NHS: Debt

Baroness Walmsley Excerpts

Monday 23rd January 2017 Lords Chamber

[Lord O'Shaughnessy]

It is certainly the case that one part of the system impacts on the other parts, whether that is primary, secondary or social care. There is no denying that and I do not seek to do so. On the picture the noble Lord paints of worsening deficits, in fact, the picture in 2016-17 is considerably better than it was in 2015-16. It has been helped not least by the sustainability and transformation plans. We are putting £1.8 billion into trusts, 95% of which have accepted control totals to get a hold of that financial sustainability. Extra funding is going in. There is a big increase this year for the NHS budget, which will help, as will the extra money for social care; but of course the challenges are there.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that 96% of hospitals say that they employ fewer registered nurses than they themselves have planned for safe staffing of the wards, and some of them employ more healthcare assistants than they had planned for? What does the Minister say to those who suspect that hospitals, in an attempt to deal with their deficits, are employing too few registered nurses for safe staffing of the wards and/or putting less qualified people on the wards?

[Lord O'Shaughnessy]

Clearly, trusts have a responsibility to make sure that they have the staffing right. There are more nursing places available and more coming through training, as we talked about in the House the other day. There has been a general uplift in staffing numbers because of the safety requirements post Francis, especially as we seek to leave the European Union, which will mean that that source of nurses and staff in general will change. We have to train more of our own staff, which is why we are increasing the number of doctor and nurse training places.

Mental Health and NHS Performance Update

Baroness Walmsley Excerpts

Monday 9th January 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for repeating the Statement, and welcome him to the Dispatch Box.

Of course we welcome any announcement that will help to improve mental health services in this country, as indeed we welcomed such announcements exactly 12 months ago, when the then Prime Minister made similar promises. But it seems that the more Prime Ministers promise, the less the NHS delivers. I remind the Minister that the Government’s record actually shows that we now have 6,600 fewer nurses working in mental health than were inherited. We have also seen a large reduction in mental health beds. I remind him of the report and analysis by YoungMinds just before Christmas, which showed that local children’s mental health budgets were raided in order to plug funding gaps elsewhere in the NHS. The survey revealed that when clinical commissioning groups were asked whether the extra £1.4 billion pledged over five years in 2015 for child and adolescent mental health services was going to be spent on CAMHS, nearly two-thirds of CCGs that responded said they used some or all of the money to backfill cuts or spend on other priorities. This has been replicated on a number of occasions when it comes to pledges made by the Government in relation to mental health. The fact is that they simply cannot guarantee that the NHS will deliver. What certainty do we now have that the pledge made today by the Prime Minister is going to be implemented, given the lamentable record of NHS England and the NHS in responding to similar pleas in the past? Why did the Prime Minister refuse to say this morning that she would ring-fence this money to ensure that it indeed went to the services that she said it had to go to?

I turn to the winter crisis. This morning the Secretary of State said that things have been falling over in only a couple of places, but the reality is that one-third of hospitals declared last month that they needed urgent help to deal with the number of patients coming through the doors; we know that accident and emergency departments have turned patients away more than 140 times; 15 hospitals ran out of beds in one day in December; and several hospitals have warned that they cannot offer comprehensive care. We know that we are going back to the dreadful days of the 1990s, with elderly patients left languishing on hospital trolleys in corridors, sometimes for over 24 hours.

Whatever the labels that charities use, whatever the semantics, the Government cannot deny that the NHS is facing a severe winter crisis, the culpability for which lies firmly with the Government. Does the Minister agree that it was a monumental error to ignore the pleas for extra support for social care in the Autumn Statement? Will he now support calls for the £700 million of social care funding allocated for 2019 to be brought forward to help services to cope this winter? Will he urge the Chancellor and his right honourable friend the Prime Minister to announce a new funding settlement for the NHS and social care in March’s Budget?

I listened with great care to the remarks the Minister made on the four-hour A&E target. The implication is that the Government are running away from the target and are now going to use different definitions for who is going to be expected to have that target met and who is not. I remind the Government that in 2010 they inherited a 98% rate for the four-hour target being met, which the NHS had achieved. Under his Government, the NHS has reduced its achievements in A&E consistently, year after year. As far as I can see, the Secretary of State’s weasel words today about the four-hour target show that the Government are now admitting that they will never achieve that target again. What are the Government doing? We know they are going to change the target and the definitions. On that subject, what guidance has the Minister taken from the Royal College for Emergency Medicines that the so-called new standard is actually appropriate?

I turn to the deaths of two patients at Worcestershire Royal Hospital. They had been waiting on hospital trolleys. Will Ministers lead an inquiry into those deaths? Are they aware whether these were isolated incidents? When does the trust intend to report back on its own investigation?

I have been reading today the draft Herefordshire and Worcestershire sustainability and transformation plan, which Ministers point to as a solution to all their problems. The problems of the Worcestershire acute trust have been known for many years—it simply does not have the capacity to deal with the flow of patients into that hospital—yet the sustainability and transformation plan actually plans for fewer beds in that trust over the next three to four years. How on earth can the Government justify reducing the number of beds in that trust when it is under such tremendous pressure because of a lack of capacity?

There is no doubt that much of the current crisis could have been avoided. Hospital leaders, council leaders, patient groups, MPs across the Commons and noble Lords all urged the Chancellor to give the NHS and social care additional resources in the Autumn Statement, but those requests fell on deaf ears. We now see the dismal consequences. The Government need to do very much better.

[Baroness Walmsley (LD)]

My Lords, I also welcome the Minister to his first appearance in his new role. I add thanks from these Benches to all the health and care staff who gave up their Christmas holidays to care for patients.

We welcome the Prime Minister’s attention being turned to mental health, and the emphasis on the roles of schools and the workplace. The NHS of course cannot do the job alone. However, many people are not getting mental health treatment, getting it late, not getting the right treatment or getting it many miles from home, which prevents their families and friends supporting them. As the noble Lord, Lord Hunt, said, the money is not getting through to front-line mental health services, despite the £1.4 billion secured from the previous Chancellor by my right honourable friend Norman Lamb when he was coalition Health Minister. Why is that?

