NHS: Targets

Lord Hunt of Kings Heath Excerpts

Thursday 6th February 2020 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House takes note of the National Health Service’s performance in relation to its priority area targets; and the impact of adult social care pressures on patients of the National Health Service, and their safety.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome this opportunity to debate the current performance of the National Health Service. I declare my membership of the GMC board, my trusteeship of the Royal College of Ophthalmologists and my presidency of GS1, the organisation responsible for the “scan for safety” programme. I am very pleased that my noble friend Lady Wilcox will be making her maiden speech in this debate.

I have instituted this debate because I am increasingly worried about the performance of our National Health Service. Despite the heroic efforts of many staff, every key indicator is being missed. Last November saw the worst four-hour wait performance in A&E since figures were first collected in 2010. Two-week waits for GP appointments rose by 13% last year. The target of a maximum wait of 18 weeks for hospital treatment has not been met since 2016. The cancer target of 62 days between urgent referral and first treatment was last met in 2013-14.

I fully accept that these targets are not the only way to judge the NHS, but they reflect overall performance. At the same time, we have seen an increase in the rationing of medicines, and failings in ambulance services and services for people with learning disabilities or mental health issues. The CQC’s review of the Mental Health Act today refers to a number of very worrying problems in that area.

Given this, it is a huge tribute to NHS staff that so much care remains of a very high quality. I absolutely acknowledge that. However, the calamitous drop in performance over the past decade is clearly having an impact on patient safety and leading to those longer waits.

I was very struck just before Christmas by the Norfolk and Norwich University Hospitals NHS Foundation Trust advising staff to make “the least unsafe decision” following a huge rise in admissions. Over the new year, the Royal Cornwall Hospitals NHS Trust told its staff to reduce severe overcrowding by discharging patients, despite the obvious risks involved. These are not isolated incidents. What has caused this? Many factors and pressures are at play. The alignment of austerity with workforce shortages, inadequacies of adult social care and a complete failure to factor in the growing older population mean it is little surprise that the NHS is reeling.

If we look at funding, the lowest five-year period of funding growth was between 2010 and 2014, and the past five years have seen little improvement. It is no wonder that the NHS is cash-strapped, in deficit and finding it very hard to invest the resources necessary to prevent hospital admissions. We can see similar trends in the workforce. In March, the Health Foundation highlighted a shortage of more than 100,000 full-time equivalent staff, including more than 40,000 nurses. The GP workforce has continued to stagnate, despite government promises to increase the numbers, and the GMC’s 2019 workforce survey showed that one-third of doctors have refused requests to take on additional workloads and one-fifth have reduced their hours. It is part of a vicious cycle in the workforce. Fewer doctors and more patients means that doctors are overworked. They get ill from stress and exhaustion. They decide to cut their hours or just leave the profession, and the remaining workforce feels under even greater pressure.

All of this is happening when social care is in meltdown. In 2018, the House of Lords Economic Affairs Select Committee reported that 1.4 million older people in England had an unmet care need. We know that the number of older people and working-age adults requiring such care is increasing rapidly, yet public funding declined in real terms by 13% between 2001 and 2015. We see a second vicious cycle. The level of unmet need in the system increases, the pressure on unpaid carers grows stronger, the supply of care providers diminishes, the strain on the care workforce continues and the stability of the adult social care market worsens.

What is the Government’s response? It seems to be twofold. The attitude of the Secretary of State appears to be to get rid of any target on which the NHS is not delivering, but I remind the Minister that the Royal College of Emergency Medicine has said of A&E that there is

“nothing to indicate that a viable replacement for the four-hour target exists”.

I strongly encourage the Government to think again before they agree to change that target.

The second line of the Government’s defence is essentially to argue that they are dealing with an unprecedented increase in demand. I am the first to acknowledge that the drivers of change are intensifying and that the NHS is clearly caring for a patient population with more long-term conditions, more comorbidities and increasingly complex needs, but this is not a new problem. The Labour Government of 1997 faced the same demographic challenge, but turned it around through investment in 300,000 more staff, 100 new hospitals and new services such as NHS Direct and walk-in centres. Waiting times came down as dramatically as public satisfaction went up. It can be done.

