NHS: Congenital Heart Disease

Lord Hunt of Kings Heath Excerpts

Wednesday 14th December 2016 Lords Chamber

[Baroness Chisholm of Owlpen]

I do not want to go into issues relating to specific hospitals but I emphasise that no decisions have been made. Where it is decided that changes need to be made, these will be managed carefully and will be carried out in partnership with current service providers, patient groups and advocates. Decisions are likely to be made in the summer but there will be no change on the ground until at least 2018. The public consultation will give everyone a chance to put forward their views and to discuss the plans further.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Baroness says that she will not discuss individual hospitals but, in the end, Ministers are accountable. Will she confirm that the reason given by NHS England is that the Brompton does not meet its specification, which insists on same-site locations for all children’s services? Can she confirm that one of the hospitals not threatened with closure has multi-site locations, and will she also confirm that the Brompton has one of the best outcomes in the country?

[Baroness Chisholm of Owlpen]

I am not going to be drawn into discussing specific hospitals and I have given my reasons for that. However, I will say that the statement made in July by the Royal College of Surgeons and the Society for Cardiothoracic Surgery said:

“We fully support these standards. NHS England must ensure that the standards are applied for the benefit of patients, by ensuring that expertise is concentrated where it is most appropriate. The proposals put forward by NHS England today should improve patient outcomes and help address the variations in care currently provided.

It is fundamentally important that specialist surgical centres are large enough and treat patients regularly enough to develop full expertise to treat all conditions. It’s vital they are properly staffed to provide on-call rotas and teams have the time to create a supportive environment where new techniques are shared and future specialists can learn”.

--- Later in debate ---

[Baroness Chisholm of Owlpen]

The noble Baroness makes a very good point. This has been fiercely debated since the publication in 2001 of the damning report into the high death rates among babies undergoing heart surgery at Bristol Royal Infirmary. The last time plans were put forward, in 2011, it led to a bitter fall-out, pitting hospitals against senior health bosses, and two years later the proposals were scrapped, with NHS bosses being told to look again. That is why we are now trying to go forward, so that we can cover both adult and children’s services.

[Lord Hunt of Kings Heath]

My Lords, may I offer some advice to the noble Baroness? It is quite clear that, in the end, the Government will not agree to the closure of the Brompton, because that has been the decision on numerous occasions since 2001. Why not just pull the consultation? It is not going anywhere, my Lords.

[Baroness Chisholm of Owlpen]

We do not yet know that it is not going anywhere. A public consultation is coming forward, and the Brompton is not the only hospital concerned; it concerns a lot of hospitals all around the country. It is fair that it should go to a public consultation. Everybody will then have a chance to put their views, and that is going to be the way forward.

Surrogacy

Lord Hunt of Kings Heath Excerpts

Wednesday 14th December 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, welcome the initiative of the noble Baroness, Lady Barker. I endorse her praise for Baroness Warnock’s outstanding work, which led to the legislation which the noble and learned Lord, Lord Mackay, took through the House. I very much hope that he will speak more often in the gap in future because his contributions in this area are always so welcome.

The noble Baroness, Lady Barker, spoke compassionately and persuasively in favour of updating the law to deal with some of the problems she identified. The noble Lord, Lord Faulks, illuminated the problems arising from a case where the children were left in limbo. However, as the noble and learned Lord, Lord Brown, said, this, of course, is not the only problem. The report of Surrogacy UK, which was endorsed by Baroness Warnock, sets out very clearly some of the challenges that we face with the current law. The report concludes that,

“the time is ripe to embark upon reform of surrogacy law”,

and makes it clear that the current law is,

“out of date and in dire need of reform”.

I will refer to three areas that the report identifies. First, it states:

“Our recommendations for reform centre on the welfare of surrogate-born children and on realigning the law with their best interests”.

Secondly, it states that,

“the principle of altruistic surrogacy in the UK”,

must be guarded. Thirdly, it states:

“The law must recognise the correct people as parents of children born through surrogacy”.

I also draw the House’s attention to the three recommendations the report makes to the Government. First, it states:

“The Department of Health … should … publish a ‘legal pathway’ document for intended parents and surrogates”.

That is a very interesting and important recommendation. Secondly, the report states:

“The Department of Health should produce guidance for professionals in the field”.

Thirdly, the report states:

“Surrogacy should be included in schools’ sex and relationships education”.

Perhaps the Minister, in responding, will say whether the Government have considered those three specific recommendations and are prepared to take them forward.

The noble and learned Lords, Lord Mackay and Lord Brown, and the noble Viscount, Lord Craigavon, emphasised their desire for the Law Commission to undertake a review. It has undertaken a consultation and the noble Viscount, Lord Craigavon, said that it is monitoring this debate. We appeal to the Government to refer this matter to the Law Commission.

If the Law Commission option is not taken forward, will the Government then be prepared to undertake their own review of the law? It is clear that, one way or another, we need this issue taken forward. The work needs to be done carefully but at a pace. I hope that the Minister will give us a positive response tonight and I look forward to her comments.