Is it not true that if there were not a shortage of funding for other services, CCGs would not be tempted to raid the mental health budget? That is what they are doing. FOI requests by Young Minds, as has been mentioned, show that half of CCGs are using money allocated to children’s mental health to prop up physical health services, which are also in crisis. That is wrong. A recent survey of child and adolescent psychiatrists show that a whopping seven out of 10 of them thought that mental health services for children and young people were inadequate. By any calculation, that is a national disgrace.

Will the Minister ring-fence the money that has been promised to mental health and improve transparency with the publication of the mental health dashboards, which are meant to show how much is being spent on mental health services in every area and on what services? The £1 billion that has already been announced for adult mental health is back-loaded to the end of the Parliament. Will the Government bring it forward to deal with the current crisis? Will they at last acknowledge that there must be a cross-party discussion about how to raise the money needed for health and social care? Will they ensure that the lessons learned in Manchester about integration are spread to other areas? That could save money and provide better service. Will the Government provide more funding for social care? As the noble Lord, Lord Hunt of Kings Heath, has said, without that, nothing will improve.

To return to mental health, I acknowledge that funding is not the whole story. The main point of the report from the values-based CAMHS commission, chaired by my noble friend Lady Tyler of Enfield, was that there needs to be a shared set of values and a shared language across all those involved with children and young people’s mental health, thereby enabling the system to have widespread change and a far more joined-up response to mental health issues. Does the Minister agree with that? How could it be achieved?

[Lord O'Shaughnessy]

My Lords, I thank noble Lords for their kind welcome. First, on mental health, which is clearly the subject of the Prime Minister’s Statement today, I think this is a good news day for mental health services. We know that this part of the system has suffered from not being seen by some people as as important as physical health. We have now legislated for parity of esteem, but of course parity of esteem comes about through practice, not just through law, and part of that is about a series of changes to ensure that this is a high-quality system that is available not just for some but for all.

With regard to performance, there is a lot of strength within the system. My predecessor, my noble friend Lord Prior, whose abilities I pay warm tribute to, would always say that there is lots of innovation and quality in the health service. One of the challenges that we face is diffusion. Part of the purpose of the strategy today is about taking best practice and moving it around the system. There is good practice. We have fantastic dementia diagnosis rates, the IAPT system is being copied by other countries and we have a record number of psychiatrists.

As someone who has spent the best part of 15 years working in schools, I think we finally have recognition that something significant and serious is going on with our young people that needs a new approach. With the promise of a Green Paper on children and young people’s mental health, I am optimistic that we have an opportunity to deliver what the noble Baroness said—getting everyone who cares about this subject around the table and making sure that we deliver the kind of strategy that is going to do two things. The first is to help schools and young people to identify mental illness where it exists and to access treatment; the second and, arguably, more important, is to build resilience so that young people are better able to resist the various pressures that they are under and to stay in good mental health, because that is our ultimate goal.

There is £1 billion to implement the plan. It is reasonable to ask how it will get to the front line; clearly, this money should not be being diverted to other services. The noble Baroness said that transparency was critical here. CCGs need to report in a much more detailed, open and honest way about where that money is being spent, so that we can ensure that it is going to front-line mental health services.

There is a challenge every winter; that is not unique to this Government. The Statement pays tribute to the incredible work of the staff in the NHS and social care system, and I add my voice to that. They are working at an extraordinary level and under a lot of pressure. Clearly, unacceptable things are going on, such as trolley waits of more than 12 hours. The key is being prepared and, where there are problems, working out what to do about them. The NHS has been well prepared for this winter, with £400 million going into preparedness plans, which it has tested to ensure that they are robust. Although I have been in the department for only five days, judging by the interest, passion and application of Ministers and officials, I can say that a close eye is being kept on this not just in the department but in NHS England and NHSI. As we say in the Statement, we will continue to support trusts to deal with challenges, particularly in fragile areas—some of which, as the noble Lord, Lord Hunt, said, we have known about for some time. Help is going in.

On social care, there was more money in the Autumn Statement, which I am sure was welcome, and a change to front-load the precept, which will make a difference, and we have the better care fund, so funding is increasing. However, more people are accessing the service, and we know why: because of the demographic pressures. Since 2010 there are now some 1 million more over-65s, so the system needs the extra support the Government have provided. The noble Baroness was quite right when she talked about integration. One opportunity that we have in the five-year forward view through the sustainability and transformation plans is the creation of much better integrated systems which focus not simply on the number of beds, although that is important, but on delivering the best outcomes. As we know, lots of people in hospitals would be better cared for if they were in the community or at home. One challenge that we face is ensuring that those patients who would be better treated in that environment have the opportunity to move out, freeing up those beds for those who need them.

We are committed to the four-hour target, as my right honourable friend outlined in the Statement, and have delivered many more doctors and nurses to ensure that we can deliver a high-quality service. We are dealing with 9 million more visits to A&E every year than we were in 2000. We need to ensure that we are delivering a service which continues to provide the best quality care in whatever setting is most appropriate, and never lose sight of the fact that A&E is there for a specific purpose, particularly for the support of the most vulnerable. About a quarter of A&E admissions are from the over-65 age group, which is growing, so this will get more challenging.

On the specific issue in Worcestershire, it is of course a terrible tragedy. The trust and NHS Improvement are investigating, and I do not think it would be appropriate for me to comment at this time, other than to say that we will be watching very closely what happens as a consequence of those investigations. Plans are already in place to support the trust and ensure that it can improve, but it is not appropriate for me to comment on the specific deaths that occurred.

We know that additional resource is not just about money; it is about service configuration and how we deliver a better service. We are providing £10 billion more in real terms to the NHS over the course of this Parliament. That is what we were asked to deliver, and that is what we are delivering, in concert with NHS England. It is the responsibility of everyone within the system to ensure that we deliver the best possible service.

