NHS: New Junior Doctor Contract

Lord Hunt of Kings Heath Excerpts

Monday 18th April 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for repeating the Answer given in the other place, which I have listened very carefully to. It now seems abundantly clear that the Secretary of State does not have the power in law to impose a new contract on junior doctors. The problem is that the Secretary of State’s various Statements over the last few months could not be interpreted in any way other than that he thought he had the power and he was going to impose a contract. The significance of this is that the junior doctors took him at his word. The importance of that is that the Junior Doctors Committee of the BMA took the unprecedented decision to escalate industrial action on the back of his apparent decision to impose the new contract when talks collapsed.

The noble Lord, Lord Prior, knows that I have absolutely no argument with the development of fully comprehensive seven-day services in the NHS. However, the tragedy is that the very group of staff on whom so much is now dependent for clinical out-of-hours care—the junior doctors—has become utterly disenchanted with the way this has been handled. We have reached a very serious situation, and I very much fear for the future of the NHS and what is happening. I just say to the noble Lord that surely, even now, the Government need to find a way through. Interestingly, in the response, which has come from Ministers in the other place, there is a recognition of the benefit of collective bargaining. Is it not time to give collective bargaining another go?

[Lord Prior of Brampton]

My Lords, the noble Lord has raised two substantial points. The first is the difference between introduction and imposition. The fact is that, in the context of the NHS, where there is really only one offer, the difference between introduction and imposition is very small. Technically, it is true that individual employers are responsible for its imposition, but in reality, as the noble Lord will know from all his years in the Department of Health, the Secretary of State has considerable powers in this matter. I do not think the noble Lord would want all trusts to cut their own deals locally—there has to be an actual contract. It is true that when the legislation for foundation trusts was brought forward by the noble Lord’s Government a few years ago, they were given the power to negotiate their terms and conditions locally but, with the exceptions of, I think, Southend and possibly Guy’s and St Thomas’, they have chosen to stick with the national contract.

On the noble Lord’s last point about a way through, there are no winners from this dispute. The patients are very clear losers, and it is tragic that we have got to the situation that we have. The threshold for withdrawing emergency cover from hospitals needs to be a lot higher than the one the junior doctors are adopting on this occasion.

Health: Neural Tube Defects

Lord Hunt of Kings Heath Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Prior of Brampton]

I will certainly draw that point to the attention of the SACN. It would be surprising if it was not already aware of that fact, but as I said I am addressing not really the science but whether it is right or proportionate to fortify bread for everybody to reach such a small number of people.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord made it clear that this is a political decision, for which we should be grateful. He also made it clear that the Government have decided that it is not going to happen. But does he accept that a 30% improvement is actually a large, positive outcome? The fact is that the voluntary approach that this Government have been wedded to is simply not working. If the answer is no, and if the voluntary approach is not working, what, then, will the Government do?

[Lord Prior of Brampton]

My Lords, the evidence given by the SACN is that it affects between 15% and 30%. My honourable friend in the other House, Jane Ellison, is bringing together a round table of all stakeholders interested in preconception health to discuss this matter.

NHS: 111 Service

Lord Hunt of Kings Heath Excerpts

Monday 21st March 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the safety and reliability of the National Health Service 111 service.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, NHS 111 is a vital service helping people to get medical advice quickly and easily. It has received more calls this year than in the same period in 2014-15 but continues to perform well overall. The Care Quality Commission has announced that it will inspect all NHS 111 providers by September 2016. The CQC will assess whether the services are safe, caring, effective, responsive to people’s needs and well led.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is not the problem that when the excellent NHS Direct service was replaced, very many experienced nurses ceased to work for the new 111 service and were replaced by call handlers with a few weeks’ training who have to follow instructions on a computer rigidly? The evidence is that there have consequently been misdiagnoses. One ambulance trust fiddled the response time for 999 calls routed through 111 to meet the targets. There have been a number of personal tragedies as a result. Therefore, in addition to the CQC’s inspection, will the noble Lord institute a review of the safety of 111 and return to having qualified nurses handling the calls?