The Government have their own long-term plan with a new five-year settlement of around 3.4% per annum. However, as the right reverend Prelate the Bishop of London said in the debate on the Queen’s Speech, the additional funding is not a bonanza; it will serve only to stabilise NHS services, and the right reverend Prelate knows what she is talking about when it comes to the NHS. Yesterday, the NAO warned that NHS trusts reported a combined deficit of £827 million and clinical commissioning groups reported a £150 million deficit in the financial year ending 31 March 2019. The NAO said that short-term fixes have made some parts of the NHS seriously financially unstable, with trusts in financial difficulty increasingly relying on short-terms loans from the Minister’s department.

As we look at the funding promised—we will have a Bill on it in your Lordships’ House soon—I refer noble Lords to a letter written by NHS leaders to the Times on Tuesday, which pointed out that this funding does not include areas crucial to the Government’s election promise to provide more hospitals, nurses and GP appointments. The additional funding does not cover investment in buildings and equipment, so there is very little relief for our crumbling infrastructure or money to fund new technology to improve care. We know that the NHS is facing a workforce crisis but the funding does not cover education and training budgets to help with recruitment and retention. Nor does it offer any relief for public health and social care services, which would, I hope, if properly invested in, keep more people healthy and independent.

Therefore, the question before us is how to turn this around. I am sure that noble Lords will come forward with many ideas in this debate but I would like to propose four key measures. First, we have to plan for the long term—not five but 20 or 30 years ahead. I want to come back to the House of Lords Select Committee report on the long-term sustainability of healthcare. It was published three years ago and chaired by the noble Lord, Lord Patel. The committee said that we have to get away from the short-term fixes that we currently see and have seen in the past. It suggested that we set up an office for health and care sustainability to look at the likely funding and workforce requirements for up to 20 years ahead. Like the Office for Budget Responsibility, which has now been well accepted as giving authoritative, independent advice to government, this body could give advice to government, Ministers and parliamentarians on the likely demands on health and social care over the next 20 years. I believe that would be the start of a much more fundamental way of ensuring that we have a high-quality healthcare service in the future.

Secondly, alongside those kinds of projections, of course we need the commensurate funding. The funding challenge is immense. No one in the health service believes, for instance, that the 3.4% being given will allow them to invest in services for the long-term five- year plan. The money is not there to invest in services to keep people out of hospital; we have a crumbling primary care service because of the pressure from patients coming through the door; and people who work in the health service regard the local plans—the STPs—as a flight of fancy. They have had to publish them and have had to agree the figures with the Government because, if they do not, they will get their heads chopped off. However, Ministers are living in a dream world if they think that these plans will be delivered. Therefore, we have to find a way of funding the health service seriously in the future, but at the moment I see no indication that the Government recognise the scale of the challenge they face.

Thirdly, on the workforce, we need better recruitment and retention, and we need to increase our training numbers, but much of the problem is due to what I am afraid I have come across many times—a bullying and blame culture. It is very off-putting for many staff in the health service. I know that Ministers are concerned about this but it starts with them, their attitude and the way they deal with the health service and the bodies responsible for it. They have to lead from the centre.

Fourthly, we have to find a solution to social care. The Government have promised to come forward with one but, as we know, the last 20 years have seen a failure of nerve and an absence of political consensus. Frankly, at the moment we seem no nearer to a solution. I must acknowledge that it is a wicked problem. However, can we really wash our hands of the pernicious situation in which many people receive no care at all and many face the loss of not just their homes but their savings as the price of their long-term care?

In this debate noble Lords will raise many other issues, including improving outcomes, developing a more robust approach to public health, targeting health inequalities, and prioritising mental health and learning disability services. However, at heart, I hope the debate will come back to the issue of performance. The targets were not plucked out of the air. They were chosen because they were a very good proxy for the overall quality and performance of the NHS as a whole. In 1997, we inherited something called the Patient’s Charter, which said that there should be a maximum waiting time of 18 months for hospital treatment. The Conservative Government at that point had come nowhere near meeting that target. We turned that around and delivered an 18-week maximum wait. We hit other targets as well. I fear that it will not be too long before we go back to those bad old days if we carry on as we are at the moment. I ask the Government to think seriously about the kind of health service that they want for the public in the future. Based on current trends, I am afraid the situation is deteriorating. I beg to move.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I first thank the Minister for her comprehensive response, and I thank all noble Lords who have taken part in what has been a wide-ranging and excellent debate. I congratulate my noble friend Lady Wilcox on what was, on any count, a brilliant maiden speech. I hope that she will speak many times in your Lordships’ House over the coming months.

