NHS and Social Care: Impact of Brexit

Viscount Bridgeman Excerpts

Thursday 21st July 2016 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I thank the noble Baroness, Lady Watkins, for securing the debate.

I draw your Lordships’ attention to a very interesting and concise blog from Miss Clare Marx, the president of the Royal College of Surgeons. She makes three important points. The first, already voiced in many quarters, is that losing non-UK staff would, in her words, be “cataclysmic”. I totally echo the words of the noble Baroness. Toughened migration rules often affect technicians, porters and cleaners. A clear message must be sent to the Government that the NHS needs to retain these vital staff.

Miss Marx’s second point is the opportunity that will be presented to the NHS to improve patient safety. Up till now, the UK has been required to accept the lowest common denominator of standards across Europe. An example is that some devices have found their way into the UK having been approved in European countries with lower safety standards. In many cases, these standards need to be toughened up, but at the same time the baby must not be thrown out with the bathwater. Care must be taken. The stricter regulations could make it harder to attract international innovators in healthcare. In other words, a sensible mean must be struck.

Ms Marx’s third point is a vital aspect of the changed climate in which healthcare in the UK will find itself post-Brexit—language testing. This is a subject not infrequently aired in your Lordships’ House. The law as it stood until 2012 was governed by directive 2005/36, which concerned mutual recognition of professional qualifications by all member states. Under this directive, healthcare was lumped in with professions such as engineering, surveying and so forth. It meant that English language testing could be made only following registration by the appropriate body, such as the General Medical Council and the Nursing and Midwifery Council.

The effect of this, particularly in the case of nurses, was that there were cases where a candidate could obtain registration and disappear, as far as the regulator was concerned, never to be seen again, with, of course, their English language ability untested. There were cases where the only evidence of English proficiency was a certificate obtained for a fee at a street corner in an eastern European capital. Representations were made, particularly from the UK, that healthcare differed from other professions, in that there was the additional consideration of patient safety and that it accordingly required special treatment. Thanks to the persistence of the Department of Health—I particularly mention my noble friend Lord Howe and my honourable friend Dan Poulter in another place, both at that time Ministers in the Department of Health—the Commission accepted the case for language testing of health professionals prior to registration. This can now be required not as a routine, but when the relevant regulator has reasonable grounds to believe that a candidate’s English language skills are not adequate.

This has been a step in the right direction, but it is not enough. At present the EU, within the constraints I have just mentioned, permits testing only on broad English language skills—effectively, conversational English—while to take the case of the GMC, candidates from outside the EU are required to show English language proficiency in, and I emphasise this, a clinical context. There is a huge difference between these levels. Note-taking is a particularly strong tradition in British medical practice. As one facetious journalist has written, the difference between a microgram and a milligram can be a coffin.

I urge the Minister to give priority to completing this mission, which is to require that all healthcare professionals coming to this country, from within and without the European Union, are subject to meaningful English medical language tests prior to registration. There is an urgency about this—patient safety is involved—and I hope this can be put in hand straightaway in the time remaining while the UK is still within the European Union, if not in the hopefully constructive environment post-Brexit, freed from any constraints imposed by Brussels.

The other matter that needs urgent review is the working time directive. Surgeons in particular have had long-standing concerns about the impact of the working time directive on time for training. In 2014 the task force on the EWTD concluded that we need greater flexibility for training hours while ensuring we never go back to a culture of excessive working hours that can only harm patient care. I understand the task force is due to report shortly. We await this with interest.

Finally, a brief word about research. It is essential that arising out of the Brexit negotiations there is sustained funding and continuing mobility of researchers and clinicians to ensure that the UK research industry can thrive and advance patient care.

I declare my record as a remainer at the referendum, but, as has been widely quoted, we are all Brexiteers now. I am confident that Brexit will provide a not-to-be-missed opportunity to rectify some of the anomalies and deficiencies in clinical practice that continuing membership of the European Union has involved.

General Practitioners: Appointments

Viscount Bridgeman Excerpts

Thursday 17th March 2016 Grand Committee

[Viscount Bridgeman (Con)]

My Lords, I, too, thank my noble friend Lord Attlee for initiating this debate. We heard from him that in his view the conduct of the practice of which he is now a patient leaves something to be desired. He has also been good enough to indicate that I might be able to sketch out for your Lordships a somewhat contrasting view. These two interventions, from my noble friend and myself, have not been co-ordinated; we only exchanged views two days ago.

I and my family are fortunate to be patients of a practice in central London which tells a different story. This practice has a walk-in surgery open for an hour and a quarter in the morning and two and a half hours in the evening Monday to Friday, with the exception of Wednesday evenings. I have never had to wait more than 20 minutes to see a GP. The practice has first-class support in practice nurses and receptionists. Repeat prescriptions can be requested online—this is now fairly common among GP practices. Significantly, and in many ways this is the acid test, the practice has some of the lowest referral rates to A&E in central London. In other words, more patients can be treated for minor ailments in the surgery without going to A&E. The cost of an A&E admission is approximately £80. Your GP is paid that same sum to have you for one year, so if you go to A&E for a runny nose that is the same money paid out again.

In 2006, under the GP settlement, practices could opt for PMS premium status where for extra work undertaken they received extra pay. On the whole the more enterprising practices—including the one where I am a patient—took advantage of this offer. Now I understand that the latest proposal from NHS England is for this premium to be substantially reduced or eliminated over a period of four years to bring the funding of PMS practices in line with the GMS practices that did not take advantage of the 2006 premium. It would be interesting to know if my noble friend Lord Attlee’s practice is one of the latter. It is policy to recycle the resultant savings thus made back to CCGs and through them to the practices within their groups. Where PMS practices are in a group with a substantial number of other PMS practices, the clawback available to CCGs will be considerable and as I understand it there will be significant funding available for improved services and financial support. However, PMS practices that stand virtually alone within their groups will not enjoy the same level of support. Note also that all funding deriving from the cutback to PMSs will be available to both PMS and GMS practices—a further subtle discrimination against the former.

