Dementia Palliative Care Teams

Baroness Watkins of Tavistock Excerpts

Thursday 15th June 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw noble Lords’ attention to the recent research report from King’s College London about better palliative care and end-of-life care for those affected by dementia. It shows clearly the cost-effectiveness that can be achieved and the reduction in the use of in-patient hospital beds. I declare that I am on the NHS Executive and am pushing for this. What can the Government do to ensure that ICBs actually take this forward?

[Lord Markham (Con)]

As I said, we think that the ICBs are the right place to manage this at a local level, but it is our responsibility from the centre to make sure they are delivering on that. I personally have seen good examples: my father was cared for at home, with palliative end-of-life care, and I know how happy he was to be able to do that, so I totally agree.

NHS National Health Inequalities Improvement Programme

Baroness Watkins of Tavistock Excerpts

Thursday 25th May 2023 Lords Chamber

[Lord Markham (Con)]

As mentioned previously, the review did not happen because of Covid, and it is very much within the plans that it is time to look at school standards again. Clearly, that is key to making sure that there is a healthy diet in schools, and of course that goes across the board.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain whether the Department of Health is working with other departments to consider funding families entitled to free school meals with additional allowances during the summer vacation in the light of the current cost of food and the need, as he has acknowledged, to provide adequate nutrition to promote health in young people?

[Lord Markham (Con)]

Yes. It is worth reiterating that the 37.5% free school meal level is an achievement, as is the fact that all infant schoolchildren receive free school meals—higher than ever before. However, the noble Baroness is correct in terms of what happens during holidays. That is why we have the holiday activity fund, which in the summer holidays, for instance, provides meals for four of the weeks, as well as for another week in winter. Clearly, we need to keep that under review to make sure that that is sufficient.

Health Education England (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Baroness Watkins of Tavistock Excerpts

Tuesday 21st March 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I very much appreciate the opportunity that the noble Baroness, Lady Merron, has given to the House to debate this reorganisation on the back of her regret amendment. In preparation for this, I had a look at Health Education England’s website; it is always good to look at the thing you are abolishing. It is worth quoting in full what it says about itself:

“Health Education England … exists for one reason only: to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place.”


That would perhaps be an appropriate motto for the Minister to have. It is timeless: we want people to be focused on that mission of delivering the right people with the right skills at the right time and in the right place.

Again, I looked at the history of the body. It was set up as a special health authority in 2012. I imagined that it was something we had had for years, but no, it was set up in 2012 and became a non-departmental body in 2014. So in about a decade we have gone from wanting a body with a singular focused mission to saying, “No, that’s a disaster; it needs to now be fully integrated into a much bigger body in order to be able to deliver”. I fear we have seen this again and again; we had it with NHS Digital. A group of people got together a decade or so ago and said that the important thing is that all these functions have a team that is solely dedicated to delivering workforce, digital or whatever, and 10 years later the fashion has changed. The Minister makes a reasonable argument that you would not now have a separate HR function. Clearly, a decade ago, we thought that was exactly what we should do, and we spent time and money constructing this thing. Now we are spending time and money destructing it.

There is a risk that we end up mistaking circular motion for forward motion. It is still motion—we are moving things around—but there is a risk that we are not making progress. I will explain why we need to have really serious measures to understand whether we are doing that; otherwise, I fear we will back here in five or 10 years’ time, with people standing at the Dispatch Box arguing why we need to separate all these functions out, because merging them into NHS England meant that we lost focus.

The one group of people that will continue to make money out of this is the consultants. I note we are told in the Explanatory Memorandum that they were paid £1 million plus VAT to create this reorganisation. I am sure a similar group was paid £1 million plus VAT to spin out HEE when it was originally set up, and we will see this again with all the different parts of the health service. We spend money and we reorganise. Even if we support the latest organisation, we in this House need to continue to hold the Government’s feet to the fire, whoever they are, to say, “Prove that the reorganisation was worth the money”.

