When will we accept that we need to develop a model where the providers and purchasers are separate?

I have run out of time so I will just end with my hope that the next Government, whatever colour they are, will get to grips with the need for profound reform, and of course include social care as well in the necessary reform.

Care Home Staffing

Baroness Murphy Excerpts

Thursday 18th January 2024 Lords Chamber

[Lord Markham (Con)]

I thank my noble friend for the question. The whole point of trying to develop the career structure that we talk about is to make sure that it is a career that people want to go into across the board, be it in urban or rural areas. Part of that is putting in place about 100,000 training places—this is the first place in the world that has been set up—to try to set up a real career structure. We are starting to see early signs of it working. The number of beds blocked has decreased by 10% in the last few months. It is early days, but it is beginning to work.

[Baroness Murphy (CB)]

My Lords, does the Minister not agree that, while the increase of 70,000 people is very welcome, it is in the context of a turnover of nearly 400,000 every year in care because of the poor career structure? I understand and appreciate that £70 million has been put into training and a care workforce pathway, but does he not agree that it is profoundly inadequate compared with the £11 million a day that is put into NHS nurse training?

[Lord Markham (Con)]

The 70,000 increase is a net increase, so it takes into account the turnover of staff, many of whom rejoin somewhere else in a social care setting. Notwithstanding that, I agree with the noble Baroness that a turnover rate of around 28% is too high in any sector. For about 20% of employers the turnover is only 10%, so clearly some know how to develop a career structure and have motivated staff who will stay there. The intention behind the programme and the career pathway we are trying to set up is to try to get more of that across the system, because retention is key.

Dementia

Baroness Murphy Excerpts

Thursday 18th January 2024 Grand Committee

[Baroness Murphy (CB)]

My Lords, like the noble Baroness, Lady Browning, I am proud to be an ambassador for the Alzheimer’s Society. I spent my entire working life as a psychiatrist, working with older people who mostly had dementia and depression.

The situation has got a lot worse in both health and social care since I started working in it. The situation in the health service is appalling, in that they have no training with dementia, and that has not improved. In fact, most people in the health service have no idea what social care is. Indeed, if you asked most of the ladies and gentlemen in our main House, they would not have a very good grasp of what social care is either.

First, we need a total rethink around how we educate the general public about what this disease is about and how it imposes costs on society. The phrase “parity of esteem” is all very well and I like it—it started as a funding phrase in the United States—but almost all the real costs of dementia in this country fall on social care services and on families. At the moment, the estimated cost is £27 billion. Of that, a good 80% is spent by families and social care.

It is not the severity of dementia that demands care; it is the activities of daily life. There was a lovely, elegant piece of research in Denmark looking at what factors of dementia require care from others, and they are always the activities of daily life. That is what social care is and where we should put most of our money.

I do not agree that more MRI and PET scanners would make a jot of difference to diagnoses because a diagnosis is usually made by the family or home carers before they get anywhere near. I know it is nice that we can now diagnose; I had a lecture called “150 Types of Dementia”, which went down a bundle at Queen Square I can tell you. The reality is that half a dozen are interesting, and there are some more that we are starting to understand better, but that is not the issue. It is about very basic care. The drugs will not be around for a long time yet. The ones we have now are nowhere near fruition in terms of clinical service to all the patients who need them.

I back up what my noble friend Lord Warner said about the need to fund both organisations—health and social care need to be integrated to deliver this service—but we are a hell of a long way off.

Neurological Conditions

Baroness Murphy Excerpts

Thursday 9th June 2022 Grand Committee

[Baroness Murphy (CB)]

My Lords, I am so pleased that the noble Lord, Lord Dubs, raised this issue. One is always humbled in speaking in a debate where so many participants either can bear witness to the personal impact of a life-changing disorder or have been close enough to have supported people throughout.

I share with the noble Baroness, Lady Fraser, the notion that we want not only neurologists. She referred to what I call the “hit-and-run brigade”: you go, you see them, you are diagnosed and you are off. That is it; you might get a follow-up appointment if you are lucky. I know because I have been there: I have been one of those people. I know how difficult and frustrating it is to provide a service. I trained for two years at what was then called the National Hospital for Nervous Diseases in Queen Square and its outpost, a delightful hospital at Maida Vale. It was one of the most fulfilling expenses of my life. It was very lovely. They used to bring us junior doctors a little silver teapot every afternoon for afternoon tea. Those were the days, when the NHS was a little different if you were at a posh hospital, which that was. In the end, I retreated to my first love, psychiatry, but I have obviously seen a lot of neurological conditions since then.