In such a wide-ranging debate, one cannot do justice to what has been said, but I would identify three core themes. First, on social care, we are united in wanting to see a solution. The Minister is reassuring about the proposals that will come from the Government at some point in the year. I say to her that it is very important that these proposals deal with the now as much as they do with the future; it is now that so much pressure is being felt. I say to the noble Baroness, Lady Brinton, that if she is really looking for a quick solution, she just has to go back: you legislated for Dilnot. Raise the means test cap; implement Dilnot; and put more money into adult social care—that at least would give you a fundamental way to go forward. Your Government legislated for it; this is the remarkable thing about capping the cost of social care for individuals. It is quite remarkable that we are here, still desperately hoping that we will get a solution for the future, when we had it.

Secondly, I echo all noble Lords who have spoken so highly about the work of staff and so many great things happening in the health service. There is no doubt about that. The noble Lord, Lord Bates, referred to the US Commonwealth Fund designation of the NHS as the number one healthcare service in the world. He was right to do so. As he will know, the reason for this is that we came out very highly on cost-effectiveness and access to services. He will also know that we came bottom, with the US, on health outcomes. My concern about the issue of targets is that our continuing failure to meet them will lead to worsening health outcomes in the future.

This brings me to my final point. The Minister referred to the pressures that we are under. These are not going to go away, whether demographic pressures, growing health inequality or the fantastic opportunities of new medicine and treatments, which cost additional money. This is the way that health will go over the next period; it is not until the 2060s that the population demographic will start to change again. At the moment, the health service is reeling under huge pressure. It is simply not sustainable to think that we can go on like this over the next 10, 20 or 30 years. We have to level with the public that, if they want the NHS—and I think they do—they will one way or another have to pay for it.

We cannot run away from the kind of debate that the noble and gallant Lord, Lord Stirrup, said that we ought to have. I go back to what the House of Lords Select Committee on Long-term Sustainability of the NHS said three years ago: that we must face up to the long term to have any hope at all of getting through this and landing the NHS in the excellent shape in which we want it to be. I thank noble Lords for the opportunity to debate this.

Motion agreed.

Paterson Inquiry

Lord Hunt of Kings Heath Excerpts

Tuesday 4th February 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

I thank my noble friend for that question, and for his important contribution. He is of course very experienced in this area. Obviously we are looking for time in the legislative agenda to bring forward HSSIB. It is appropriate that we consider the patient safety elements of this report’s recommendations in the context of that Bill. In the previous Second Reading debate, which we look forward to repeating, we discussed the issues around the independent sector. But we will also separately, and perhaps in conjunction with that, consult on the key changes necessary to enable data on admitted patient care to be transferred from the Private Healthcare Information Network and independent providers directly to NHS Digital, which should start to take us in the direction of closing the gap, which I know that many noble Lords in the House are rightly concerned about.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare an interest as a board member of the GMC. I also chaired the Heart of England Foundation Trust from 2011 to 2014. Mr Paterson worked for the trust as well as in the private sector hospital that the Minister mentioned. I would like to add my personal apology to that of the Minister to the patients and families for the suffering that they endured. Mr Paterson was suspended shortly after I became chairman and we instituted Sir Ian Kennedy’s review. We now have a second inquiry and I pay tribute to Bishop Graham for his work. I have only had the chance to read the Statement quickly, but it seems a thorough piece of work and has many far-reaching lessons and recommendations for the health service.

I have a couple of suggestions for the Minister. First, one of the recommendations is around the way that regulators work together, or not. At the moment, legislation is rather out of date and sometimes gets in the way of collaborative working, although one should never use that as an excuse. As part of the legislative review, I wondered whether the need for reform of the whole regulatory system will be kept closely under review.

Secondly, I want to follow the Minister on this issue of NHS bodies being reluctant to own up to things that have gone wrong because of the potential legal liability. I have discussed this with bodies at the national level and they all say that that is nonsense and organisations should not fear apologising, but it is heavily in the culture of the NHS not to apologise because of potential liability. As part of the consideration of these recommendations, I suggest that the Government seriously look at giving an explicit statement to the NHS on the facts of this and encourage those working in the NHS always to be open about things that have gone wrong.