Health Service Medical Supplies (Costs) Bill

Baroness Walmsley Excerpts

2nd reading (Hansard): House of Lords
Wednesday 21st December 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for his explanation of the Bill. However, while I have no problem with the Government’s intention of closing the loopholes identified in the statutory scheme for medicine cost regulation, aligning schemes and ensuring that medicines are reasonably priced and affordable to the NHS, I do have quite a lot of questions. I also share the concerns raised by the noble Lords, Lord Warner and Lord Lansley.

My first question is whether this is the right time to make these changes, with Brexit on the horizon. Some of the Bill’s provisions add further uncertainty to what is already a very uncertain time for the businesses affected by them. If trade between the UK and other EU countries becomes subject to customs duties, import VAT and border controls, it will increase costs to the life sciences industry and drive up costs to the NHS. This will certainly impact on patients. As the Minister has acknowledged, the life sciences industry is very important to our economy, and these changes could impact upon it very adversely.

There is no doubt that the medicines bill has risen over the past five years, but what evidence is there that this is just because of unreasonable price rises in the pharmaceutical sectors that are not currently controlled, such as generic medicines? We have heard a lot about increased demand in all areas of medicine and care, and this is usually attributed to greater longevity and a general increase in medical advances to treat more conditions better. So why do the Government think that the rise in the medicines bill is any different? Yes, of course, like other noble Lords I have heard of one or two particularly outrageous cases of enormous unexplained price rises in generic medicines, and this is suspiciously like profiteering. But is it really necessary to go as far as this Bill does in order to deal with just a few very unethical cases? I am a little surprised that the Government are acting before we see whether the current cases under competition law are actually going to deliver the right result. As I said, I accept there is a loophole for generic medicines sold by companies in the voluntary scheme, but what is the extent of the use of that loophole? How much is the NHS losing, and how much are patients suffering because of profiteering?

Clause 1 provides the Government with a much stronger enforcement mechanism for obtaining the payments rightly owed, but does this constitute an amendment to the current PPRS, and if so, does it require the agreement of all those involved in a future scheme? Will there be any discussion with companies that propose price rises? There are many reasons why prices sometimes rise, apart from a desire to make more profit. There should be some mechanism for finding out whether the price rise is justified and reasonable, rather than someone in the DoH just making an arbitrary judgment.

We have concerns that the traditional appraisal methods and notions of cost-effectiveness are no longer suitable for some modern medicines, especially for very innovative new drugs which will be suitable for only a very small population of patients. The NHS has been slow to respond to these changes and I would not want to think that the Bill could make things worse.

There is a need for much more clarity about Clause 3. The payment mechanism, which really amounts to a tax on net sales, will, we understand, be set somewhere between 10% and 17%, so it seems reasonable to ask how the Government will assess the impact of their chosen level on the availability of the medicine concerned. Will we know what percentage the Government plan to choose before the Bill completes its passage through your Lordships’ House? We would not want its unintended consequence to be shortages of certain useful medicines.

As we have heard, Clause 5 brings medical devices within the scope of price regulation. Is there really any evidence that there has been price abuse among suppliers of medical devices, as we have heard there is in relation to pharmaceutical items? With these items it is vital that there is a range of products for patients to choose from, as something that suits and works for one patient may be very uncomfortable for another. That is why driving down the cost of products will not necessarily save money in the long term. If a patient cannot get on with his or her life and contribute to society, an unsuitable but cheaper product could cost the economy more money in the long run.

Companies have told us that this section of the Bill is vague and does not make the Government’s policy intentions clear, so they need more reassurance. Nor are those intentions adequately covered in the Explanatory Notes or the impact assessment accompanying the Bill. That has prevented companies fully understanding how the provisions will affect their business. It is not very reassuring for the Government to say that they do not intend to implement all sections of the Bill immediately, because this uncertainty makes it impossible for businesses to plan when their main customer might be able to hold them over a barrel on price at some unknown time in the future. I certainly could not run a business in that sort of climate. Unsurprisingly, businesses are very concerned about this. Some clarity was offered during the Bill’s passage through another place, including, as I have just mentioned, the fact that the Government have no immediate plans to use the powers, but they could decide to use them at short notice at any time in the future. That provides the very uncertainty that investors hate and it is very bad for business.

Clauses 6 and 7 concern data collection. It seems very strange to me that the National Health Service Act 2006 already contains the power for the Government to require medical technology suppliers to provide them with information, and the Government have said that the Bill will clarify and modernise those powers. We have heard from officials that the penalty for non-compliance will be changed from a criminal to a civil one, which will be more proportionate to the offence. However, as these powers have not been used to date, the fact that the Government are making these changes suggests to some that their use may be planned in the not-too-distant future, and that brings more uncertainty.

One can understand the Government wanting and needing information in order to ensure that the reimbursement system works effectively, but the new provisions go a lot further than the current requirements and may put a very heavy administrative burden on companies. We have been told by officials that the intention is to make this burden as light as possible, and that is good, but how will this be done when, I understand, separate information will be required for every product throughout the whole supply chain, even for those outside this country? Companies tell me that currently they do not collect all the information the Bill requires and they would find it very difficult to do so. Is all this information really necessary to achieve the Government’s intentions in the Bill?

There is an issue about consultation. Some suppliers are claiming that the Government’s statement in another place that there has been extensive consultation is simply not true. They were not consulted. Only a few large trade organisations were consulted. We really need from the Government a clear commitment to proper consultation before these regulations are finalised and implemented. It is essential that the Government proactively engage with the entire industry before bringing forward legislation such as this.

I believe in evidence-based policy and that the Government should always be transparent in their intentions when they make changes, as mentioned by a previous speaker. However, at the moment that is not the case. If the powers are to be used, they should say so, and then there should be proper engagement and consultation with the businesses affected. It is in the interests of the companies affected that they work with government to support consumers and the NHS. After all, that is what they do; that is their business. The Government are asking for clarity from NHS suppliers about costs throughout the supply chain, so should not suppliers be able to expect clarity from the Government in return?