Care Quality Commission Review: Deaths in the NHS

Lord Hunt of Kings Heath Excerpts

Tuesday 13th December 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for repeating the Statement and take this opportunity to offer my condolences to the noble Lord, Lord Prior, on the death of his father.

The circumstances of Connor Sparrowhawk’s death were shocking and I pay tribute to his family, who fought so hard for justice and to ensure that other families do not have to go through what they did. The findings of this report are a wake-up call: relatives shut out of investigations, reasonable questions going unanswered and grieving families made to feel like a pain in the neck, or that they would be dealt with better at a supermarket checkout. This is totally unacceptable and we therefore strongly welcome the recommendation of a national framework and the specific measures which the Secretary of State has outlined. I assure the Minister that we will work with her and the Care Quality Commission to support the establishment of such a framework in a timely fashion.

Families and patients clearly should not be forgotten in the process. Will the Minister pledge that families and carers will be equal partners in developing the Government’s plan for implementing the CQC’s recommendations? Does she agree that those who work in the NHS show extraordinary compassion, good will and professionalism but also that when something sadly and tragically goes wrong, it can often be the result of a number of interplaying systematic failures? A national framework will therefore provide welcome standards and guidance across the service.

Does the Minister recall that the previous Labour Government set up the National Patient Safety Agency, based on airline experience, which was responsible for monitoring patient safety incidents, including medication and prescribing error reporting? Does she also recall that the agency was scrapped under the Health and Social Care Act 2012 and will she acknowledge that this decision was a mistake? Can the Minister tell me what happened to the national reporting and learning system which the NPSA had developed to do the very work that she has outlined in the Statement today?

I was interested in the Minister’s comments about the Secretary of State not setting any targets for reducing reported avoidable deaths. I understand the reasons—it is a sensible approach—but it is one thing for the Secretary of State to say it and another for the different multilayered sections of bureaucracy to understand it. Can she assure me that the Secretary of State will make it clear to the various regulators that targets are not to be set? Equally, I agree with her point that seeing an increase in the number of reports of potentially avoidable deaths may well be a sign of care getting better rather than worse. But explaining that to the media and the public will be a challenge. Can she tell me that that will be a priority for the Government when these reports are published?

For a national framework and the proposed measures to succeed, investment will be necessary as well. Can the Minister confirm whether hospitals will receive extra funding to carry out the additional requirements that the CQC has recommended? Crucially, will this include safe staffing levels? The House will know that hospitals across England are suffering chronic staff shortages, leaving doctors and nurses overstretched. To go back to the mid-Staffordshire inquiry, Sir Robert Francis called for safe nurse staffing levels to be published by NICE. But when NICE attempted to do that, it was blocked by the Government. Will the Minister now commit to NICE publishing safe staffing levels, as recommended by the Francis report?

We saw reports over the weekend that the bed shortages in England have got so bad that seriously ill patients with eating disorders have to travel to Scotland for treatment. This is leaving some of the most vulnerable in our society hundreds of miles away from their homes. If the Government are interested in safety, does the Minister believe that this practice is safe and sustainable?

In conclusion, the CQC has called for the issues addressed in its report to be a national priority and for all those involved in delivering safe care to review the findings and publish a full report. The Opposition absolutely agree with that. Action is needed. We welcome the recommendations and we stand ready to work with the Government to ensure that these issues are no longer ignored.

[Baroness Jolly (LD)]

My Lords, I, too, thank the Minister for repeating the Statement and echo the condolences offered by the noble Lord, Lord Hunt of Kings Heath. I declare my interests as set out in the register. I am chair of a learning disabilities charity caring for adults across England.

We welcome the findings of this report but are saddened that we should need one. However, we welcome its publication and recommendations and hope that they will be taken forward and acted upon as a matter of urgency.

I am going to talk about families, governance and learning good practice from unexplained death inquiry processes. In the report, the Secretary of State said:

“The lesson of Mid Staffs, Morecambe Bay and indeed other injustices like Hillsborough is that when families speak out we must listen”.

Surely another lesson is that a trust, or even a regulated care setting run by a charity or the private sector, should reach out to the family first after the family member dies in an unexplained way. We recognise that the emphasis in the report on the importance of including and listening to families in investigations is extremely important, but is this not what common decency should require and families expect, and should this not already be happening?

The situation at Southern Health NHS Foundation Trust reflects what is known across the sector: that whether we like it or not, mental health and learning disabilities are always considered after acute and community services. As long as I can remember—and my involvement with the NHS began at the end of the 1990s—commissioners thought of them last and there was certainly nothing approaching parity of esteem. Now, at least for mental health, we have parity of esteem, and we should have processes in place that are as good and as robust as in all other NHS settings. The chair of the trust should work with the CEO to make sure this happens and a named non-executive director on the board should have ownership of the process. Sadly, this situation is nothing new. Trusts have struggled with this for years and it has to be kept on the agenda. I mean this literally as well as figuratively. It should not be relegated to a subcommittee; it should be on a full board meeting agenda by default.