The problem is that we are down to one neurologist per 170,000. France has one per 50,000. Italy has one per 5,000 head of population. They are very well-trained neurologists, who are almost all dually trained in psychiatry. That makes a phenomenal difference to access and to the importance of the specialty in the general bargaining power.

Some very welcome changes have happened. National clinical directors are to be appointed in neurology, neurosurgery and spinal surgery. They will be crucial, because the commissioning of these neuroscience services will be devolved rather than done centrally. Those appointments will be utterly crucial for making an impact. Noble Lords might ask what difference they will make, but I remind them about getting the right person in the right place. When I was at Queen Square, stroke disease was not a neurological condition, even though it is the commonest neurological condition there is. It took a neurologist, Charles Warlow, in Edinburgh and his colleagues saying, “No, important physicians and neurologists should be interested in this as a core business.” In part, we need that focus again around these very disabling, chronic disorders.

I have a special interest in one range of disorders: that spectrum that goes from Parkinson’s disease through Lewy body dementia through Alzheimer’s disease. They are similar, but if you treat one with the wrong medication you get adverse reactions. They are highly disturbing and very disabling conditions. It is a very sad way to end your life with any of these conditions when they become very serious. Because we do not have access to neurology or specialist neuropsychiatrists, we have a situation where access to diagnosis and to the right kind of support and care just does not happen. People fight for months to try to get a diagnosis; it goes on for years. People get one diagnosis after another, and shoved from pillar to post. Sometimes it is only five to 10 years later that people actually get the right diagnosis.

It is crucial that we get some kind of agreement about who should care for these people and how we should get them channelled. The number is increasing as the population ages; naturally, the prevalence is rising in the older population. I give major support to the notion that we should have a neurological task force to look at the increasing demands of these serious and disabling disorders.

Health and Care Bill

Baroness Murphy Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Murphy (CB)]

My Lords, I am an NHS recidivist, like many in this House today, but, after 40 or 50 years of employment in it, I am not necessarily a great fan.

Somebody mentioned 20 reorganisations; I can think of nine that I was personally involved in, some of which I was very enthusiastic about at the time. Looking back, I see that none of them addressed the NHS problems of chronic low productivity and some very poor outcomes—the noble Viscount, Lord Bridgeman, mentioned some relating to cancer. I know some of the data is difficult and not easily comparable, but we are consistently producing poorer outcomes than we should be getting for the resources we are putting in, particularly resources going into those who are employed in the NHS.

The third great problem is, as always, the attitudes—the hangover—which are particularly marked in some parts of the country. Certainly, there are the attitudes of the NHS to its patients and to our feeling that we are supplicants asking for help when we should be receiving a service as of right. These attitudes have not really shifted and have, in many ways, got worse.

I understand why we might be having a reorganisation now. After all, the direction of travel that we have been moving in for so long has come to a bit of a standstill because of the difficulties of foundation trusts not being able to exercise any powers because they are in debt. The direction of travel seems to have come to a full stop. Everyone is asking for better integration between health and social care. We must deliver that. The difficulty is that, if you look at where integrated social care works, it does not work because of senior management only. We have had integrated care boards in Northern Ireland since 1973. I have visited and seen them enthusiastically in action. In fact, at senior level, they work quite well, and some interesting programmes have come out of them. However, when you look at them on the ground, you see that health and social care staff are not necessarily working together. They must be collocated in teams that are jointly managed to make a real difference to individual patients and their carers.

This Bill is a little part of the start of a system that could work but there are some great big holes. For example, I would like to know to whom the integrated care partnerships are accountable. Certainly, we cannot see any way that their strategic plans might be necessarily taken over by the integrated care boards. Do we have some guarantee that they will take notice of what the integrated care partnerships want?

The other problem is the great white shark of the NHS swimming alongside a shoal of sardines, including local authorities, care providers and independent sector care provision. I have seen it time and again: the shark always gobbles up the resources. We saw it again in the recent care Bill. I want to know how that will be addressed. Can the Minister guarantee that we will get mental health as an equal partner on the integrated care boards? That seems utterly essential. Public health must also be in there. Can the Minister reassure us that that will be in statute?

Another problem with this Bill is the clawing back to centre of powers. Again, I understand the frustrations that Ministers see. I remember watching Sir Edward Heath hold up the closure of a rather second-rate neurosurgical unit for 10 years because it was in his constituency. I watched Sir Frank Dobson being seduced by consultants at Barts and the London and ending up with a profoundly expensive two-site system that was quite unnecessary for east London. I want to know how—I hope that the Minister will be able to reassure us on this—those doing the detail on this Bill will somehow constrain ministerial meddling.