My primary concern is that any increase in payments by manufacturers and suppliers to the Department of Health should be put to use in improving access to new medicines and ensuring that existing medicines are provided in a timely way to all patients who need them. So far, I have not been assured by the Minister that this is what will happen to any increased payments. I wonder whether he is willing to do that today—after all, it is Christmas.

We need to see this Bill in the wider context of the struggle of the NHS and social care to provide services in the light of rising demand and costs. Apart from their efforts in this Bill to control costs, the Government have ignored that. The recent Statement announcing a small amount of additional money for social care, and the allowance of a raised local authority precept, will not bring money into the deprived areas that need it most. Until this is dealt with, measures such as those in the Bill are only scratching the surface of the problem.

Finally, I join the noble Lord, Lord Lansley, in paying tribute to the noble Lord, Lord Prior. It has been a great pleasure to work with him. He has always been very patient and courteous with us in this House in answering our questions. I also thank the noble Baroness, Lady Chisholm of Owlpen, who I understand is also moving on. I wish them both a very peaceful and restful Christmas and extend that to other noble Lords and to the Bill team. I look forward to working with whoever it will be in the new year as we move on to the Committee stage of the Bill.

HIV Diagnosis: Clinical Guidance

Baroness Walmsley Excerpts

Thursday 1st December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I am very happy to arrange a meeting of that kind. We are expecting an announcement very soon on the PrEP issue and it may be worthwhile having that meeting after that announcement.

[Baroness Walmsley (LD)]

My Lords, a high percentage of people living outside London compared to those in it are unaware of their HIV infection. It is 24% compared to 12% in London. Are the Government doing anything in the regions to replicate the good practice that we are beginning to see in London, so that that situation disappears?

[Lord Prior of Brampton]

My Lords, I think more is done in London simply because there is a greater incidence of HIV there. I was not aware of the difference between those two figures—the 12% and 24% which the noble Baroness referred to. I should like to look into that point and write to her.

Social Care

Baroness Walmsley Excerpts

Thursday 1st December 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been an excellent debate with many thought-provoking speeches, including, in particular, that of the noble Baroness, Lady Pitkeathley, in introducing the debate and that of the noble Baroness, Lady Cavendish.

Yesterday morning, there was a story on Radio 4’s “Today” programme that neatly illustrated how problems with social care affect the whole health and care system. The story was about ambulances and the fact that in the past year 500,000 extra hours were spent by ambulance crews waiting outside A&E departments, unable to discharge their patients, while other serious and urgent cases stacked up awaiting their arrival. The head of emergency medicine for the NHS gave an account of new ways of working that may help put a sticking plaster on the problem. However, the story illustrates very clearly the interaction between the various parts of the health and care system.

Of course, the reason ambulance crews have to wait so long is that A&E departments are full, unable to move their patients to beds in the wards because they are full too. One of the reasons that the wards are full is the delays in discharging patients to appropriate care in care homes or their own homes with a suitable package of help—and we know that people go to A&E, where the lights are on, because they cannot get an appointment with their GP. Nearly 570,000 bed days were lost in acute hospitals during the second quarter of 2016-17 as a result of delays in discharging patients, with problems in arranging social care now the main reason given by hospitals for these delays. This comes at a cost to the NHS of £820 million a year. The story illustrates why we need to sort out social care, apart from the need to ensure that elderly and disabled people get the care they need in a timely and dignified way.

The Care and Support Alliance of 90 charities points out that, as well as relying on help with everyday tasks such as washing, dressing and eating, social care plays a vital role in supporting recipients and their carers to move into, or stay in, employment, and in preventing avoidable expenditure, particularly in other parts of the health service. The charity Sense, which works for deafblind people, points out that in the past year alone 11.4% fewer people with sensory impairment were able to access services. This has greatly curtailed their community involvement and life chances.

The whole system is like a pack of dominoes that will fall with a great clatter unless something is done. That is why I, along with others who have spoken today, was shocked and horrified that, despite all the evidence that has come forward about the dreadful state of care funding, the Chancellor said not one word about it in the Autumn Statement and provided not one extra pound. The interoperability of all parts of the system of health and social care indicates strongly the need for a cross-party consensus on how we fund it in this country—I welcome the support on that from the noble Lord, Viscount Hanworth. While I look forward to the report of your Lordships’ ad hoc Select Committee on sustainability in the NHS, chaired by the noble Lord, Lord Patel, we need to go much further, as my right honourable friend Norman Lamb has so often proposed. We need to look at all the options: insurance schemes, the German scheme, the Japanese scheme, general taxation and national insurance.

The nearest thing we have to an independent commission is the King’s Fund and the Nuffield Trust, which work together and with others to inform the debate. Since the disaster of the Autumn Statement they have said that they now expect a funding gap of at least £2.4 billion in social care next year. That means that the intense pressure on services will continue to grow, increasing the burden on older and vulnerable people, their families and their carers, as the noble Baroness, Lady Farrington, has told us.

In its recent report on the sector, the CQC said that social care is at a tipping point. The CQC does not often use such language, but it should know, since it inspects all the services. However, it did report that 72% of settings were good or outstanding, and that is a credit to all those working in the sector who do their very best for the service users despite all the problems. The facts, however, are dismaying. Following multiple cuts to local authority funding over the past six years, 26% fewer older and vulnerable people are receiving services, while demographics mean that demand is rising. Because the potential for most local authorities to do any more within existing resources is limited, my colleagues in local government tell me that they will soon struggle to meet even basic statutory duties.

As we have heard, companies providing places in care homes are handing back contracts to local authorities because they cannot provide adequate care—the sort of care they want to give—with the funding that they get. Some are concentrating on self-funders. Indeed, self-funded service users are subsidising state-funded users in some places, and I agree with the noble Baroness, Lady Browning, that that is not fair. The national minimum wage—I still refuse to call it a national living wage because one cannot live on it—is putting enormous pressure on already small margins. Aside from the quantity of care available, good-quality care matters for many reasons, not least of which is that good care homes, working with their local GPs and community pharmacies, keep people out of A&E and other hospital departments.

