Allied Health Professionals: Training

Baroness Walmsley Excerpts

Monday 8th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, as I said, overall there is a small net increase of 334. That is largely for paramedics, where HEE believes that there is a more serious shortage than for other allied health professions. As I said, we have seen a significant increase in AHPs of more than 16% over the last five years and we expect that growth to continue after 2017.

[Baroness Walmsley (LD)]

My Lords, how will the Government achieve their objectives in relation to modernised cancer treatment and an enhanced role for radiographers when Health Education England is cutting the number of training places for therapeutic radiographers by 4.3%?

[Lord Prior of Brampton]

Actually, I think the number of radiographers is going up slightly. I will check, if I can, and write to the noble Baroness. It is also worth mentioning that the number of medical endoscopists is planned to go up by 200 over the next three years.

Junior Doctors

Baroness Walmsley Excerpts

Monday 8th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the noble Lord said he had three questions; I think there were only two questions there, which is unusual, if I may say so. We do not want to impose a contract. We want the BMA to come back and continue the talks and we still hope that that will happen. Clearly, imposing a contract is not what we ever wanted to do when this whole process started. As was said in the Statement, the Secretary of State’s door is open and we hope that we can resolve these difficult issues in a negotiated, consensual way.

On the noble Lord’s second question, he rightly said that this is an appalling situation, but actually I describe it more as a tragedy. Let me quote from a trainee doctor:

“I feel undermined and not valued at work and I have seen how this flagging morale among colleagues has caused more than ever to leave the profession. It is a hard job that takes dedication and stamina to continue. But as we are criticised and treated as ‘cogs in a wheel’ rather than as individual professionals, I think we will see ever increasing numbers of people leaving this profession”.

That was in 2005, after the contract came in. The issues facing the junior doctors go back a long way. It is not just about plain time on Saturdays or this particular contract but about how we value, reward, train and trust junior doctors. That is the issue we must come to when the current dispute is resolved.

[Baroness Walmsley (LD)]

My Lords, I think that the Minister did not answer the question from the noble Lord, Lord Hunt, about which hospital chief executives believe that the junior doctors’ contract is what is getting in the way of seven-day services. Surely the state of primary care, which is stretched all over the country, and the lack of diagnostics, laboratory services, X-rays and so on in hospitals are much more significant.

My own question is about plain time, which I believe is the sticking point. It occurs to me that the best way of ensuring patient safety is to make sure that we do not have tired doctors. Can the Minister convince me about the fact that we are being told that junior doctors will not have to work any more hours than they do now? If you are extending plain time from 8 am until 10 pm, instead of 7 pm, and into Saturdays, then it strikes me as quite possible that they will work much longer hours. I would be very interested to know what the average working week of a junior doctor is now compared to 20 years ago, because it strikes me that we are in danger of going backwards.

[Lord Prior of Brampton]

My Lords, I apologise for not replying to the question earlier about the number of chief execs. The point is that this is not just about junior doctors; I think we all understand that totally. We are hoping to have more primary care, more social care, more diagnostics and more senior consultant cover at weekends, which will support junior doctors and make their lives better at night time and over the weekend. As far as the hours are concerned, the new contract proposal puts far greater safeguards over the amount of time that junior doctors will be working. I think that is largely accepted by the junior doctors. Going forward, the maximum number of consecutive nights will be down from seven to four; the maximum number of long shifts—that is, over 10 hours—will be down from seven to five; the number of consecutive late shifts will be down from 12. We are putting in those safeguards to ensure that we do not go back to the bad old days of very long hours. They were the bad old days on one level but if you actually talk to most doctors, they did get tired and it affected safety but it built a sense of teamwork, camaraderie and purpose in hospitals. We need to be careful about rubbishing the old days when they built up a lot of really serious, good professional work.

Opticians Act 1989

Baroness Walmsley Excerpts

Monday 8th February 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, first, I apologise to my noble friend Lord Newby for missing the first half-minute of his speech. I am afraid that I was not informed that this debate was to start 15 minutes early; I thought that I was 10 minutes early.