[Lord Prior of Brampton]

My Lords, the decision to stop NHS Direct was, of course, taken in 2008, when I think the noble Lord was in post. He shakes his head, so perhaps he was not, but the decision was taken in 2008, before this Government were in charge, if you like. The new system uses the NHS Pathways algorithms developed by the Royal College of GPs, on which the BMA and the Royal College of Paediatrics and Child Health sit, so we have considerable confidence in the algorithms used. We will also increase the number of clinicians. I accept the noble Lord’s point that we need to have more clinicians answering these calls rather than call handlers, as he puts it. It is our intention progressively to increase the number of clinicians in these 111 hubs.

General Practitioners: Appointments

Lord Hunt of Kings Heath Excerpts

Thursday 17th March 2016 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the noble Earl, Lord Attlee, for allowing us to debate this very important question and congratulate him on the quality and range of his contribution, which was extremely interesting. I echo his initial comments about the value of the National Health Service. However, he also referred to the considerable challenges we face, not least the amount of money that is being made available. I note the comments that the noble Lord, Lord Rennard, made and I will be most interested in the Minister’s response to his suggestion that we need to move to hypothecated taxation. Interestingly, we have a recommendation from the Liaison Committee—of which I am a member—which I hope will come to the House next week to establish a special Select Committee in the next Session looking at the long-term sustainability of the NHS. I think that that will be a very interesting discussion, not least because it is clear, as the noble Earl said, that alongside A&E and ambulance services, general practice is facing considerable pressure.

Like my noble friend Lord Turnberg I am very lucky to enjoy an exceptional GP practice, which is a small branch of a large inner-city practice. It is clear from the comments of noble Lords and from the regular GP patient survey that people’s experiences are very mixed. The noble Earl focused on economically active members of society, but his comments could have applied to all patients. Noble Lords are often fond of quoting the Commonwealth Fund’s international comparators, which do not always compare with the OECD research covering the same ground. I was interested in its latest report on public perception of primary care in the UK and the fact that there has been a dramatic drop in the positive view of how primary care works, with the percentage of those expressing satisfaction going down from nearly 50% in 2009 and 2012 to just over 20% in 2015. So there has no doubt been an appreciable change in attitude by the public in relation to GP services. The GP patient survey shows, for instance, that only 70.4% of patients find it easy to get through to someone at their GP surgery on the phone. This is down from previous figures. It also showed that 6.5% book their appointments online, up from 3.2% in December 2012. It is really disappointing that such a low number of people actually take advantage of online booking or, indeed, that such a low number of practices promote online booking. Obviously, it would make life so much easier if it were easier for people to do that, and it would deal with the problem that the noble Earl, Lord Attlee, described, about the differentiation between an urgent appointment and one that is important but does not have to take place within 48 hours. Many GP practices seem quite unable to devise a system to cope with those circumstances.

It is also interesting that the GP patient survey showed that 23.1% see their preferred GP a lot of the time. We need to think through the implications of that, particularly with seven-day working, because I suggest that with the move into larger federations, which I support, the seven-day working concept inevitably means that people will have less opportunity to see their preferred GP—particularly, as we know, when many GPs do not want to work full time any more. That seems to me to depend on information, particularly electronic information, being available, so that a patient does not have continually to tell different GPs in a practice about their conditions, because they actually have systems where that is noted down.

I also note that in the survey 57.7% were happy with the amount of time that they had to wait for an appointment. Again, that is down—it is not a great figure. The overall satisfaction with GP opening hours, at 74.8%, is down and again not very satisfactory.

The noble Lord, Lord Rennard, referred to the PAC report on access to general practice, which came out only a couple of weeks ago. I thought that it was a very interesting report and, no doubt, the Government will respond in due course. But it showed that we have problems with retention and recruitment, that good access to GP care is too dependent on where patients live, and there is an unacceptable variation in patients’ practices and in the appointments system. Tellingly, it said that the Department of Health and NHS England do not have enough information—that is a point that the noble Lord made—on demand, activity or capacity, which one would have thought might have been of interest to NHS England. I think that it is clear that both the department and NHS England has really failed to ensure that staffing in general practice has kept pace with growing demand. I think that they have been complacent about general practitioners’ ability and, indeed, willingness to cope with the increase in demand caused by rising public expectations and the needs of an ageing population.