Domiciliary care fares no better. Fifty-nine councils have had home care contracts terminated, affecting nearly 4,000 people. Three large national domiciliary care providers with multiple contracts have withdrawn from the market or are planning to do so. The critical condition of home care services threatens to undermine policies to support people at home, which, as we have heard, is where most people prefer to be, near their families and friends who can often help with care and are happy to do so within their capabilities. An estimated 1 million people now have unmet needs for care and support in England and research on disabled adults suggests that at least two in five are not having their basic needs catered for.

The new 2% precept increase that local authorities are allowed to raise does not help deprived areas where the majority of care users are state-funded and low council tax receipts from low-value properties will not raise anything like the amount of money needed. In those places, the potential for cross-subsidy from self-funders is minimal too. Besides, the precept, if fully applied overall, will raise only two-thirds of the cost of the increase in the national minimum wage in a sector where most employees are on that level of pay. At the same time, the Government have delayed until 2020 the implementation of Part 2 of the Care Act 2014, which introduces a cap on care costs and changes to means testing. These are reforms proposed by the Dilnot commission in 2011 and this breaches a Conservative Party manifesto commitment. So can the Minister say when it will happen, since many people are now doubtful as to whether these reforms will ever see the light of day?

The King’s Fund believes that our starting point for reform should be the Barker commission recommendation of a new settlement for health and social care, based on ending the historical divide between the two and moving to a single budget and single local commissioning of services. I agree with that, but there is also a very large elephant in the room, and that is the looming Brexit. We spoke about this at length in last Thursday’s debate. A damaged economy, resulting in a lower tax take, and uncertainty about the future of the many thousands of care staff who come from other EU countries cast an enormous shadow across an already staggering system. When will the Government do the right thing and offer them certainty?

It cannot be right that the care and support received by older and disabled people increasingly depends on where they live and how much money they have—a postcode lottery—rather than on their real needs. Although additional funding is badly needed in the short term, in the long term reform is what is required. The only game in town on that front at the moment is the sustainability and transformation plans, funded by the Better Care Fund, but there is evidence that, first, the emphasis is on sustainability rather than transformation and, secondly, that local authorities, patients and care providers are the last ones to be consulted on the plans. How can services be integrated when crucial parts of the system are not being properly consulted and funds that should be used to develop and pilot new ways of working are just being used to prop up budgets in deficit?

As the King’s Fund said:

“England remains one of the few major developed countries that has not reformed the way it funds long-term care in response to the needs of an ageing population … A number of commissions and reviews have been set up over the years and made recommendations about how to place social care on a sustainable footing. However, successive governments have failed to grasp the nettle”.

I am a gardener and I know the value of nettles: they support wildlife and you can even make nourishing soup out of the small leaves at the top of the plant. So will the Government grasp the nettle, because they may find it good for them?

Health and Social Care

Baroness Walmsley Excerpts

Thursday 24th November 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I, too, thank the noble Baroness, Lady Finlay of Llandaff, for introducing this debate. I note with interest that not one speaker thinks Brexit will be good for health and social care. The tragedy of the vote on 23 June—by 37% of the electorate—is becoming more apparent every day, not least yesterday, following the Autumn Statement. The OBR has reacted to the statement by giving us an independent assessment of where we are now and where we are likely to be, as a nation, as a result of the actions of this disastrous Government, who cannot even stand up for their own judges, let alone stand up to their own right wing.

The Government say that we have a £220 billion Brexit black hole and will have rising unemployment, lower wages and higher inflation, resulting in lower living standards. The projected fall of £8.2 billion in tax receipts over the next two years will seriously impact on our public services. That fall is enough to fund more than 330,000 nurses.

It was shocking that there was not a single mention of social care in yesterday’s Statement from the Chancellor, despite the £1.3 billion hole in social care budgets needed by 2020 simply to stabilise the system, let alone deal with rising demand and reverse the fall in the number of people able to squeeze through the rising eligibility barriers for care. More than two-thirds of acute hospital trusts are in serious deficit and this figure is projected to rise. These are the real effects of Brexit on our national treasure. We cannot pay for the staff we need in the NHS and social care if tax receipts are falling unless the Government make different choices.

Our public sector workers have not had a decent pay rise in years and are promised in the coming year less than expected inflation—in other words, a real-terms pay cut. That is why we on these Benches called for the Chancellor to announce £4 billion extra for the NHS and social care yesterday and a decent pay rise for public sector workers—but he did not. Instead, we will be spending much more than that on additional civil servants charged with getting us out of the EU. You could not make it up.

In addition to that situation, since 23 June there has been enormous uncertainty, as we have heard from other speakers, among providers of health services and social care about whether they will be able to retain the staff from EU countries already here and recruit new ones in the future. The current staff from these countries are valued and essential to the operation of health and social care, and yet the Government refuse to give them any reassurance. Thirty thousand doctors, 55,000 nurses and others, 90,000 care workers and goodness knows how many medical researchers from the EU are currently working in the UK. Without them, the NHS and care services would fall over and our research efforts will be damaged. EU funding supports many of our medical research programmes and I am very concerned that without it, after Brexit, UK patients will no longer benefit from clinical trials and early adoption of the cutting-edge treatments that they bring.

Others have picked up their own areas of concern about the health and social care workforce but I should like to mention two groups: midwives and people supplying medical equipment. In April this year there were 1,192 full-time-equivalent midwives from other EU countries working in the NHS in England, according to figures from NHS Digital. In London alone, 16% of the NHS midwifery workforce was from elsewhere in the EU—674 full-time equivalent midwives. At University College London Hospitals NHS Foundation Trust, 32% of the midwifery workforce was from the EU. Outside London, in both Basildon and Thurrock, and in Walsall, more than 10% of midwives were from other EU countries.

On the latest calculation, the NHS in England is already short of around 3,500 full-time midwives. Without EU midwives, that shortage figure would be over 4,500. We need more midwives, not fewer. The Royal College of Midwives believes that any policy that could see EU midwives blocked from continuing to be able to work in the NHS post-Brexit would be very damaging for maternity services across the country and truly catastrophic for London. Can the Minister tell us what plans the Government have in their negotiations to protect our maternity services?