I thank my noble friend for explaining what this debate is all about and for putting the case for looking at this issue again so comprehensively that there is no need for me to repeat it. To me, there are three principles that should apply when considering this matter.

First, the best interests of the patient must come first, so we must ask ourselves whether changing the law would or could do any harm to patients. Secondly, we need to consider whether availability of this new eyewear would deter people from getting a full eye test from a qualified ophthalmologist. Thirdly, would the state of the current law prevent patients receiving any additional benefits that might be available to them through the over-the-counter availability of this new product? We should bear in mind that, when the law went through Parliament, there was no such thing as self-adjustable eyewear, so perhaps it is time to review it.

In considering this matter, we must be impartial to both those already in the optical services business and to those who want to get into it. Could the briefings we have received amount to vested interests? Some noble Lords think so. I am afraid that I think that those who have provided the briefings might have vested interests, although it is perfectly reasonable for them all to make their case and I am sure that they are all providing legitimate information. That is why I ask the Minister whether the Government will set up a completely independent impartial investigation to receive evidence from both sides of the argument and make a truly impartial recommendation, and then will they act on it at the earliest opportunity?

The evidence we have received from the manufacturer Adlens suggests several benefits and no harms. Like the noble Lord, Lord Faulkner of Worcester, I really must congratulate it on its charitable work in Rwanda and other places. It is doing some very important and worthwhile work, which will benefit the economy of that poor country enormously, as well as individual patients. However, it stands to make money in the UK if the law is changed, so we should be aware of that. Mind you, it would probably be a very small amount compared to what companies make in the USA and Japan where these glasses are already allowed to be sold off prescription.

On the other side of the argument is the General Optical Council, the Optical Confederation, the professionals and the retailers who have a financial interest in selling the fixed-prescription spectacles which they prescribe. Of course, they also have a professional duty to put the patient’s eye health first, and I am sure that is their priority.

There would be a very strong argument for refusing to change the law if clear evidence existed that the availability of these adjustable spectacles over the counter deterred people from having a proper eye test—but I have seen no such evidence. We must bear in mind that eye tests are not just done to diagnose and correct vision but also, as the noble Lord, Lord Faulkner of Worcester, pointed out, to screen for eye health and indicators of other types of ill-health. They are very important, which is why we give them free to children and older people.

The fact is that we have been choosing our own vision correction for years. When I go to the optician, I select “red” or “green” and lens 1 or lens 2 all the time. I am selecting my own correction. What, therefore, is the difference between doing that and twiddling a little screw on your own spectacles to get the correction that you need? I accept that these may not be suitable for people with serious astigmatism, but those people probably would not choose them anyway because the quality of vision would not be as good as that from their correct fixed-lens prescription.

Concerns have been expressed about the safety of driving in self-corrected glasses. I was impressed by the study done by the University of Michigan Transportation Research Institute, which showed that there is no statistically significant difference between US drivers wearing prescription glasses and those wearing self-adjusted glasses in their ability to see a hazard ahead. I have seen no evidence to the contrary but, of course, it would be the task of the independent committee that I am calling for to see whether there is any.

As I said earlier, I would be concerned if ownership of these glasses were to deter regular eye examinations, but, again, the evidence I have seen is to the contrary. When over-the-counter reading glasses became available, there was no evidence that this deterred people from getting their eyes tested. Indeed, they need to do so in order to determine what strength to buy from the local chemist. Rather, government agencies and professionals alike believe that the best way to persuade people to look after their eyes and get them tested regularly is by public information and education. A number of these programmes have been mentioned, and they have been around in the UK for years; I am sure Governments would not spend money on them if they did not work.