[Baroness Blackwood of North Oxford]

I thank the noble Lord for that important and knowledgeable contribution. His point about the sharing of lessons between regulators was well made. Part of the reason for proposing HSSIB is for systemic learning of lessons that might otherwise not be available because an inquiry might happen in one trust or group of trusts and lessons might not transfer across the entire system. The whole principle of HSSIB is cross-system learning. We already have evidence that that is working.

Furthermore, the principles at the heart of the patient safety agenda that my right honourable friend Jeremy Hunt put in place were to embed a culture of learning and not blame within the NHS so that apologies can be forthcoming. We have some way to go in achieving that change of culture, but the noble Lord is quite right that leadership starts from the top and having the right statements is a good start. The principles around the place of safety, the protection of whistleblowers and allowing people to come forward and say when they think that things are going wrong without fear of retribution are steps in the right direction. The right action after that is transparency and the recommendations in this report about transparency lead to the right actions being taken from that point.

NHS: A&E Waiting Time Target

Lord Hunt of Kings Heath Excerpts

Tuesday 21st January 2020 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what plans they have, if any, to change the four hour accident and emergency waiting time target.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, the existing standard is still in place. NHS England and NHS Improvement are reviewing access standards in four key areas, including urgent and emergency care. The Government will respond to recommendations from the review once it is concluded.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in December, for 68.6% of patients the four-hour target was met, against the actual target of 95%. That is the worst month ever. The Government’s response, behind the warm words of the Minister today, is that they want to get rid of the target, yet research published last week by Cornell and the IFS shows that the current target saves at least 15,000 lives a year. The Royal College of Emergency Medicine has said that there is no viable alternative to the current target. The college says that the Government should get on with getting this target back on track. Will the Government do that?

[Baroness Blackwood of North Oxford]

The noble Lord always asks astute questions. Winter is a challenging time. Over 2 million people attended A&E last month, and we have to pay tribute to the dedicated NHS staff for seeing over 70,000 people every day—the highest number in December ever. Although we have more NHS beds open this winter than last, our A&Es have had to treat more people. The A&E waiting standard is being looked at by clinicians, who are considering whether it is appropriate, given the changes that have occurred in clinical standards. The five key reasons considered for moving away from the standard include: the standard does not measure total waiting times; the standard does not differentiate between the severity of conditions; the current standard measures a single point in an often very complex patient pathway; and there is evidence that processes, rather than clinical judgment, are resulting in admission or discharge in the period immediately before a patient breaches the standard, which is a perverse incentive. The Government will not do anything without public consultation and clinical recommendation. We will wait to see that, and no decision will be made until that comes forward.

Health: Vaping

Lord Hunt of Kings Heath Excerpts

Tuesday 14th January 2020 Lords Chamber

[Baroness Blackwood of North Oxford]

The Government have consistently highlighted that quitting smoking and nicotine use completely is the best way to improve health. Although they are not risk free, research shows that e-cigarettes are effective in helping smokers to quit. That is why we committed in the long-term plan to roll out “stop smoking” services in the NHS, to support improvements even on our smoking cessation rates—smoking is now at its lowest level on record, down from 18.4% in 2013 to 14.4%.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Baroness agree that, looking back over the past 10 or 20 years, apart from the ban on smoking in public places, vaping has been the most successful intervention to reduce smoking? Does she therefore agree that we need to be cautious before we rush into trying to ban or overregulate its use, as some campaigners want?

[Baroness Blackwood of North Oxford]

As I said, more than 50,000 additional people quit smoking through e-cigarette use each year. We see e-cigarettes as an effective and safer route to quitting smoking than other routes. However, we understand that, at the moment, there is no evidence on the impact of long-term vaping, which is why Public Health England continues to update and publish the evidence base on e-cigarettes annually. We will continue to monitor the impacts of that use.

Queen’s Speech

Lord Hunt of Kings Heath Excerpts

Thursday 9th January 2020 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have to say that the Conservative Party did not do so well in Birmingham.

It is a great pleasure to declare my interests as a member of the GMC, a trustee of the Royal College of Ophthalmologists and president of GS1, the barcoding association responsible for the Scan4Safety programme.

I greatly welcome my noble friend Lady Blower. She made a brilliant maiden speech, and debates on education will be very much strengthened by her presence.