The information I have just mentioned concerns the proportion of the current midwifery workforce coming from the EU. It does not take account of how many join or leave in any one year. It is important to consider this churn because, even if existing EU midwives were able to stay, any who then returned to their home country might not be easily replaceable. The latest figures available on that churn, from September 2014-15, show that during that period 189 EU midwives left NHS employment and 248 started—a welcome increase. Simply allowing existing EU midwives to stay without taking any account of allowing new ones to come would lead to a fall in numbers. In summary, the NHS in England has been short of midwives for years. We need all the midwives we can get; currently well over 1,000 of those we have are from other EU member states. We need them.

Turning to my other concern, many people working in health and social care are involved in the provision and support of medical devices for their patients. Brexit will pose problems for them, too. At present the UK is closely involved with EU regulatory bodies in licensing about 150,000 medical devices. Licensing by these EU bodies ensures that patients receive safe and appropriate medical equipment. It also means that the businesses responsible for their research, development and sale can trade easily within the EU, and with other countries, based on EU-wide approval. There are thousands of jobs in these businesses and they affect millions of patients.

Many EU countries value UK expertise in the regulatory field and much of the approving of medical devices for use across the EU is done here in the UK. Casting us adrift from this EU-wide process and creating a wholly separate regulatory process will weaken the process of approving innovative medical devices and create barriers for businesses working to develop them.

Who knows what the results of negotiations will be, but it would make sense to continue the regulation of medical devices on an EU basis. However, that will not be possible if the EEA, EFTA or customs union models are rejected. What we do know is that creating a “bespoke” regulatory process as part of a hard Brexit will make it more difficult to develop and get approval for the kind of medical devices that will assist those working in health and social care to support patients properly, and in many cases to help them live their lives as independently as possible. That includes patients of all ages with chronic conditions, elderly people, people with disabilities and people with learning difficulties.

Creating our own bureaucracy for regulating medical devices will be costly and at the expense of direct support for people who may benefit from them. Why spend the money on new bureaucracy rather than on more prostheses, heart pacemakers, computerised blood sugar regulators, mobility aids and much more? In addition, failing to maintain EU-wide systems will threaten their future development here in the UK. If we are to leave the EU, the UK businesses that are researching, developing and promoting medical devices would clearly prefer a new arrangement in which the system remains EU-wide, even if that means a loss of sovereignty and the need to pay a share of the costs of EU-wide regulation. If the Government are determined on a hard Brexit to appease their right wing, however, this important UK industry will suffer, work will move to the EU, and those working in the health and care sector will find that the changes have been detrimental to their patients. There could be huge and unnecessary costs for the supplying of medical devices if there are not, at the very least, long transitional arrangements allowing issues such as labelling to be addressed. Will the Government’s industrial strategy take account of this important health-related industry?

The process and consequences of Brexit will cost this country millions and have already cost us trillions of pounds because of the fall in the value of the pound. What will the Government do to minimise the negative effect of Brexit on the health of the nation?

Mental Health: Children and Adolescents

Baroness Walmsley Excerpts

Wednesday 16th November 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, there is no doubt that whether it is housing for young people or loneliness for old people, many factors affect people’s mental well-being. The noble Lord may be interested to know, as I know that his particular interest is in looked-after children, that we have set up an expert working group to look particularly at that case. Interestingly, 85% of the local transformation plans that have been developed single out looked-after children as a group that requires special attention.

[Baroness Walmsley (LD)]

My Lords, I welcome the mental health dashboards, which allow people to hold their local clinical commissioning group to account for how much it spends on mental health, including on children, and on the quality of the services that it provides. However, can the Minister say how those dashboards are being publicised, and whether there is any way in which local people can benchmark the performance of their local CCG compared to others across the country?

[Lord Prior of Brampton]

My Lords, transparency is critical to this and every CCG will have its improvement assessment framework. Unless I am badly mistaken, they will all be in the public domain and it will be possible to look at the relative performance of each CCG. NHS England will also produce its own matrix and integrated dashboard, which will have all the key information about funding, the numbers of people accessing mental health provision and the improvements that those people achieve once they are in the system.

Hospitals: Unsafe Discharge

Baroness Walmsley Excerpts

Wednesday 9th November 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Baroness, Lady Wheeler, on submitting the same Question for Short Debate as the one that I submitted myself, but clearly she was in front of me in the queue.

This is a very important topic, impacting, as it does, both on the health of individual patients and their families and on the sustainability of the health and social care services. As usual, we see in the PHSO report evidence that we will never achieve sustainability in the health service until we address the shortfalls in budgets and provision in the social care service. Only recently we heard about more social care providers handing back local authority contracts because they are unable to make a reasonable profit while providing an adequate standard of care. One of my colleagues, who is a local councillor, told me that, in fulfilling its statutory duties relating to social care, her council now has to spend 33%—and rising—of its budget and that, if this carries on, the council will soon run out of money.

Care providers are not fat cats who do not think that they are making enough money; on the whole they are caring companies which have reluctantly had to admit that they cannot go on as they have recently been forced to do and deliver the standard of care they want to give. We have also had media stories about the fact that those who are self-funding in care homes are paying a premium of up to £400 per week to subsidise the home’s budget and compensate for the shortfall in local authority payments for publicly funded patients in the setting. From every point of view, this is an unsatisfactory state of affairs, which threatens to get worse, and it backs up the call by my right honourable friend Norman Lamb MP for an independent or cross-party commission on how the health and care systems can be sustainably funded.

I turn to the detail of the report. When I asked an Oral Question about this on 15 June, the Minister’s first Answer was to the effect that the sustainability and transformation plans would integrate health and social care, fill the black hole in funding and solve all our problems. So my first question to him today is to ask him to follow up on that Answer. We have heard in the news recently that STP boards must delay making their draft plans public for two weeks because of the concerns of some Conservative MPs that the plans may involve controversial hospital closures. Is that the case?