These new products would have considerable value as a temporary solution for three groups of people: older people may need three different pairs of glasses for different tasks—I know I do—and many find it difficult to afford three pairs; people who have had cataract operations have a period during which their eyesight is settling down and might find these useful then; and new diabetics, whose eyesight may vary while they are working out the right dose of medication to control their blood sugar, may also find these a useful temporary solution. In the last two cases, it is very unlikely that an optometrist would prescribe several pairs of glasses just for a few months. Of course, it is vital that people get their eyes checked regularly, particularly diabetics as there are a number of risks to vision associated with diabetes. However, a pair of these new glasses could be part of their solution.

The fact is that we are already in charge of our own eye health. I recently had to apply for a new driving licence and, as part of the process, had to confirm that I have an appropriate level of vision to drive a car safely. Nobody asked me to get an optician to verify that, although I am in the habit of having regular eye tests and would recommend that everybody do so. In addition, correction prescriptions do not have a finishing date on them, so you can buy contact lenses on the internet using a prescription that is years old if you want to, even though that may no longer be the correct prescription for you. This solution would be a great deal better than that.

I am inclined to allow people to take responsibility for their own eye health, and I thought that a Conservative Government, being in favour of the free market, would be inclined to allow these glasses to be sold without prescription and to give people a choice. However, the cautious thing to do is to set up a truly independent inquiry. I hope the Government will do that, and then the evidence can speak for itself, as can the patients.

Drugs

Baroness Walmsley Excerpts

Thursday 4th February 2016 Grand Committee

[Baroness Walmsley (LD)]

My Lords, I thank the noble Lord, Lord Patel of Bradford, for raising this important issue. The increase in the number of deaths from drugs poisoning is a matter of great concern, since every single death is an indication of failure—failure of individual services and failure of the system of health and care to look after that patient. I refer to “the patient” because my party has always believed that individual drug abuse should be regarded as a health issue, and is not always a police issue. The pushers and dealers, however, are a very different matter.

As has been said, although some are suicides, most of these deaths are accidental, caused by lack of knowledge of the strength of the drugs that people are taking, or someone’s lack of understanding of their own body’s ability to process the chemicals. I will return to that point later. Accidental deaths also occur when a person is not in full possession of his or her faculties and has a fatal accident. I have read the various reports that have tried to analyse the statistics, and that is clearly a very complicated and difficult task, because in many cases there are several causal factors and they are hard to untangle. Few of those who die from drug use have one single simple problem. About one-third of patients abuse alcohol as well as banned or prescription drugs, and many have mental health problems. There is clearly interaction between the various issues.

A recent report called “Solutions from the Frontline” by MEAM—Making Every Adult Matter, an alliance of mental health charities chaired by my noble friend Lady Tyler of Enfield—calculated that there are 58,000 people who face homelessness, substance abuse, mental health problems and offending behaviour, distributed all over Britain. Of course, not all of them are at risk of accidental death because of their drug problems, but clearly their risk rises because of their multiplicity of needs and the great difficulty that services find in reaching and helping them. The problems get worse because people experiencing multiple needs are also likely to live in poverty and experience stigma, discrimination, isolation and loneliness—and, of course, loneliness is a great mental health and suicide risk. Although the ONS report indicates a large protective factor when people are in treatment, which is encouraging to know, those services are suffering, as we have heard from the noble Lord, Lord Patel of Bradford.

I shall concentrate my remarks on dual diagnosis, and on offenders and ex-offenders. According to MEAM, people experiencing multiple needs often have ineffective contact with services, as in most cases services are designed to deal with one problem at a time and to support people with single severe conditions. This can mean that people with multiple needs are more likely to access emergency, rather than planned, services, such as going to accident and emergency rather than their local GP. Accessing services in this way is costly as well as risky: estimates suggest that costs for the 58,000 individuals nationally are between £1.1 billion and £2.1 billion per year. So it is absolutely vital that people who are registered as being addicted to drugs, especially the depressive opiates such as heroin, have their mental health needs assessed and addressed. This is not always happening, partly because of cuts and partly because of shortages of staff with the right experience. Many patients claim that mental health crisis services are not there for them and many have to wait far too long for routine therapies. I do not underestimate the difficulty of dealing with these patients but we must make more effort to do so, for their own sake as well as for the sake of the NHS budget.