The noble Baroness, Lady Merron, is quite right to keep bringing us back to the information in the Explanatory Memorandum and the reports we get from the scrutiny committee. We are given explicit information about the costs. We are told that it is £1 million plus VAT for the consultants and another £1 million for staff costs, so a couple of million pounds here and there for direct costs. The savings are much less clear. We are told they are £1.3 million because we no longer need a separate board; then the big savings are wrapped up in this aspirational 40% for all of these reorgs into NHS England, but we are not given any more detail than that. I know the current body of staff in Health Education England is some 2,000 people, overseeing approximately £5 billion of expenditure, so there is clearly a lot of scope for potential savings.

I ask the Minister to make a firm commitment that the Government will come back and that future NHS England reports will give the kind of detail we need in order to understand whether those savings were realised. When these reorgs happen, there is a risk that NHS England’s future reports will be structured in a way that disguises the savings so that we cannot pull them out. It would help the House and the public if, when NHS England reports in a year’s time, there is a separate item that says, “For NHS Digital, we did or did not realise these savings”, and, for Health Education England and the education functions, “This is how many staff we now have working on it and that is why we think we are getting better value for money from the budget”.

From an accountancy point of view, you can go either way: you can either try to hide things by smushing them all up together or try to make them explicit by ensuring that the data is there. I hope that the Minister will commit so that we can come back at this time of year in 2024, 2025 and 2026—I recognise that this will take time to play out—to see whether this reorganisation has had the effect. This would inform the debate next time we are asked to reorganise; I am sure we will be told every time that they will make savings.

Finally, the substantive point raised by the noble Baroness, Lady Merron, is around the workforce plan. We can repeat our previous exhortations: that this is desperately needed; I know the Minister agrees that it is desperately needed. There are concerns that the reason it is being held up is that the funding is not there. Every time we see good news—the pay settlement for nurses and others is good news—a little bit of us asks where they will find the money; we hope they will not find the money by cutting in other areas. We need continual reassurance that the workforce plan will be accompanied by the money that will be needed to deliver it, and that we will not see it shaved away as it goes through the process of finalisation. That might be partly why we want it quickly. Once it is published, it is much harder to step back. The fear is that, the longer it takes, the more likely it is that there will be a process of salami slicing and the bold, ambitious workforce plan, which I am sure the Minister and his colleagues in the department supported, ends up “Treasury-fied” and no longer quite as ambitious as it was.

Finally on the workforce plan, we are talking about the NHS and we are rolling Health Education England into NHS England. As we have discussed many times in this House, health and social care are intimately related in terms of being able to deliver for people out there and being able to run an efficient service. I hope the Minister will at least be able to say that this reorganisation will not negatively impact joined-up workforce planning across both sectors. Ideally, I hope he will be able to say that there will be some positive impact from this reorganisation in terms of making sure that social care staff numbers correspond with the increase in NHS staff that he knows we need.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a relatively new non-executive director of NHS England, appointed together with two expert doctors to give clinical input to the board and tackle the issues that have just been discussed. However, I want to put on record that I think Health Education England has been a success and has set up sound processes that have enabled a good estimation of the workforce needed for the next 15 years.

The workforce plan is in draft and is being considered by the Government, but I want to underline the fact that, without sufficient funding, it will not achieve what everybody wants it to achieve. I believe that making it mainstream in NHS England should mean that, working with the ICBs, we have a sound approach for the future. I am aware that the two previous speakers will be able to hold NHS England to account on whether we get it right or not. I felt that I should be here this afternoon to say that I think it will work, but only because of the sound foundation that NHS Education has left behind.

I also want to echo one concern: that we have to calculate social care needs within the workforce development plan, in particular the needs of leaders of teams in social care, who are often nurses or allied health professionals such as physiotherapists. On that note, I will sit down; I wanted to express my current understanding of the situation.

[Lord Scriven (LD)]

My Lords, I wish to add briefly to the very useful and interesting debate that the noble Baroness, Lady Merron, has stimulated with her amendment. In so doing, I point out my interest as a vice-president of the Local Government Association.

I support the general direction of the merger. I can see why HR functions need to be streamlined together rather than partly devolved and partly in NHS England. The Minister quite rightly pointed out his business background; I have a background in organisational development and public sector reform, not necessarily in the UK but in Africa and south-east Asia. One of the key failures in the public sector when these organisational structures happen, predominantly for cost reduction reasons—it is always said by those leading them that cost reduction is not the reason, but it is important—is that there are no measurements for success in three, five, 10 and 15 years. Without that, you get a structure without understanding how the structure will deliver exactly what is needed.