I commend the processes adopted by Mersey Care NHS Foundation Trust. In such circumstances as we have been discovering, it carries out a review within days, very quickly, while all the involved staff are still in post and details are not forgotten—and, of course, families are involved.

Any good unexplained deaths investigation or complaints system should always have an element of learning built into it. This should be shared within the organisation and also within the sector, and there should be a process to make that happen. Processes currently seem to be ad hoc. Standards and definitions should be standardised into a common framework, as indicated by the report.

I have three key questions for the Minister. First, will the Government consider extending the recommendations of this report to regulated residential settings where those with a learning disability or a mental health condition are being cared for? Secondly, the report outlines the need for a national framework. Will the Minister outline who will co-ordinate the work outlined in the report and who might be involved, and indicate its expected completion date? Finally, will the framework contain recommendations about sharing good practice within the organisation and the sector?

House of Lords Act 1999 (Amendment) Bill [HL]

Lord Hunt of Kings Heath Excerpts

Committee: 1st sitting (Hansard): House of Lords
Friday 9th December 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I wonder if I might follow the noble Lord, Lord Cormack, because he spoke a great deal of sense, in terms both of the debate that we had about retirements and the impact of the noble Lord’s amendment today. I remind the noble Lord, Lord Trefgarne, that I was the Government Whip on the 1999 House of Lords Bill and I well recall our debates. Like the noble Lord, Lord Cormack, I accept that the noble Lord has raised a point of principle which it is quite right for us to debate. Of course, we are nearly 18 years on from that Bill and much has happened in the meantime.

The noble Lord is a very distinguished Member of your Lordships’ House. It is clear that he disagrees with the principle of my noble friend’s Bill. Why on earth did he not challenge at Second Reading or put a Motion down and let the House come to a view? Why is he engaging in a clear filibuster not just in the context of the point that the noble Lord, Lord Cormack, has made about this House but at a time when we are very likely, depending on events, to be debating hugely important issues around Brexit? Does he really think it sensible to set a precedent that filibustering is to be allowed in your Lordships’ House? I would caution him against that activity. I hope that when he comes to wind up he will explain what he is doing, why he has not allowed his amendments to be grouped and why he is not allowing the House essentially to come to a view on the principle.

[Lord Dykes (CB)]

My Lords, I support the two previous interjections. I thank the noble Lord, Lord Cormack, for many years of toil, with others, in the modernisation and reform group which he has led. I came into this House in 2004. I have always regarded myself as a friend of the noble Lord, Lord Trefgarne, and he of me—we know each other well. I regard the noble Earl, Lord Caithness, as a man of great wisdom and as a hard-working and diligent Peer—in fact, we are all effectively full-time working Peers nowadays, which counts for a lot. However, I beg the noble Lord, Lord Trefgarne, as a friend, to reconsider pressing these amendments, with the damage that they will do to the reputation of this House. I ask him to think again and to bear in mind the suggestions that have been made already by people with more authority than me in these matters, hoping that he and the noble Earl, Lord Caithness, will have the courage and wisdom to respond.

--- Later in debate ---

[The Earl of Caithness]

It is true, my Lords. Some 33% or 34% of those appointed are ex-politicians. We are a pretty good dumping ground. The appointment system has also failed us in that only 22% of appointments were women.

I am sorry that my noble friend Lord Cormack is going—I need to refer to him again. He is coming back; wonderful. Our average age now is 69 to 70. I took my seat here when I was 21. Where are the youth represented in this House? We have only two Members under 39, and 29 under 50. I do not think that is a good recommendation for an appointment system.

It seems to me that the best chance of getting into this House in future will be to become an MP. You could possibly increase your chances if you change party as an MP. I have a friend in Scotland who changed from the Conservative Party to the SDP-Liberal party; he was promised a peerage. He did not get it so he changed to the Labour Party. He was promised a peerage, but he did not get it. He is disillusioned with politics now. There is a serious point in there which we need to consider, and I hope it will come up as a result of Monday’s debate.

These words were spoken in 1999: the hereditaries are,

“the ones who sit in the second Chamber not as a result of patronage”.

[Lord Hunt of Kings Heath]

My Lords, will the noble Earl tell the House how hereditaries got here in the first place? Were they elected or appointed by the monarch?

[The Earl of Caithness]

My ancestor was given a title. I cannot remember quite what it was for; I did not talk to him about it. It was 500 or so years ago. That is why I want to get rid of us—but I also want to get rid of the life Peers as well.

Let me continue. The important quote from 1999 is that,

“the House … will be the stronger, the more independent of patronage and the better”,

and:

“I believe without equivocation … that the House of Lords will be better for the 92”.—[Official Report, Commons, 10/11/99; cols. 1200-01.]