Eating Disorders: Provision of Care

Baroness Murphy Excerpts

Tuesday 4th February 2020 Lords Chamber

[Baroness Murphy (CB)]

My Lords, I think that it was Wallis Simpson who famously said that you cannot be too rich or too thin. We never in this House debate being too rich, but we occasionally debate the problems of those who aspire to be too thin. Wallis Simpson, famously, ate almost nothing and was probably mildly anorexic.

The noble Baroness, Lady Parminter, has outlined the terrible situation that families find themselves in when they have a child or young person suffering from this terrible disorder, whether or not it is anorexia nervosa, obesity or bulimia—bulimia in particular is very difficult to treat, as is anorexia.

While I was driving down from Norfolk this morning, I listened to an excellent edition of “Woman’s Hour”, on which a young woman called Hannah described her own anorexia and how it felt to her. She had been waiting for treatment in the Greater Manchester area for 18 months, and she was offered just one of a group of services that were available in the area, with no thought as to whether it was appropriate for her. Even then, it was a great time coming. Dr Agnes Ayton, chair of the eating disorders faculty at the Royal College of Psychiatrists, made many of the points, brilliantly and articulately, about the difficulties that people have in accessing services, saying that while we have invested in young people’s and children’s services through child and adolescent mental health services, we have left young adults far behind in their ability to gain access.

Having re-read the debate instigated by the noble Lord, Lord Giddens, back in 2013, it strikes me that we have repeated this evening exactly what was said during that debate: that there has been very little improvement—and, of course, the numbers have gone up. As to why the numbers have gone up, the noble Lord’s own specialty has told us: they have perhaps been rising since the 1960s. We are very keen to say that it is not a lifestyle choice, but it is lifestyle factors that have made people want to go down this route in the first place. Biological triggers turn a normal seeking of a slim, elegant, beautiful figure into something much more pathological. That is the thing that we really do not understand.

As the noble Baroness, Lady Parminter, said, the report by the NHS ombudsman on how patients are failed was truly shocking. Since then, we have had much better guidance in commissioning, but those documents are often ambitious, noble but pie in the sky and are not widely taken up, for all the reasons which have been articulated. Eating disorders are more common than people realise. Some 80% of people who have them never go to a doctor, and many episodes are managed in families with no access to specialist services. Such services may not be needed, because, within a few weeks or months, the child or young woman has tackled the disorder themselves and has been able to get to grips with what has become a pathological desire to be thin without flipping over into something that does not get better. It is important to remember that, because those who are referred are therefore often in great need of specialist care, and that is the thing that is so difficult.

Eating disorders are of course prevalent in young men as well, particularly those with a gender disorder of some kind or who are troubled by their sexuality. I have treated at least two young men with anorexia nervosa and found them quite as difficult as young women to reach and help through their disorder. It is also common—and getting commoner—in older people. My Aunt Florence never recovered, and died when she was in her 90s. She was slim, but healthily so, all her life until she was in her 80s, when she started to adopt strategies identical to those of a much younger woman. This was similarly pathological, and she starved herself almost to death. Elderly people who get these disorders are often inappropriately investigated, because of the link between physical ill-health in old age and loss of appetite. Perhaps “inappropriately investigated” is not fair, but these things are much commoner in later life than one might imagine.

We have had the commissioning help after the ombudsman’s report and we got the extra £30 million put into young people’s services, but it has simply not touched adult services. Other noble Lords have already mentioned the mortality rate, so I will not stress that.

Historically, such disorders were a lot commoner than we think. There is a description of an illness suffered by Mary Queen of Scots which is a classic eating disorder. There are explicit medical descriptions from about 1670. In the 19th century an awful lot of young women had a condition called chlorosis. People turned slightly green because they had iron deficiency, but it is also thought that this was largely caused by anorexia. There were pressures on young women then which they too addressed in that way.

Treatment is extremely difficult. Evidence-based treatments are few and far between. What we try to do is keep people alive and at a healthy weight long enough for them to get a grip on it and recover for themselves. That is true not just for anorexia nervosa but for many other mental health disorders, for which we do not have the specific treatments we have for psychoses. People need a lot of help, support and psychotherapeutic approaches. The ones that are good for some people may not be for others. The commissioning document makes it clear how important it is for people to be given choices.

My time is up. I stress that we need more investment in a choice of services which are readily accessible for people locally, so that they do not have to just accept what their local service provides. That is the major thing the Government should be doing. What are they intending to do?