So, what are the measurements for success in three, five, 10 and 15 years? Without those, everyone can say there is a target, but no one knows what that target, or bull’s-eye, really is. What are the clear measurements within three, five, 10 and 15 years? If they are not there, how do we know what success looks like based on what the merger was about in the first place? That is really important.

The other part of this is that you can have all the training and numbers you like for the workforce, but if the support, conditions and culture are not right, people will leave, as they are doing now in parts of the NHS. In certain specialties, you cannot get a doctor for money, no matter how much you offer. Part of that is about working conditions, culture and support. How does this merger deal not just with numbers and education but more holistically with the culture and support? For example, in many trusts, junior doctors cannot even get a meal in the evening. You can have all the numbers you want in terms of training, but if people decide not to work because of the conditions, how does that help holistically? How do we ensure we have not just the training and numbers but the culture and support within organisations so that people decide to go and work there?

My final question is simple. All noble Lords who have spoken have mentioned social care. As I said, my question is simple: how does this plan link with a plan for the social care workforce? What problems are envisaged and what mitigation has been put in place to ensure, first, that the two plans work in tandem and, eventually, as a long-term aim —I have heard Ministers talk about this—that staff will be able to move across the organisational divide? How will the links be there? What mitigation is being put in against the risks for a social care plan and a healthcare plan? This is important because people who start with a health problem then require social care to make as good and independent a life as possible. It is important that, when the Government start on one plan, they understand the linkage with the other and the mitigations needed. I hope that the Minister can put the mitigations in place.

As I said, in general, I understand the reasons for this but there are serious questions that the Minister needs to answer to ensure the maximum impact from this merger.

Mental Health Act Reform

Baroness Watkins of Tavistock Excerpts

Thursday 26th January 2023 Lords Chamber

[Lord Markham (Con)]

The noble Baroness is correct; these things do need resources. We have committed to £2.3 billion of extra spending next year and an increase of 27,000 in the number of mental health nurses; I am glad to say we are well on the way, with a 7,000 increase over the last year. This all comes back to workforce planning—I am sure I will be asked that question later. And, yes, we will publish our plan soon.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister comment on why it is 50 years since we have had a revision, and say whether in fact the Government are delaying this legislation because of the resources that will be required, as has just been referred to?

[Lord Markham (Con)]

No, I hope that all noble Lords will see that there is no sense of delay on this side—and we are not waiting for the legislation to introduce a lot of these measures. It is very important, and we are ready to push on as soon as parliamentary time allows.

Osteoporosis: Early Detection

Baroness Watkins of Tavistock Excerpts

Thursday 19th January 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, could the Minister comment on whether the department of health is working with the department of energy to ensure that we can afford to heat our swimming pools? Swimming is a really good exercise and reduces the risk of falls, particularly in older people.

[Lord Markham (Con)]

As previously mentioned, prevention is always better. Exercise, as I have learned from my noble friend Lord Sandhurst, is a good way of preventing osteoporosis. Where we can find cost-effective ways of getting that exercise, such as swimming pools, we should be promoting them.

Care Homes: Staffing

Baroness Watkins of Tavistock Excerpts

Wednesday 11th January 2023 Lords Chamber

[Lord Markham (Con)]

I thank the noble Baroness. I think that the House will recall that I have mentioned on a number of occasions that this is a critical part of the workforce plan. What has become clear, even in the short time that I have been at this box, is that social care is a vital cog in the whole chain, so to speak, which goes right back to ambulance wait times and A&E, because if we do not get the flow going out of the system, we have got problems there. So I can assure the noble Baroness that it is key to my thinking, and to all our thinking.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a future member of the NHSE board. I want to ask how we are going to monitor the advancement from care homes back into domiciliary care, in order to ensure that we do not just move the problem from the hospital to care homes so that, very quickly, there are no beds left in care homes to continue this transfer system. In particular, who is going to pay for the residents in those care homes, and for how long?