That is not the only concern I have heard. I am told that the development of the plans has been very top down and has been led by the acute hospitals, despite the fact that one of their main purposes is to plan how patients can be treated in primary and community care rather than in expensive hospitals. I have also heard that local authorities and community groups have not been involved in developing the plans but have been told that they can comment after the plans are complete. Once the ink is dry on the paper, people can do no more than tweak the plans. Given that these plans need to fundamentally reform the way that care is delivered, and given that the most successful change is bottom up, this is no way to go about it. It will produce the “not invented here” syndrome. I have found that health and care professionals will engage enthusiastically with change that they know will work because they have recommended it, but not when change is imposed on them. Every manager knows that the best changes, and those that are easiest to implement, come from the staff suggestion box.

Also, I have heard that “sustainability”, not “transformation”, has become the over-riding objective. In other words, boards have been told that the books must be balanced, and this has resulted in outrageously unrealistic plans. The Government were wise to call these plans “sustainability and transformation” because, through transforming how services are delivered, we might achieve savings. However, it cannot be the other way round. I also heard a health economist make the very valid point last week that in mental health there has been a transformation from in-patient care to care in the community, but this has taken 20 years. The point he was making was that the timescale for the Government’s STPs is quite unrealistic.

If ever there was a demonstration that this process needs to be carried out properly, it is to be found in the PHSO report on unsafe discharge. The point that I made in my supplementary Oral Question in June, quoting examples from the report, was that there are problems on both sides of the discharge cliff edge: problems in the hospital and problems with the care to which the patient should be discharged. The Minister answered:

“My Lords, there are millions of interactions between patients and consultants and doctors every day of the year, and there will be some mistakes. We cannot draw conclusions from one or two desperate situations. In so far as they reveal systemic problems, it is valid to draw attention to individual cases of this kind, and there are some systemic issues lying behind the PHSO's report. In particular, it states:

‘We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight. …health and social care ... have historically operated in silos’”.—[Official Report, 15/6/16; col. 1216.]

I agree with the Minister that there are millions of satisfactory—nay, exemplary—interactions every day, but the report quoted specific examples only where the ombudsman felt that they did demonstrate systemic issues. That was made very clear in the report. But common sense tells us that mistakes are more liable to be made when people are under great pressure. The Minister also acknowledged that these historic barriers to safe discharge cannot be fixed overnight. So why are the STPs expected to fix them in the health service equivalent of overnight, which is in three or four years?

No doctor or nurse wishes to discharge a patient into unsafe circumstances, but mistakes will be made when the pressure on the service is so great and there is such a shortage of hospital beds, according to the briefing from the BMA. In its submission to the Public Accounts Committee inquiry on this very same subject, the Royal College of Physicians revealed that 40% of advertised consultant vacancies remain unfilled, mostly due to the lack of suitably qualified candidates. At the same time, the Government are telling us that they do not want to bring in doctors from abroad. This is quite unrealistic in the timescale quoted. The RCP says that the,

“staffing crisis is impacting on physicians’ ability to swiftly assess patients… to tailor their care plans and to work across disciplines to achieve safe and timely transfers of care”.

The RCP also emphasises that more needs to be done to prevent unnecessary admissions, and quotes examples where early access to multidisciplinary assessment led to a reduction of up to 24% in hospital admissions. Patients were given care in more appropriate settings and pressure on hospitals was reduced. That is what we should be seeing across the board.

It also makes the point that better integration between hospital and community settings is fundamental in preventing patient readmission to hospital. That was one of the regrettable consequences of unsafe discharge, according to the report. To be fair, this integration is one of the major objectives of the STPs. Why, therefore, in too many cases, is one partner producing the plan and then showing it to the other for comment?

The Royal College of Nursing, in its briefing for this debate, accepts that poor care is unacceptable, and agrees with many of the findings of the report. It mentions the problems with recruiting and retaining nurses in the NHS and shows a link between shortages and poor patient experience. Can the Minister tell us what impact the Government expect the change in funding for student nurses to have on this situation and what effect this will have on the availability of nursing homes?

The RCN also points out that discharge targets mean little if the resources in social care are not there to meet them. What do the Government plan to do about this? They must surely accept that the small precept for social care which has been allowed to local councils to cover the cost of the increase in the national minimum wage will not do so—and by the way, I refuse to call it the national living wage because no one could live on it. We also know that in the areas where most is needed for social care, because of the predominance of publicly funded patients, the ability to raise extra cash from the precept is the lowest. This is a topsy-turvy policy that the Government are labelling a legitimate solution to the problem.

I ask the Minister what plans the Government have to address the shortfall in funding for social care and the shortage of doctors and nurses, the main causes of unsafe discharge? There are problems with communications and poor interoperability of IT systems, but—although they should be addressed—they are not the great big elephant in the room. We all know what that is. When will the Government address it and stop burying their head in the sand? Even Simon Stevens and a Select Committee in another place have questioned the Government’s claim that they have given the NHS all it asked for. They have not, and the five-year forward view remains an aspiration and not a plan.

Without a properly funded plan, the crisis in health and social care, of which unsafe discharge is very sad evidence, will continue as demand continues to rise. Instead of picking fights with junior doctors and community pharmacists, the Secretary of State would be better advised to tackle this with his usual energy. If he did so, his name would go down in history as the best Secretary of State for Health we have ever had. I await that day with bated breath.

NHS Funding

Baroness Walmsley Excerpts

Monday 31st October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I will try to respond to those last three points. First, the noble Lord is right: the NHS is—and I would regard it still as—the highest-value healthcare system in the world. It does have fewer doctors and MRI machines—however you want to measure it—compared to many other OECD countries, but its outcomes, on the whole, are very good. I can, therefore, certainly confirm that the NHS is a very high-value healthcare system. As far as the involvement of the NHS in the plan is concerned, it was very much put together by the NHS and signed by all of the arm’s-length bodies at the time. This is a quote from Simon Stevens about the spending round settlement:

“This settlement is a clear and highly welcome acceptance of our argument for frontloaded NHS investment. It will help stabilise current pressures on hospitals, GPs, and mental health services, and kick-start the NHS Five Year Forward View’s fundamental redesign of care”.