The recommendations of the MEAM report include asking the Government to ensure that funding structures prioritise recovery and rehabilitation and allow local areas to develop a flexible response. As part of this, they should consider a new national focus on multiple needs. Locally, commissioners should be accountable for ensuring that local areas have joined-up services and identify where people with multiple needs could fall through the gaps. At the front line, services should involve staff and people with multiple needs working together in designing programmes and the environments where they are to be delivered.

As for drug-using offenders, of course there are a lot of treatment programmes in prison although we know that security in many prisons is poor and they say you can access any drug you like in most prisons. It should, of course, be easier to help addicts when you have them incarcerated in prison than it is when they are part of the general population, and a lot of good work is done. However, I am not convinced that the underlying mental health problems are always addressed in the same way. It is difficult for a lay person like me to understand whether it is the mental health problem that brings people to take drugs in the first place or the drugs themselves that cause mental health problems. I understand it can be either way round, but what matters is to accept that dual diagnosis is not always properly addressed; it is very risky, and we need to do something about it.

The other issue that I would like to raise is continuity of services after release. There is supposed to be a seamless transition into community services but too often that does not happen, perhaps because the services are not there, the person drops out, or the professionals concerned are too busy to work with each other and do not realise how important and effective that is. A very senior psychiatrist told me only yesterday that, if someone gets clean while in prison and then comes out and starts using again, they are at greater risk of dying. While they are under treatment their liver stops having to process the poisonous chemicals in the drugs, so it stops being able to do so. If an ex-offender then starts using again, they should be advised to start on a very low dose and build up, but actually they tend to go back on the high dose they were used to using before they went to prison. This is too much for the body to cope with and it kills them. The dose they were accustomed to before prison now becomes an overdose.

Obviously, we do not want ex-addicts to come out of prison to start again at all but, if they do, they should be made aware of the danger and they should have continuity of care until their rehabilitation is well embedded. Often a patient has very good motivation to keep off drugs but, if something goes wrong in their life, such as losing a job or becoming homeless, the mental health problems recur and they do not have the support or resilience to resist self-medication with drugs that make them feel better.

The mention of resilience brings me to my final point. The roots of mental illness often go back a very long way. We must address the issue we are debating today in the very long term. By that I mean that we need to focus on two things in schools: education about the harms of drug and alcohol use and prevention of mental ill-health among children and young people. We need schools to be able to recognise mental health problems and know how and where to get help. They should also positively promote good mental health and well-being and help their pupils to develop resilient personalities. Of course, we should also go even further back in life and provide mental health therapists in all maternity units and help new mothers bond well with their children, given the crucial importance of attachment to the child’s future mental health. I wonder whether the increase in deaths is not because more people are taking drugs—from what the noble Lord, Lord Patel of Bradford, said, that is not the case—but are we getting more mental health problems that push users over the edge?

Good mental health does not happen by accident any more than good physical health. Just as we need to foster good physical health through diet, exercise and avoiding risky behaviours, so we also need to be aware that good mental health can be fostered. This should be part of the healthy community plans of all local authorities as well as schools, but sadly it is often at the bottom of their priority list because they have the money to do only what is mandatory. But by ignoring this we are storing up problems for the future. I would ask the Minister to be kind enough to comment on the points I have made and let noble Lords know how the Government are dealing with them.

Sugar Tax

Baroness Walmsley Excerpts

Wednesday 3rd February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the Government are considering a whole range of options for tackling the scourge of obesity in young people, which include portion control, reformulation, advertising and many others. One issue they are considering is a sugar tax, but we will announce the results of that strategy in the very near future.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that the key to weight management is correcting energy imbalance? Will the Government therefore consider forcing manufacturers of junk foods to put on their labels the number of hours of vigorous exercise that are equivalent to the contents of the packet?