[Lord Markham (Con)]

The question is absolutely correct: as I said earlier, less than 10% of these 13,000 people need to be in care homes full-time. The danger is often that once you put them there, they remain. That is why the package is focused on stays of up to four weeks, and absolutely making sure that they are monitored through, because it is vital. It is a step-down situation to help people ease from the acute—where they need a bit of extra support—so that, most importantly, they can get back home as soon as possible.

NHS Winter Pressures

Baroness Watkins of Tavistock Excerpts

Tuesday 10th January 2023 Lords Chamber

[Lord Markham (Con)]

As with my answer to the previous question, I look forward to that meeting and learning everything we can. I will repeat the statistics on that subject that struck me most: of those 13,000 people who are fit to be discharged, we think that only 3% need to be in social care in the long term; 97% could be at home, which is the best and most cost-effective place for them. We need to ensure that the support is in place to ensure that that option exists.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a nurse and as a new appointment to the NHS England board as a non-executive director. There are two things missing from this discussion. First, there has been no reference to people waiting for mental health support. How can we ensure that people in mental health crisis are moved rapidly out of busy A&Es to be supported in quieter environments? There is a very good example across the road, at St Thomas’ Hospital, which is helping the A&E. Secondly, it is high time that we seriously consider giving full-time contracts to care workers in domiciliary services, because, as soon as somebody goes into hospital, the care worker’s hours are cut and, although they know that individual, they very rarely get reallocated to them when they are transferred back out of hospital. The lack of continuity of care often results in readmission, so what will the Minister do to ensure that, in the way that the noble Lord, Lord Turnberg, just outlined, we improve the lot of those particular care workers?

[Lord Markham (Con)]

First, I welcome the noble Baroness to the NHS England board, with high expectation of the value that she will add to it. I am very interested to understand her point further; I will speak to Minister Whately about that and respond to the noble Baroness in writing. Where people have knowledge of a patient at home, they can add that to their care when they come back out again.

Social Care Sector: Staff Shortages

Baroness Watkins of Tavistock Excerpts

Monday 21st November 2022 Lords Chamber

[Lord Markham (Con)]

I thank the right reverend Prelate for the passion that she clearly displays in this field. As I mentioned in my Answer to the Question, we have a national recruitment campaign, and looking at the staffing plan for allied health professionals and what needs to be paid to recruit people in the right areas will be part of that. The national living wage is a start, but clearly we need to make sure that this is an attractive career that people want to join and stay in.

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw attention to my interests in the register. Recently, the coroner in Cornwall ruled that some deaths in the county are probably attributable to delays in ambulance services, which are in turn associated with delays in transfers of care from acute services to care homes. There has been a reduction of more than 600 care bed places in Cornwall in the past four years. This is an example of the challenge that we face. Does the Minister accept that the Government’s objectives for the NHS will never be effectively achieved without resolving the social care challenges, and that the difficulty of recruiting from overseas, particularly in rural areas, should be acknowledged?

[Lord Markham (Con)]

I agree and have often made the point that solving this part is key to the flow and to getting people through discharge quickly, which has a knock-on impact on A&E and ambulance wait times. That is why I was delighted to hear the Chancellor recognise this specifically and mention £2.8 billion of funding in 2023-24, which will account for 200,000 new care packages in this space, as well as £4.7 billion in 2024-25 to resolve the exact problems that the noble Baroness brings up.

Long Covid

Baroness Watkins of Tavistock Excerpts

Thursday 17th November 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

It is a pleasure to follow the right reverend Prelate the Bishop of Exeter, whom I know well and whose speech I completely concur with. Happily, mine does not completely reflect it. I also acknowledge the work of the noble Baroness, Lady Thornton, in getting this debate for us to consider today.

I will particularly highlight the challenges of long Covid on mental health services, healthcare staff and children’s education and health, and therefore need to declare my interests as a registered nurse and president of the Florence Nightingale Foundation.

I note that the lack of consistency on the definition of long Covid makes it difficult to measure and analyse the emerging evidence. Despite this, the NIHR estimates that 1.8 million people in the UK—as others have said, 3% of the population—are experiencing symptoms of long Covid. Its studies published in 2021 showed that up to one in three people who have had Covid-19 report long Covid symptoms, and up to one in seven children. The scale of chronic ill health and disability after Covid-19 has been described as the next big global health challenge. I am not sure that it is the next big one; I think it is the immediate one.