Those words were spoken by my now noble friend Lord Cormack, who clearly does not now believe that.

He is not the only former MP to change his mind about this House. On Monday, we heard a very good speech from the noble Lord, Lord Rooker, who admitted that when he was in the House of Commons he was totally ignorant about this House and did not pay any attention to it. I totally concur with that. When I was a Minister in the 1980s, I found that my Secretaries of State were not very conversant with the procedures of this House and found us an irritation—there were then far more hereditaries—but subsequently changed their mind.

Health: Parity of Esteem

Lord Hunt of Kings Heath Excerpts

Monday 28th November 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to wind up for the Opposition tonight and congratulate the noble Lord, Lord Alderdice, on what can be described only as a powerful tour de force. It was a fascinating insight into parity of esteem, as he saw it, in Northern Ireland more generally, which set the context for our debate. Almost all noble Lords have agreed with his proposition that, despite any number of pronouncements, policies and changes in the law, mental health continues to be a Cinderella service. Certainly, my impression of mental health services is that, although they came as part of the health service in 1948, although in the original structures they had their own hospital management committees, which were brought into area health authorities and then district health authorities—and then there was the development of NHS trusts and foundation trusts—and although they were in some cases integrated with those organisations and in some cases were not, they remained invisible throughout. It is a service that continues to be invisible when it comes to the key policy decisions that the Government, NHS England and the regulators make on the health service.

From a managerial point of view it is my impression that, once you become a manager in a mental health service, you stay a manager there—you do not move over. You are not perceived to have the qualities needed to become a leader in a more acute trust. If you look at the NHS people seconded into the department, NHS England or the regulators, you can see how few of them are experienced in mental health services. The noble Lord, Lord Lansley, suggested that this was rather underpinned by the financial system of mental health services whereby, because there is no tariff-based system, clinical commissioning groups tend to negotiate around the tariff and then what is left goes under block contracts to mental and community health services. This puts them at a disadvantage.

Although structures are not important, there is an issue in relation to both the culture and some of the structural issues which seems to account for the lack of focus on and priority for mental health services. Yet my experience when I chaired an acute NHS foundation trust was that many of the challenges we faced were because of the lack of proper support for patients with mental health problems. In any emergency department there will be a huge number of people with these issues. Unless there are properly based mental health services, working side by side with the acute trust, you end up with people inappropriately cared for in inappropriate places, with their outcomes often getting worse and worse.

The noble Baroness, Lady Hollins, asked the Minister a very good question about the sustainability and transformation plans. She thought that the department should not sign off STPs unless it was satisfied that the principles of parity of esteem were fully embraced within them. That is a very good suggestion which I hope the noble Baroness will agree to consider. I have looked at the names of the leaders of the 44 sustainability and transformation plans. They are clearly eminent people, many of whom I know, so there is no doubt that NHS England has appointed people of high calibre. However, they are mainly chief executives of acute trusts, clinical commissioning groups and, in one or two cases, local authorities—particularly Birmingham and Manchester. Why is this? Why have we not turned to mental health chief executives to lead some of these STPs? In my experience, mental health services often know a lot about the system because their clients impact on so many aspects of the service. If we want to make a real, visible indication that mental health services are important, we should look for leaders from mental health services to lead the sustainability and transformation plans. Even if that does not happen, I hope that both NHS England and the Department of Health will ensure that legal requirements for parity of esteem are applied before they are signed off. More than that I hope it is recognised that, unless you put mental health right at the heart of these plans, the ambitions in them are very unlikely to be realised.

I will briefly come to the question of finance. We know that the Government have ordered the NHS to put more money into mental health services. We have heard from noble Lords about the commitment for £1 billion more for mental health by 2020-21. We also heard from the noble Lord, Lord Prior, only last week, that the spend on mental health in 2015-16 is up by 8.4% on the previous year. He said that,

“there is clear evidence that the money that we have been talking about is getting through”.—[Official Report, 16/11/16; col. 1417.]

Yet most noble Lords who have spoken would say that they disagree that the money is getting through to the front line. I do not know whether the Minister has seen the recent work by the Royal College of Psychiatrists on mental health services for children and adolescents. It points out that 52 CCGs in England are allocating less than 5% of their total mental health budgets to services for children and young people. We know of the horrendous problem of young people having to be sent to places hundreds of miles away from their homes because of a lack of facilities. We have also heard, from other noble Lords, that the money simply does not seem to be getting through to other mental health services. Is the noble Baroness assured of the accuracy of the returns made by the NHS to her department on the sharing out of the mental health budget, because there is a suspicion that there has been a rebadging of existing programmes to massage the figures to make it look as though mental health spending is up when the clear experience on the front line is that services are being squeezed and squeezed?

I do not doubt Ministers’ good intents in regard to mental health and ensuring that parity of esteem is achieved. However, the reality is that on the front line mental health services continue to be discriminated against and services are under great threat. There is great concern that in the major changes we are going to see in the health service in the next two or three years as a result of the sustainability and transformation plans, mental health, far from being at the core of the changes, will once again be treated as the neglected hidden Cinderella service. I hope that the noble Baroness can prove us wrong.