No doubt the Minister will tell us about recent initiatives, which are welcome in themselves, but a lot of changes will come about because GPs themselves will make them happen. I am really impressed by the large federations that have been established. There is one very large one in west Birmingham and the Black Country, which has had some incredibly impressive results in relation to access. It is through having a large enough federation that you can meet the work patterns of individual GPs, and it is through the simple use of phone and email to have much more flexible appointments. I do not know whether the noble Lord has read a report from David Pannell, the chief executive of Suffolk GP Federation, which complains that the department is not really giving support to the development of provider networks and federations and that the only initiative promoting working at scale was the Prime Minister’s GP access fund, which was doing little to diverge from the traditional model of contracting with individual practices.

The point being made here is that every single contract which is part of the PM’s access fund has been a traditional primary medical services or general medical services one with an individual practice. Would the Minister be prepared to have a look at this and to talk to the National Association of Provider Organisations? Its chair has commented:

“Whereas NHS England supported the vanguards programme, there has been virtually no support for the leadership of federations which are not part of a vanguard”.

I have quoted from a story in the Heath Service Journal and I have also looked at comments which have been made on it. One comment, which was anonymous—I do not know why—said:

“Brighton and Hove CCG have been developing a really innovative and ambitious contract with GPs working at scale which the LMC have supported”.

It may well be worth looking at that to see whether more can be encouraged.

Finally, I wonder if the development of federations means that the Government need to look at CCG governance. If you have a large-scale federation covering an area roughly the same size as a CCG, I can see a potential conflict of interest. The federation could dominate the election of members to the CCG board. The contracts should be at that level, not held by NHS England, so I wonder if we need to go back to the issue of CCG governance and have a majority of lay people on CCG boards. That would enable the Government to be much more proactive in supporting these federations. I am convinced that they are the only way we can deal with the problems raised by the noble Earl.

Royal National Orthopaedic Hospital: Redevelopment

Lord Hunt of Kings Heath Excerpts

Thursday 17th March 2016 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, mea culpa. The noble Lord certainly got me bang to rights. As noble Lords have heard, many noble Lords and Ministers have commented on the position of the RNOH. I start by paying tribute to it for its outstanding work. I certainly paid a ministerial visit. I do not know about the noble Lord, Lord Lansley, but I remember digging a hole in the ground there. Alas, I think that the hole is still there. I have no doubt he too has been to see the site to look at where the development would take place.

Clearly, a powerful case for this wonderful hospital’s development has been made by my noble friend. It is significant that the NHS TDA gave business-case approval a year ago. Therefore, it is absolutely right to press the Minister to say what on earth has happened and why the NHS TDA apparently, if not reversing its decision, does not seem to be able to take it any further forward.

I pay one other tribute to the RNOH and that is to the partnerships that are developing. We have already heard about UCL, but my noble friend Lady Dean is also aware of the work that is being done with the Royal Free. That is very encouraging in relation to the comments made by the noble Lord, Lord Lansley, about the importance of specialist hospitals working with other hospitals.

I shall put four or five points to the Minister. First, it is always risky to ask a Minister for a straight answer, but it seems to me that the time has come when a straight answer needs to be given. If it is no, no should be said, and the hospital can make other dispositions. It surely cannot be left in abeyance for another one, two or three years because it must be impossible for the people running this institution to know whether to invest any money in the current infrastructure, whether they should wait, what they should do about the staff and how they retain staff. An honest answer is required at the very least.

Secondly, is the state of the current public capital programme within the Department of Health having an impact? I know of the Department of Health’s financial difficulties towards the end of this financial year, and the five-year forward look at money for the NHS involves a transfer of capital to revenue. What has happened to the public capital programme? Is that the real reason that the NHS TDA cannot give approval?

The noble Lord, Lord Tebbit, and I probably disagree about PFI because, although some of the contracts were clearly badly negotiated, we have very fine buildings and hospitals as a result of it. However, if there is no public capital—and public capital is much less than was expected—and we do not use PFI, how are we going to see investment in health infrastructure over the next five to 10 years? It is a very serious question which the noble Lord, Lord Prior, is, no doubt, looking at very carefully.