This brings me to my last point, the fundamental redesign of care. That was possibly not really recognised at the time of the NHS review, because it is a fundamental redesign of care. As the noble Lord said, it means moving resources away from acute settings into community settings, very much as mental health care was restructured 20 or 25 years ago.

[Baroness Walmsley (LD)]

My Lords, the Secretary of State said that there were going to be another million over-75 year-olds in five years’ time, and I very much hope that I am going to be one of them. May I give the noble Lord a couple of other statistics? The King’s Fund quarterly monitoring report found that, for each month in the first quarter of this year, there were an additional 54,000 attendances at A&E departments and 14,200 emergency hospital admissions compared to the same time last year. All these emergencies are no way to run a health service.

The noble Lord and the Secretary of State pray in aid the five-year forward view as if it were a statement of fact. It is a plan; it is an aspiration, and at the time it was written, the hole in the funding of the NHS was not £4.5 billion, as the Select Committee says has been given to the health service; it was not £8 billion or £10 billion: it was £30 billion. The Government gave about a third of it and suggested, through the five-year forward aspirational plan, that the rest could be done by efficiencies. We have the STPs, which are supposed to find those efficiencies. We have heard many times in this House over the last few weeks about the shortcomings of those, so when will the Government respond to my right honourable friend Norman Lamb when he calls for a cross-party commission on proper funding of social care and the health service?

[Lord Prior of Brampton]

My Lords, I am sure that the noble Baroness will be here well past the age of 75, and that there are many years to come before she reaches that age.

The noble Baroness is absolutely right: for many elderly people, the worst way to be treated, frankly, is to be blue-lighted in an ambulance into an A&E department of a very busy acute hospital. The whole purpose of the five-year forward view is to deliver care to many more such people outside. I think we all agree with that. The noble Baroness’s party, like ours, agreed with the £8 billion of extra government spending over the course of this Parliament, and accepted the fact that very significant efficiencies could be generated from the NHS. We still subscribe to that view, and the STPs will be the right vehicle for delivering many of them.

Mesothelioma

Baroness Walmsley Excerpts

Thursday 27th October 2016 Grand Committee

[Baroness Walmsley (LD)]

My Lords, I, too, would like to focus on the patients—the 2,500 British people who are expected to die each year of mesothelioma, most of whom have contracted the disease as a result of exposure to asbestos. The use of asbestos in industry and construction, although now banned, was a practice that has had a detrimental effect on many lives, and it is our duty now to offer sufficient aid to those it has affected.

Asbestos lurks in many strange places, including, as we have heard from the noble Lord, Lord Alton, this very building. My husband and I recently demolished an old cottage on our property, and we discovered that there was asbestos in the floor tiles with which my late mother-in-law had been living for 40 years. We had to have them removed by specialists. In the 1970s, when I lived in an old farmhouse, I used an asbestos product to fill the rather irregular holes that I used to drill in the walls to hang pictures and bookshelves, having no idea that there may be a problem with it. Concerns about the dangers of asbestos were first raised early in the 20th century, but its use was not outlawed until 1999. For the thousands of cases now arising 40 or 50 years after first exposure, it is our responsibility to ensure that they are given the compensation and support they require. Unfortunately, the median survival time for pleural mesothelioma, once it has taken hold, is 12 months from diagnosis, but this time, and beyond for the dependents of those affected, must be made as comfortable as possible for those who need help.

Over the years, there have been many shortcomings in the handling of asbestos-related cases across the globe, one such case being the fire at the central ordnance depot in Donnington, Shropshire, in 1983. The blaze which released a huge cloud of asbestos into the air has had a huge repercussion which is still being felt today. Paula Ann Nunn, Ellen Paddock, Susan Maughan, Richard George and Marion Groves are just five local people who contracted mesothelioma and unfortunately passed away as a direct result. Mrs Maughan died only last October. Her daughter told the inquest that it took the local authority five days before they told the community so they were exposed to asbestos for all that time. The ash cloud which spread over an area of 15 square miles attracted many small children who played in it as if it were snow which fell in local gardens for days before people were told it was unsafe. We have heard from the noble Baroness, Lady Finlay, how very harmful that could be to those children. My colleague and noble friend Lady Pinnock has told me about many cases in her area of Kirklees, resulting from working for a brake linings factory, long since closed down.

Mesothelioma is generally resistant to conventional cancer treatment. Long-term survival and cures are extremely difficult, but that does not mean that the mistakes of government and industry alike over the past century should not be paid for by compensation to those affected. The current range of available benefits, both lump sums and long-term allowances, must get to the right people at the right time. The Mesothelioma Act 2014, for which we have to congratulate several noble Lords present today, went a long way to help those who had been unable to access compensation because of the passage of time or a lack of effective record-keeping identifying those responsible. Since 2014, a total of £62.2 million has been awarded. However, of those who were unhappy with the result and requested a review of what they were awarded, 25% had their compensation rate altered—I presume upwards. Given that this illness is still an issue affecting thousands of British people every year and that the nature of mesothelioma’s progress means that time is literally of the essence, it is essential that the correct support is awarded without delay in all cases. Given the significant number of cases reviewed since the launch of the scheme, how do the Government intend to learn from those cases and improve the process so that the right decision is made the first time in as many cases as possible?

Can the Minister also outline the ways in which the Government are promoting the compensation scheme, so that those most in need are fully aware of the support available? Given the vital work done by the charitable organisation, Mesothelioma UK, and its invaluable lung nurse specialists, do the Government intend to follow its lead and introduce more specialist nurses into hospitals to support patients?

Finally, to safeguard against mesothelioma cases slipping under radar given the disease’s lengthy latency, are the Government willing to begin actively seeking out those involved in previous incidents, such as the Donnington fire, so as to promote early identification of their disease and to get immediate support to them?