NHS England: HIV Prevention

Lord Hunt of Kings Heath Excerpts

Tuesday 18th October 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether NHS England is informing patients that lifesaving drugs will be denied them if funding has to be made available for pre-exposure prophylaxis (PrEP) for HIV prevention.

[Baroness Chisholm of Owlpen (Con)]

Clinicians can apply for funding for the drugs in question where there is a clinically exceptional or clinically critical need. Each year NHS England receives many proposals for investment in specialised services. Difficult decisions then have to be made on behalf of taxpayers about how to prioritise the funding available.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Baroness. She will know that evidence from clinical trials shows that PrEP can be highly effective in reducing the spread of HIV when given to those who are at most risk. Quite disgracefully, NHS England has sought to avoid funding responsibilities by saying that it is the responsibility of local authorities, at a time when there have been big cuts in the public health budgets of those councils. Even more disgracefully, government sources appear to have briefed the media that if they were forced to fund PrEP, treatments for serious conditions would have to be stopped, including treatments for children with cystic fibrosis. This was deeply unpleasant, caused great offence and may well have added to the stigma faced by many living with HIV. Will the Government assure the House that this will not happen again, and instruct NHS England to fund the drug forthwith?

[Baroness Chisholm of Owlpen]

The decision on which drugs to prioritise and how it should happen should surely be made by clinicians and NHS England, and not by politicians. As with all new drugs, PrEP needs to be properly assessed in relation to cost and effectiveness to see how it could be commissioned in the most sustainable and integrated way, and how it compares with other cost-effective approaches.

Disability: Premature Deaths

Lord Hunt of Kings Heath Excerpts

Monday 17th October 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I warmly welcome this debate and thank the noble Baroness, Lady Hollins, for her excellent introduction. I also very much congratulate the noble Baroness, Lady Fall, on her maiden speech. I hope that she will make up for her earlier enforced silence by speaking more often in your Lordships’ House. Perhaps she will also look a little more kindly on noble Lords in her current position than she did in her previous post.

What can one say about the late Lord Rix? What an extraordinary man and humanitarian he was. Above all, his passionate advocacy on behalf of people with learning disabilities is surely a beacon to us all. I hope that tonight constitutes a small tribute to him for all that he did for so many.

The noble Baroness, Lady Hollins, was very telling when she talked about too many people in health and social care not listening to people with learning disabilities or those who know about people with learning disabilities. When one looks at the issues that have been raised—the statistics mentioned by the noble Baroness, Lady Rawlings, or the issue of the Southern Health NHS Foundation Trust, mentioned by the noble Baroness, Lady Tyler—what is most striking is the failure of so many health and social care bodies to treat people with learning disabilities with a sense of equality and respect.

The Mazars report is shocking in relation to the Southern Health Foundation Trust. It identified the lack of leadership, focus and sufficient time in the trust spent on carefully reporting and investigating unexpected deaths. That was followed up by the Care Quality Commission, which found that the trust failed to mitigate the significant risks posed by some of the physical environments in which it delivered mental health and learning disability services. It did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths.

Following those two reports, we had the saga of the former chief executive being offered an opportunity to stay on the staff, on the same salary. She has now left. I cannot help wondering whether underlying this was a board that did not accept those reports. I do not know whether the Minister is able to say a little more about that, but it seemed to me that it encapsulated the problem that the noble Baroness, Lady Hollins, suggested. Although I am sure that many parts of health and social care do their very best by people with learning disabilities, the cold statistics would suggest that we have an awful long way to go before we can be satisfied that attitudes, policies and procedures are right for these vulnerable people.

In the time available, I do not want to say very much more, but I want to ask the Minister three questions. The first relates to the 18 key recommendations from the CIPOLD review of deaths. Of course she cannot go through all 18 recommendations tonight, but can the Minister write to noble Lords who have spoken in this debate to set out how the Government consider that the health and social care system—and the Government —are responding to those 18 recommendations? In particular, will she pick up the point raised by the noble Baroness, Lady Tyler, about whether the local action that NHS England has instituted, which is not mandatory, can be seen to be a response to the recommendation of a national learning disability mortality review body? I do not think that it can be unless there is a proper mandating of the NHS to take part in it.

The second question comes back to the point made by the noble Baroness, Lady Hollins, about a national strategy. Do we have a national strategy? If not, will the Minister say how the Government intend that there should be a proper national strategy, nationally led, that will ensure that the kind of changes that need to happen will take place?

Finally, I do not think that funding is the only problem: attitudes are much more important. But no one can deny the funding challenges in health and social care at the moment—nor that, despite the Government’s intention that more money should be spent on mental health, it is quite clear that clinical commissioning groups will not do that because they are under intense pressure to balance the books. It has become clear that balancing the books is trumping any other policy. So my final question for the Minister is, essentially, what will happen to protect the funding of those services, which impact directly on people with learning disabilities?