[Lord Prior of Brampton]

My Lords, as the noble Baroness will know, there are plans for later this year to have compulsory labelling of sugar content on packaging. However, I am not aware that there are any plans to have pictures of well-known athletes on the packaging as well.

NHS: Trust Finances

Baroness Walmsley Excerpts

Monday 1st February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the noble Lord asked a number of questions. Starting in reverse order, the Five Year Forward View was signed by not just the NHS Commissioning Board but also all the ALBs. Of course the £22 billion is a huge stretch. No one denies that and it requires a transformation in the way in which healthcare is delivered in this country. In terms of efficiency savings, the requirement for next year is 2%. We expect that to continue at around 2% to 3% over the five-year period.

I come to the noble Lord’s other questions. There is not a direct conflict between safe staffing levels, efficiency and financial balance. In good hospitals, the three go together. Of course I accept that there have been tensions and it is not surprising, looking back on it, that the reaction to what happened at Mid Staffs led to a number of hospitals increasing staffing levels very rapidly. I remember talking to the noble Lord when he was chairman of a trust—as I was at the time, or I might have been at the CQC—and of course I understand those pressures. All boards of all hospitals must live with those pressures and come to the right balance. I accept that the newly reinvigorated CQC has added to some of the pressures on hospitals to increase the level of staffing.

On the King’s Fund, I have not seen the report that the noble Lord mentioned and that reference to the “financial meltdown”. We expect to break even across the NHS this year. There is £3.8 billion extra spend going into the NHS next year and we hope that when all the plans have come in from the hospital trusts we will be in reasonable shape.

The noble Lord referred to the letter sent out, which I think was leaked in the Guardian, which led to this Urgent Question. I did not see the actual letter before it went out, but there is nothing in it that comes as a big surprise.

[Baroness Walmsley (LD)]

My Lords, a good example of NHS trusts doing what the Government have asked them to do and working together to deliver care more efficiently is the Uniting Care Partnership in Cambridgeshire and Peterborough, which collapsed after only eight months. We are told that the three NHS entities involved in the contract will continue to deliver care under the new model without disruption. If this is able to be done, why was so much money wasted in the bidding process? Could not they have worked together anyway? How much did the whole process cost and how much was paid to their advisers, the Strategic Projects Team, which did not seem to realise that the contract at the agreed price was simply undeliverable? Is not it clear that the CCG simply did not have enough money to deliver those services?

[Lord Prior of Brampton]

I think that the noble Baroness’s party was in government when that contract was negotiated, although it seems a bit churlish to remind her of that. The fact is that, as we move to these new ways in which to deliver care, risk is going to have to be taken. Some of the new ways in which we do it are not going to work. In this case, it clearly did not work. It was a very big project—£800 million in total value, I believe, over five years, for older people in Cambridgeshire. It was a highly complex contract and, tragically, it has not worked out. I shall have to come back to the noble Baroness if I can about how much it cost in fees.

National Health Service: Nurses

Baroness Walmsley Excerpts

Tuesday 26th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I completely agree with my noble friend’s sentiments. She will be pleased to know that from August of this year, Health Education England will be funding 1,000 new nursing associates, who will not be taking a degree but will effectively do a nurse apprenticeship, although they will be able to switch over to doing a degree later in their career if they so choose.

[Baroness Walmsley (LD)]

My Lords, given that hospital trusts are recruiting 5,600 nurses from outside the EU every year, that is surely much more of a pull factor than anything the Government might do with benefits. Given the fact that trainee nurses have to work on a clinical placement outside term time in which they add value to the NHS and take on responsibility, why are they not paid?

[Lord Prior of Brampton]

My Lords, I do not entirely follow the noble Baroness’s question. All I can say is that we are all pleased that we are able to attract nurses from overseas, but that cannot be the right long-term policy for this country. We must train our own nurses and not rely upon recruiting nurses from overseas.