According to the NIHR’s survey of 3,286 people with long Covid, 71% said it was affecting family life and 80% reported that it affected their ability to work. The Ulster University survey of 3,499 healthcare staff demonstrated that 49.3% felt overwhelmed by pressures of the pandemic, with social work and nursing the most impacted.

NHS Check, a study by King’s College London—where I must declare I have a visiting chair—looked at 18 partner NHS trusts and found high levels of distress and symptoms of anxiety in staff working in healthcare. A concerning finding was that there was a high prevalence of PTSD symptoms and self-harm. This has caused long-term absence of staff due to Covid-related sickness, resulting in people at work carrying out jobs out of their skill set and/or being overworked. It is reported that these issues have directly impacted the quality of care and waiting times and, in extreme situations, have led to unsafe practices. Dissatisfied patients have resulted in increased abuse towards healthcare workers, exacerbating their exhaustion and anxiety levels. Those on long-term sick-leave have suffered isolation and financial difficulties, intensified by the recent soaring cost of living, leading to further distress and longer absences from work, and some healthcare workers have lost their jobs due to long Covid.

The impact of staff shortages from long Covid has also led to a breach in some patients’ human rights: namely, the illegal detention of patients. Last week, the Independent reported that mental health patients were being held “unlawfully” in A&Es due to shortage of staff to undertake timely mental health assessments. I must stress that I believe that that has been to protect their safety, but none the less it is a severe problem.

The effects on our children are highlighted in Ofsted’s second report on the impact of the pandemic and school closures. It demonstrates that children have regressed in basic skills, physical fitness and learning, particularly those whose parents were unable to work flexibly—including, of course, health workers. Children were found to show increased signs of mental distress, including a rise in eating disorders and self-harm.

Social isolation and greater exposure to family conflicts have added to children’s mental ill health, leading to an increase in the number of referrals to CAMHS, which has not been matched by an increase in investment in children’s services. A large study by the NHS in 2020 found that mental health conditions among children had risen by 50% compared to three years earlier. I think that will be even higher in the next piece of work on that issue. It is sad that Baroness Sally Greengross is not here to argue for intergenerational fairness on this issue.

These academic studies have shown major organisational changes across the NHS, with substantial physical and mental health challenges for NHS staff and other care workers during the pandemic. Results also indicate the importance to support staff so that they can contribute to service recovery. Therefore, can the Minister explain the Government’s position regarding the implementation of the proposed 10-year mental health and well-being plan for NHS staff and, in particular, the investment to support staff with long Covid?

Will the Government make further contributions to NIHR for global collaborative research to increase our understanding of long Covid and its impact and, in particular, to generate evidence-based interventions that may enable the health recovery and mental resilience of staff impacted by long Covid and support them to return to work, thus ensuring their retention in healthcare practice?

Ambulance Delays

Baroness Watkins of Tavistock Excerpts

Wednesday 9th November 2022 Lords Chamber

[Lord Markham (Con)]

The noble Lord is referring to the whole-system issue here, which I mentioned before. There is a £450 million investment to increase capacity in A&E facilities; that has already worked to upgrade 120 trusts to enable them to offload quickly. There are also 7,000 extra beds, and the £500 million social care discharge fund is all about freeing up more beds so that ambulances can discharge quicker.

[Baroness Watkins of Tavistock (CB)]

My Lords, I must declare that I am a former deputy chair of an ambulance trust that was an exceptional performer but is no longer, associated with the fact that, in some circumstances, it cannot get patients admitted to two of its largest local hospitals in under four hours. The problem is social care, not increasing the number of ambulances on the roads. Will the Government consider much more innovative approaches to respite care support for people who are ready to leave hospital and whose families cannot afford to leave work to look after them but, with incentives, probably could do so? That would be a practical way of moving the system forward at the moment.

[Lord Markham (Con)]

I agree with the noble Baroness that social care is a key solution to all this. As I said, that is what is behind the 13% of beds that are currently blocked and the £500 million spend in this area. However, we can be more innovative. That is what the virtual ward initiative, which I saw working so well in Watford, is about; it has reduced reattendance rates after 90 days from 46% to around 8% for COPD patients. This is an area where we need focus and innovation, and which is very much top of my agenda.