Clinical Pharmacologists

Lord Hunt of Kings Heath Excerpts

Monday 12th September 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the impact of the decline in the numbers of clinical pharmacologists practising in the National Health Service and teaching in universities on treatment and research capacity.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this debate was organised at a very late stage on Wednesday evening so I am most grateful to all noble Lords who are taking part in it, and indeed to the Minister who will respond.

Most of the major advances in medicine in the past 50 years are related to the better use of better medicines. That is what makes this debate so important. Clinical pharmacology is the study and use of drugs in men, women and children. Clinical pharmacologists are to be found in hospitals and teaching settings, employed by the NHS and the university sector, with many employed by both. Clinical pharmacologists teach clinical pharmacology at undergraduate and postgraduate level, and provide training and support for other healthcare professionals in hospital settings. They practise those branches of medicine where drug treatment and the safer medicines agenda are pre-eminent. They can help other doctors who practise in other branches of medicine to learn about dose response, inter-individual differences in drug response and drug-to-drug interactions in order to improve patient care and prescribing practice.

By working with and training healthcare professionals, clinical pharmacologists can save the NHS money by stopping unnecessary drugs and using cheaper, more appropriate and equally effective alternatives. This is particularly pertinent given recent discussions about the NHS drugs bill; medicines spending accounts for around 10% of the overall NHS budget and costs in the region of £16 billion.

In addition to playing a valuable role in the NHS and teaching in medical schools, clinical pharmacologists are researching pioneering medicine in British universities and the UK biopharmaceutical industry. They are experts in experimental medicine, designing early-phase clinical trials, establishing NHS clinical research facilities and providing overarching clinical support. The specialty provides leadership in the use of medicines, and the benefit is felt across the broader NHS—in primary and secondary care and in areas such as regulation and medicines assessment.

Clinical pharmacologists hold a number of strategic posts within the UK healthcare and regulatory environment, so they can make decisions with widespread impacts. The National Institute for Health and Care Excellence, the Scottish Medicines Consortium and the All Wales Medicines Strategy Group have all been led by clinical pharmacologists to ensure the best use of NHS resources. They hold and have held a number of key posts within the Medicines and Healthcare Products Regulatory Agency as well. The MHRA’s yellow card scheme, which collects information on side-effects, has centres led by clinical pharmacologists across the UK. Consultants in clinical pharmacology lead the National Poisons Information Service. They have jointly led the development of the prescribing safety assessment with the UK Medical Schools Council, an innovation in medical education that aims to increase prescribing competence among newly qualified doctors.

The past 50 years have seen a huge use of this highly specialised group of clinical doctors. Looking to the future, the question is: do we need them? Indeed we do. Thinking about personalised medicine as a new frontier, clinical pharmacologists can play a crucial role in refining the use of currently available medicines and developing and pioneering the medicines of tomorrow. With an ageing population and many people with multiple illnesses who use multiple medicines, the potential of the clinical specialty is very great.

There can be no argument about either the past contribution of clinical pharmacologists or their potential contribution in future, but here is the rub. At a time when we need more of them, actual reductions in their numbers are taking place. This is affecting clinical posts as much as university teaching opportunities and it is producing a vicious circle. Changes in teaching at medical schools mean that many students pass through their training without ever hearing the term clinical pharmacology. In addition, the British Pharmacological Society has found that there is about one consultant in clinical pharmacology to 500 undergraduates, compared to one cardiology consultant to only 40 undergraduates. That means the specialty has low visibility among students and trainees, so there are few role models. Indeed, many medical students can go through the whole of medical school without even hearing of the specialty. Furthermore, the low number of consultant posts can be a deterrent in itself. Unsurprisingly, trainees are unwilling to start training in a specialty where local consultant jobs are at best uncertain, at worst unavailable. There is therefore compounded uncertainty, which makes it difficult to fill trainee posts.

We then come to the NHS and its employment of consultants. The problem is exacerbated by Health Education England’s workforce plan approach, which is an aggregate of local plans. Inevitably, those local plans are focused on immediate pressures related to targets and waiting times, so the decision-making of Health Education England operates on a demand and supply model. It asks NHS trusts what they need, collates those requirements and that essentially becomes the strategy. As most NHS trusts do not have a clinical pharmacologist consultant, they will never ask one. Hence, Health Education England states that there is no demand and therefore no need to increase supply. This is a problem for all small specialties. What we need, above all else, is strategic thinking at national level for these very important, small-number specialties. It needs to be multifaceted because we need to increase visibility to the next generation, supporting training and securing more consultant posts.