Failures of the 111 Helpline

Baroness Walmsley Excerpts

Tuesday 26th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I echo the tribute that the noble Lord paid to the Mead family and their recognition that we can only learn from these terrible tragedies. The fact that they are prepared to make available the report to other parts of the NHS will help in that learning process. I, or one of the other Ministers concerned, will certainly undertake to meet the UK Sepsis Trust.

The noble Lord raised the issue of the 111 service. It is worth making the point that, in this case, the call handler took the call and referred it to a GP who was part of the out-of-hours service. The GP then spoke directly to William’s mother and decided on what the right course of action was. However, I take on board exactly what the noble Lord said about training and the mix between clinicians and non-clinicians in 111 call centres. It will become a better service when the out-of-hours service and the 111 service are integrated.

One point that came out of the report was that had there been an electronic patient record indicating the evidence of the time that William had spent with GPs in the preceding six weeks, the GP who took the call might possibly have come to a different decision. This was a tragic case of all the holes in the Swiss cheese lining up to cause this awful tragedy. Therefore, I take on board what the noble Lord said about 111 and will pursue that with NHS England.

[Baroness Walmsley (LD)]

My Lords, I share the concerns of the noble Lord, Lord Hunt, about 111, but does this not go much wider? On the issue of medical and public education about sepsis, what are Public Health England and Health Education England going to do about this? We cannot rely on the BBC1 programme “Trust Me, I’m a Doctor”, which this week has certainly increased my understanding of the symptoms of sepsis. But that needs to be spread to the wider public. I recommend that people go on iPlayer and watch that programme if they want to know about this. Does this not also indicate that this very conscientious and determined mother was not listened to? She knew her child was behaving abnormally and all the people who talked to her—from GPs through to everyone else—just did not listen.

[Lord Prior of Brampton]

My Lords, the facts of this case demonstrate that a lot of things went wrong. That is the real tragedy of it. Had one of those things not gone wrong, the tragedy may not have happened. The noble Baroness referred in particular to medical education but it is wider than that. As I said, a whole stream of things went wrong and we must learn from that.

Health: Hormone Pregnancy Tests

Baroness Walmsley Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, this issue goes back to the 1950s, so trawling back over that period may not be that helpful. What is helpful is that we learn lessons from the past so that the existing regulatory system can learn from those errors. I am, however, very happy to meet the noble Lord and others who are interested to discuss this further, if they wish to do so.

[Baroness Walmsley (LD)]

My Lords, given that many of the survivors of Primodos, the drug in question here, were not told that they were taking part in a clinical trial, will the noble Lord assure us that today nobody would take part in a clinical trial without their knowledge?

[Lord Prior of Brampton]

My Lords, I understand that to be the case but I will double-check and, if it is not, I will of course write to the noble Baroness.

Health and Social Care: State Pension

Baroness Walmsley Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

The right reverend Prelate is right to remind the House of the report by the Commonwealth Fund which indicated that the National Health Service is the most efficient and overall the best healthcare system in the world. He also referred to prevention. The childhood obesity prevention strategy is due to be announced by the Government in the next couple of months. We have made huge progress on reducing smoking and in other areas of prevention, but I agree with the right reverend Prelate that prevention is a critical part of our long-term approach to healthcare.

[Baroness Walmsley (LD)]

My Lords, the Minister talks about the support for the five-year forward view, but is he aware that more than 80% of finance leads within the health service do not believe that the five-year forward view can achieve the savings that it says it can? It just cannot be done without extra resources. Surely, particularly with the state of affairs in social care, where the Government’s extra money is being back-loaded, not front-loaded, we need to take an overall holistic look at health and social care and how much we should be spending as a country and how we are prepared to raise that money fairly.

[Lord Prior of Brampton]

My Lords, I think that the same question is being asked in slightly different terms by many different noble Lords. I cannot really add to what I said before. We are supporting the NHS’s plan. By the end of this Parliament we will be putting another £3.5 billion into social care through the social care precept and an extra £1.5 billion into the better care fund. We believe that we have a plan for social care and healthcare over the course of this Parliament.