I want to come back to the point made by the noble Lord, Lord Lansley. We have already heard of the number of reviews that have taken place. All have come to the conclusion that this hospital should be redeveloped on its current site, yet he will be aware that within the NHS managerial culture there is opposition to single-site specialty hospitals. I wonder whether at heart the issue is that, although Ministers and reviews have said this hospital should be redeveloped, the truth is that the managerial cadre at NHSE and in London do not think it should take place. That was always my suspicion. When I answered that debate in 2001, the distinct impression I had was that actually the powers that be, below ministerial level, simply did not want this to happen because they do not believe in specialist hospitals. The noble Lord mentioned Oswestry. He could have mentioned the Royal Orthopaedic Hospital in Birmingham as well, which is another stand-alone hospital. I have always got the impression that senior executives in NHS England now and before in the department think these hospitals should not be stand-alone and should move into DGHs. It is legitimate to ask whether this is the real reason. Given that NHS TDA officials almost all come from NHS managerial backgrounds, I ask whether this is the real reason, alongside the squeeze on capital.

The noble Lord, Lord Lansley, asked about the tariff. It is my impression that NHS England is not favourably disposed towards specialist services in general and that the squeeze on specialty tariffs is because of that. I remind him of the order that he forced through this House taking away the right of providers to object to tariff proposals. They can no longer use the arbitration system because they need commissioners to object as well, and frankly the chance of a commissioner objecting to any tariff proposals by NHS England is a little remote.

Finally, will the Minister arrange for the NHS TDA to meet parliamentarians to discuss this urgently? The NHS TDA has new leadership: its chief executive and its chair. Mr Ed Smith will bring a great deal of fresh thinking to the work of the NHS TDA, and I would appreciate an opportunity for noble Lords to talk with him further rather than either the decision being delayed for many more months or years or it simply not going ahead.

NHS: Hospital Overcrowding

Lord Hunt of Kings Heath Excerpts

Tuesday 15th March 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the latest NHS performance figures and the concerns expressed by the Society for Acute Medicine that overcrowding in hospitals may result in avoidable deaths.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, a significant increase in emergency demand in January put the NHS under great pressure. Compared to January last year, the NHS had almost 175,000 more attendances in A&E in January 2016. We recognise this rise in demand is not sustainable, which is why we have invested £10 billion in the NHS’s five-year forward view.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister, but he will know that the January performance was the worst A&E performance of the NHS on record. The Society for Acute Medicine has warned that this is bound to have an impact on the number of avoidable deaths that take place. Ministers cannot just blame the public for coming to A&E departments. The fact is: they have cut nurse training places; they have cut social care; they have squeezed the NHS budget; and today the Public Accounts Committee says that the NHS has no chance whatever of clearing the financial deficit. I would simply ask the Minister when he thinks the NHS will next meet the four-hour target.

[Lord Prior of Brampton]

My Lords, there was a 10% increase in demand in January, which put the NHS under huge pressure. It is much to the credit of A&E services that we saw 111,000 more people within four hours than we did the previous January. It is also worth mentioning that, over the last five years, the number of consultants working in A&E has increased by 49%. The number of people working in emergency care as a whole has increased by 3.7%. It does not alter the fact, which I recognise, that A&E departments are under tremendous pressure—they often are in winter. We hope that that pressure reduces as spring approaches.

E-cigarettes: Regulation

Lord Hunt of Kings Heath Excerpts

Monday 7th March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the benefits of e-cigarettes are well understood. The figure of 1 million people who have given up smoking by taking up e-cigarettes is a valid and true one. The tobacco regulation that the noble Viscount refers to does not have any proposals for an excise tax—it purely relates to ensuring that these products are used safely and are of a given quality.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister will know that the impact of this directive is to make it much more difficult for e-cigarettes to be promoted. Why is that, given the clear benefit to public health? The answer is that public health programmes can substitute for it—but this Government have slashed those programmes. Given the Prime Minister’s success in EU negotiations about a change in direction, can the Minister confirm that we will not now have to implement Article 20 if we do not want to?