In many cases, even more worryingly, the problem has spread to industry. A shortage in clinical pharmacological skills in the UK biopharmacological industry was highlighted last year as part of a call for urgent development of a skilled workforce by the Association of the British Pharmaceutical Industry. We have traditionally enjoyed a very high reputation in this field: we can think of eminent people, such as Sir Michael Rawlins, now the chairman of the MHRA, previously the chairman of NICE, or Sir Alasdair Breckenridge, former chairman of the MHRA. Alongside these global leaders in thinking in this area is a pharmaceutical sector that is hugely important to Britain, given the scale of R&D investment and the consequent developments that take place in the UK. That is important not just to patients but to the UK economy.

Some of this is at risk because the people who make the key decisions are essentially NHS bodies and universities who do not have the strategic picture. Indeed, at the moment there are only 72 consultants in post in the NHS, despite a recommendation from the Royal College of Physicians that there should be about 440. Over the past 10 or 15 years we have seen a huge increase in the consultant workforce, but in terms of clinical pharmacologists there was a massive increase in the last 12 years from 72 to 77. These gains have not been protected and my understanding from the British Pharmacological Society is that the number has now gone to 72 consultants.

The case I want to put to the Minister is that we need some action. The British Pharmacological Society is calling for more investment by the organisations responsible for workforce management in the four UK nations—this is a UK issue as well as an issue for England—to provide a minimum increase of 78 consultant posts to bring the total up to 150 by 2025. It also wants to provide clear career pathways with associated career support and development.

How is this to be done? I hope that this afternoon the noble Baroness will signal her support for some action to be taken. I hope she will recognise the fundamental contribution of clinical pharmacology to the NHS and the safer medicines agenda and, as importantly, its potential pivotal role in maintaining the UK’s leading international academic and industrial position in the pharmaceutical sciences. I hope she will agree to meet the British Pharmacological Society with Health Education England, NHS England and the NIHR to agree workforce numbers, and to discuss what can be done in terms of a high-level strategy for clinical pharmacology. I also hope she will urge the British Pharmacological Society to work with the ABPI, the Medical Research Council and other employers and training providers on developing joined-up careers and training pathways as part of this strategy.

We are all aware of the financial pressure on the NHS at the moment, but I just point out that the clinical pharmacology specialty delivers essential cost savings. Indeed, work for the society to be published shortly by PWC estimates that for every pound invested in clinical pharmacologists, £5 can be saved through more efficient use of medicines and fewer adverse drug reactions.

This country has a pre-eminent role in the field of clinical pharmacology. It is very clearly at risk and I very much hope that the Minister will signal that the Government are prepared to take action to reverse the very worrying trend we are seeing at the moment.

--- Later in debate ---

[Baroness Chisholm of Owlpen (Con)]

My Lords, I begin by thanking the noble Lord, Lord Hunt, for securing a debate on this important subject. He has spoken today about the vital role fulfilled by clinical pharmacologists and the contribution they make to effective treatments for the population of this country.

As the noble Lord pointed out, pharmacology lies at the heart of biomedical science, linking together chemistry, physiology and pathology. Those that take up the speciality work closely with a wide variety of other disciplines, including neuroscience, molecular and cell biology, immunology and cancer biology, to name just a few. They improve the lives of millions of people globally by providing vital answers at every stage of the discovery, testing and clinical use of new medicines.

The ability to use medicines effectively, to optimise their benefit and minimise the risk of harm to people, relies on pharmacological knowledge and understanding. We hear much about new diseases such as Ebola and Zika and their emergence and also hear much about older medicines—most notably antibiotics—no longer working as well as they did, so the contribution of pharmacology to finding better and safer medicines continues to be vital.

While it is true that there has been a decline in the number of clinical pharmacologists practising in the UK, it is important that we recognise that the fall in numbers is relatively small. Data from the British Pharmacological Society and the Royal College of Physicians show that the number of CPT consultants in the UK fell from 74 in 2002 to 72 in 2013, and that 52 of the 72 consultants were based in England, but perhaps a drop of even that amount is important.

As regards the supply of the profession, as noble Lords will be aware, from being established in 2013, it has been Health Education England’s responsibility to ensure that there is sufficient future supply of staff, including those needed in specialist fields such as this, to meet the workforce requirements of the English health system. It is the responsibility of the devolved Governments to ensure their health systems have the staff they require. Each and every year, Health Education England produces a national workforce plan for England. This is built upon the needs of local employers, providers, commissioners and other stakeholders who, as members of the local education training boards, shape their local plans.

Health Education England therefore has a responsibility for ensuring an adequate supply of trainees to provide the consultant workforce of the future, but is not responsible for setting the number of consultant posts inside the NHS. As I have just set out, this is the role of trusts, commissioners and others. HEE annually reviews the number of training places in medical specialties in response to demand expressed by the NHS. It is therefore crucial that trusts have a clear view of how they wish to utilise and promote clinical pharmacology and therapeutics positions in their hospitals.