I welcome the emphasis in the Queen’s Speech on the NHS but it is the absence of any concrete proposals on social care that causes most concern. Frankly, the search for cross-party consensus seems to be no more than a promise to put it once more into the long grass. A number of my noble friends have talked about this. I urge the Government to go back to Dilnot. They commissioned Dilnot. He produced an excellent report, which was acclaimed. We legislated for it in this House. It is on the statute book. If we were to combine Dilnot with a more generous means test and more resources to local authorities to fund adult social care, it would not be perfect but, my goodness, it would be an improvement on the current iniquitous system.

I also welcome the return of the health service safety investigations Bill. It will be eagerly anticipated. Of course, it calls into question the Government’s patient safety strategy as a whole. I express my concern to the Minister that the strategy published just a few months ago claimed that the past 20 years have seen great progress in patient safety but no evidence was given. Talking to people on the ground—doctors and nurses—they are concerned that patient safety is compromised every day because of the huge pressures on the system. I was struck by the note sent out by the Norfolk and Norwich University Hospital just before Christmas, which told staff to make the “least unsafe decision” following a huge rise in admissions. Every day, up and down the country, NHS staff are having to make unpalatable decisions about priorities and about how to deal with the pressures and patient safety is clearly being brought into question.

I very much agreed with the noble Lord, Lord Hunt, when he talked about financial regulation. I believe the same sentiment should apply to medicines and medical devices regulation. We are promised a Bill, but the key question is whether regulation in the UK will continue to be aligned with the EU. We have had great advantages from that. Many overseas companies have invested in the UK, partly because of our life science sector and partly because regulation—either licensing or receiving a device’s charter mark—has meant that they could go into Europe and the licensing would be accepted. Despite the fact that the NHS is a poor adopter of new medicines, devices and innovations, it made the UK an attractive country in which to do business.

The Government say that they no longer want us to be aligned to the EU. What does this mean for medicines and medical devices regulation? Let us say that a US global pharmaceutical company had invested a lot of money in the UK; does it mean that, in future, it can continue to invest in the UK and get a licence from our regulator but would then have to seek a separate licence with different criteria in the rest of the EU? If that is the case, I can tell the Minister that investment will stop. If companies have to come here first, invest in R&D, go through all our regulatory procedures and then have to go to Europe and go through different processes, they will simply not come to the UK any more. This is a very important issue, which I look forward to debating when we get the Bill.

On NHS funding, I simply echo the right reverend Prelate the Bishop of London. The 3.4% per annum over five years can do no more than stabilise the current situation. As she said, we are failing lamentably on all the core targets and there are no signs as yet that we will get anywhere near meeting them. I welcome that Bill because we will want to amend it to ensure that the NHS has funding for the long term to meet all the pressures that it needs to face.

NHS: Nurses

Lord Hunt of Kings Heath Excerpts

Tuesday 7th January 2020 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government when they expect to meet the Conservative party manifesto commitment to deliver 50,000 more nurses in the National Health Service.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, we expect to increase nurse numbers by 50,000 by 2025. Eligible preregistration students on courses at English universities from September 2020 will receive additional support of at least £5,000 a year, which they will not need to repay. Additional payments of up to £3,000 will be available for some students in regions or specialisms struggling to recruit and to help students to cover childcare costs. We encourage everyone considering this incredible career to apply before the deadline on 15 January.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister, but the manifesto pledge and what she said today seem to me to have a whiff of fantasy, due to double counting, uncertain finances and a less than precise timetable. Of the 50,000 extra nurses, it turns out that only 30,500 will actually be additional nurses, of whom 12,500 will have to be recruited from other countries. Of the 18,500 that the Government are so magically going to persuade to stay on against the current trends, 12,400 were already pledged in the NHS plan published earlier in the year. It all seems to be on a bit of a wing and a prayer as to whether the Government will get anywhere near a net increase of 50,000. How can the Minister be confident that they are going to succeed when the student nurse attrition rate is at 25% and 14,000 qualified applicants were turned away from nurse courses last year?

[Baroness Blackwood of North Oxford]

My Lords, first, I thank the NHS staff who have worked so hard over the Christmas and new year period. I point the noble Lord to the recent record; the NHS now has over 20,300 more nurses on our wards than in 2010 and over 52,000 more nurses in training. We have increased our training places by 25% since September 2018 and made available 3,000 more midwifery places to ensure that we can achieve this outcome. We have put in place several actions on recruitment and retention, because we need to retain our extremely experienced and excellent nurses and to recruit more nurses to support them. That is why we have announced this new package, which will not only increase nurse payment by 12% but provide support for those in training, attracting more nurses in to support those already in place.