[Lord Prior of Brampton]

My Lords, this directive originated partly because a number of European countries wanted to ban these products. The fact that there is a directive, which will lead to a regulated market, means that British manufacturers will have access to those large European markets. As I understand it, the main issue that the noble Lord may be concerned about is that where the nicotine content goes above 20 micrograms per millilitre, there will have to be MHRA approval, which may mean that the higher strength nicotine substitutes are less readily available. But that is done on safety grounds.

Pharmacies: Funding

Lord Hunt of Kings Heath Excerpts

Wednesday 2nd March 2016 Lords Chamber

[Lord Prior of Brampton]

The noble Lord raises an important point which I regret I cannot answer. I will have to write to him on that matter. However, for community pharmacy to play the important role in primary care that we expect it to do, it will have to have access to integrated patient records. The confidentiality that surrounds those records is very important.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this is all very well but will the noble Lord confirm that one of the ideas of his department is for doctors to prescribe medicines for a longer period so that fewer trips are made to the pharmacy, thereby compensating for the closure of up to 3,000 pharmacies? However, is he aware that it is estimated that £300 million-worth of medicines are wasted every year? I understand that a third of that is in medicines that are never opened by patients. Surely it is not cost-effective to extend the length of the prescription time because all you will do is add to wastage of medicines.

[Lord Prior of Brampton]

My Lords, there is no intention to extend the prescription time just for the sake of it. But there are many people who have stable long-term conditions, for whom a 90-day prescription period might be appropriate. We are not saying that all prescriptions should be for that length of time but some of them might be.

Health: Black and Minority Ethnic Psychiatric Patients

Lord Hunt of Kings Heath Excerpts

Monday 29th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the Government are committed to putting more resources into mental health. There is a recognition, across all parties in this House, that mental health has been a Cinderella service for ever. We are all committed to parity of esteem between mental and physical health and more resources are now going into mental health.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in his Answer, the Minister mentioned the Mental Health Taskforce report. It points out that, while there is a workforce race equality standard, there is no equivalent standard for access to services. He said that the Government will appoint a champion, but why not agree to set a standard and appoint a national director to make sure that it is implemented?

[Lord Prior of Brampton]

My Lords, there are two separate things there. We are committed to the recommendation of appointing an equalities champion. Extending the workforce race equality standard to carers and patients was recommended by the noble Lord, Lord Crisp, and welcomed by Paul Farmer in his report. I hope that we will adopt that recommendation, but I cannot promise it.

NHS (Charitable Trusts Etc) Bill

Lord Hunt of Kings Heath Excerpts

Friday 26th February 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am highly indebted to my noble friend Lady Massey for introducing the Bill. I congratulate her on a remarkable 50th wedding anniversary today. I also congratulate the noble Lord, Lord Bird, on his remarkable maiden speech. The noble Lord, Lord Patel, was so right when he described it as extraordinary, inspiring and heart-warming. As the noble Lord, Lord Cormack, rather subtly put it, it is a great advert for the benefit of an appointed House of Lords.

The point raised about the message to trustees of charities is important. The noble Baroness, Lady Barker, rightly described the last 12 months as being a very difficult time for charities. One does not need to go through the various issues that have arisen. It is clear from what she said—I very much agree with her, certainly in the context of the Bill—that the role of charitable trustees over the years has become ever more onerous and transparent. It has sometimes brought considerable pressure on those trustees. In supporting the Bill, it is right to pay tribute to charitable trustees, but also to say to the Minister that at a time when it is easy to criticise those trustees, the Government need to look at ways trustees can be collectively supported in the very difficult job that they are sometimes called on to do.

The first part of the Bill has arisen mainly from representations from the Association of NHS Charities and a number of individual NHS charities that have called for reform. I very much support the change that would be made. My understanding, and maybe the Minister could confirm this, is that there is a view that removing the current ministerial involvement in the appointment of trustees may encourage donors rather more in the future than in the past. I do not know whether the Minister agrees with that, but if it is true it is certainly to be welcomed.

I can only support Clause 3, on the transfer of rights to “Peter Pan” royalties. We all see Great Ormond Street as a hugely important national and international institution. The more it can be supported the better. My noble friend Lady Blackstone eloquently described the reason for the Bill, and the Opposition are wholly in support.