To its credit, HEE has increased the number of training posts available. However, not all of these have been filled. Clinical pharmacology and therapeutics has suffered in terms of its fill rates against other high-profile specialties. However, as my noble friend Lady Gardner of Parkes mentioned, there needs to be more recognition of the career, more involvement with related healthcare organisations and perhaps more understanding of how fascinating and interesting this career can be, as the noble Baroness, Lady Thornton, said. In an attempt to counter this, HEE has been working to make the profession more attractive to junior doctors as they begin to specialise, including making the role more flexible to trainees, offering joint training with other specialisms and actively promoting the role at careers fairs.

The noble Lord, Lord Hunt, mentioned people not coming forward because of the uncertainty of a job. That is why some clinical pharmacologists already train towards a dual CPT, which then broadens the scope of their practice, making them more desirable to employers due to increased flexibility. I am aware that HEE has also been undertaking a review of this area and will, in due course and upon completion, share these findings with stakeholders, including the British Pharmacological Society. Leading on from that, the role has also been promoted by the chair of the British Pharmacological Society and is supported by the four UK health systems.

It may be interesting to note that the supply of clinical pharmacologists is primarily domestic, with only a very small number coming from overseas. In the three years 2012 to 2015, only one of the newly appointed consultants was trained outside the UK. Both the Royal College of Physicians and the British Pharmacological Society feel that there is a need for growth in this area and assert that current and predicted supply is insufficient to support that growth, and as such are calling for more training posts. There is, though, a lack of consensus between the Royal College of Physicians and the British Pharmacological Society about the level of future demand and the numbers required. This is perhaps an indication that it is not easy to evaluate future demand or possibly indicates a lack of understanding of these roles out in the wider health system.

Given the need to spend taxpayers’ money responsibly —and the difficulty filling the existing training posts—HEE is not able to increase the number of training positions until the demand is signalled by the NHS. At this stage, no significant increase in demand has been signalled in HEE’s annual collection of forecast demand from providers, which forms the basis for the annual training commissions for medical specialties.

In summary, I strongly encourage professional bodies with an interest in this field of medicine to actively engage locally with NHS trusts to ensure that where there is a need for additional clinical pharmacologists, they feed this in to the HEE workforce planning process. This process is the fundamental bedrock for NHS workforce planning. HEE actively engages with its stakeholders in developing its annual workforce plan, and any change in workforce planning numbers needs to be debated and resolved through this process. It is interesting that this is obviously not only a problem in the United Kingdom, because several reports have come out of the United States which show that it is having similar difficulties.

I thank the noble Lord, Lord Hunt, for giving us the opportunity to discuss this important matter.

[Lord Hunt of Kings Heath]

I am most grateful to the Minister for giving way and for the eloquence of her response. From what she said, the Government’s view is that this is solely a matter for Health Education England, and I understand that. However, does she accept that because HEE is concerned only with the accumulation of the local plans, it is not able to take any account of the national significance of this clinical speciality, and that there is a risk here because local employers do not see this as particularly important, although nationally we can see that it is vitally important? Is there a case for asking HEE to look at the national strategic importance of the professions? That would be one way of looking at this from a rather different viewpoint.

[Baroness Chisholm of Owlpen]

The noble Lord stopped me just as I was about to say that very thing. This is one of the important problems. There is not joined-up thinking—certain bodies are not aware of the importance of this—so it becomes a kind of vicious circle. I was going to say that we need joined-up thinking, and I hope that debates such as this will increase awareness and get people to think further. I will be happy to meet those bodies involved; they might well prefer to meet my noble friend Lord Prior but I will be happy to accept on his behalf.

I thank all noble Lords who have taken part in this debate.

Record Copies of Acts of Parliament

Lord Hunt of Kings Heath Excerpts

Monday 11th July 2016 Lords Chamber

[Lord Bridges of Headley]

I am very delighted to be discussing this pressing issue today because there is not much else going on. I respect what my noble friend has to say but I gently repeat that the recording of Acts of Parliament is a matter for the two Houses. We very much hope that a way forward can be found to continue the use of vellum. If that is not the wish of this House, a way will have to be found, but, as I say, we await the outcome of the committee’s meeting this afternoon.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I cannot really believe that that is the Government’s position. This House, through our committees, has decided to phase out the use of vellum. To reintroduce it would be hugely expensive and a complete waste of time. I hope the Government are not reversing their position on this.

[Lord Bridges of Headley]

I gently say again that this is a matter for both Houses. It is a matter for the committee of this House and the committee of the other House to come to some agreement on. I am delighted, though, that the Labour Party is now looking to save money; this is a great turn up for the books. As I say, this is not a matter for government. We have made an offer but it is up to the Houses to decide.

Security: State Procession

Lord Hunt of Kings Heath Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the noble Lord refer this matter to the appropriate Joint Select Committee of both Houses, which looks into these matters? I think that would give a great deal more confidence.

[Lord Bridges of Headley]

My Lords, let me take that concept away with me. I have looked into this matter over the last few days and I am assured that the relevant security matters have been addressed, and that we have balanced those matters with the need to deliver savings in government.