Let me attempt to be constructive with three examples of welcome initiatives instituted by NHS England. The first is integrated care: a structuring for the patient to formulate with his GP a health plan. In my case, this involved an hour-plus session with the doctor—just think of that length of time being made available in an NHS practice. As I understand it, that model draws on experience in the US and elsewhere where patients with planned maintenance prove to be much less of a demand on healthcare services. This is being funded by CCGs, which are investing very considerably in it. It is a nation-wide initiative and much to be welcomed.

Another development in our part of London is the rapid response teams under the control of local health trusts but funded by CCGs. These consist of doctors, nurses and paramedics and I understand they are extremely effective in saving GPs in practice from having to leave their surgeries to answer emergency calls. The noble Lord, Lord Turnberg, suggested the damage caused by such calls in terms of the time of doctors in small practices.

Thirdly, I draw attention to the development of GP federations, where GPs join together in a unique and largely unprecedented way. These are set up as limited companies and their mission is to bid for services that hospitals may wish to contract out. Examples I know about are smoking cessation clinics, cardiograms, testing patients on warfarin for anti-coagulation and looking after airways disease—in short, widely disparate procedures. I think we can assume that in all cases there will be cost savings for NHS England and any profits made by the federations will be available to their GP shareholders.

I revert to the subject of my noble friend’s debate. My question for the Minister is how NHS England is to reconcile the very different standards that are emerging from this short debate. The challenge for NHS England is how to bring the less adventurous practices up to an acceptable standard without effectively dumbing down the forward-looking practices which, as I have tried to illustrate, have the potential to introduce new, co-operative practices with a substantial contribution to cost savings.

My own NHS practice reckons it will lose around £400,000, resulting in a cutback to the PMS premium over four years. From the resulting benefits that are to be made available by the CCGs to the practice, and I have given three examples, it is estimated that the practice will reduce the loss to about £200,000. Why should any loss be acceptable in this of all branches of healthcare? This is one branch of healthcare which is showing real initiative, particularly in regard to enterprise and its financial viability. Surely the NHS is in danger of killing the goose that lays the golden egg. I shall very much welcome my noble friend the Minister’s comments on that. I am in danger of mixing my metaphors, but general practice is one of the jewels in the NHS, which has been made clear by all the speakers today. Let the entrepreneurial practices not only be an example to their less-motivated colleagues but also lead the way in taking advantage of the imaginative developments that NHS England has initiated—but free from the financial penalisation that many practices are now facing.

Access to Palliative Care Bill [HL]

Viscount Bridgeman Excerpts

Friday 23rd October 2015 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I am the last of many speakers today to congratulate the noble Baroness, Lady Finlay of Llandaff, on this, her latest contribution in her distinguished record of palliative care treatment in this country. I declare a non-pecuniary interest in having been for 11 years chairman of the hospital of St John and St Elizabeth in St John’s Wood, London, which, unusually for the hospice movement in this country, has within it St John’s Hospice, forming part of the same charity. In common with most other hospices of similar size—in this case, 22 beds—St John’s has contracts with a number of adjacent health authorities, in its case seven in north and west London. I have to say that patients who are near the end of their lives, whether they wish to spend their last days at home, in hospital or in a hospice, are liable to find themselves participants in a postcode lottery —rather surprisingly, in such a small area of London.

I shall give your Lordships some examples. Hospice at home is developed by many hospices. It is vital but it has administrative problems. Statistics show a slow but steady increase in end-of-life patients wishing to spend their final days at home. Some of the health authorities in the group pay for hospice at home but some do not. Some commissioning groups, which are the flagship of the innovations in the 2012 Act, pay great attention to palliative care but, regrettably, others—again, this is the experience of the hospice with which I am familiar—have palliative care low down on their list of priorities, a point that has been raised many times in this debate. Again, I refer back to hospice at home: here there are, more than ever, likely to be continuing problems of communication as most are elderly patients, many with varying degrees of dementia and of course in dispersed locations. In the catchment area of St John’s, several CCGs do not include in their team the post of palliative lead GP, a GP who, being especially experienced in palliative care, is ideally placed and qualified to ensure good communication with patients at home, and indeed good communication between hospice and CCG. Here again, some CCGs have this very important post and some do not.

A final example of the postcode lottery is the matter of contracts between hospice and health authority. In the St John’s group, only two out of seven health authorities have contracts for more than one year —in both cases, for three years. This is probably outside the scope of the Bill but the advantage to both parties is obvious with regard to long-term planning, and it is surely likely to be reflected in the treatment and facilities available to end-of-life patients with the right postcode.

How, therefore, is all this addressed in the Bill before your Lordships? I suggest that that very point I have sought to raise is addressed directly or indirectly in the Bill under Clause 2(2). In its 10 paragraphs there is in effect a series of minimum benchmarks of performance which I am confident should serve to raise minimum standards across the board and thereby go some way to eliminating the more glaring effects of the postcode lottery to which I have referred.

In conclusion, I must say a word about funding of the hospice movement, which has been referred to, particularly by my noble friend Lord Howard of Lympne. Traditionally the funding of hospices by Governments of all parties has varied widely, from 50% of operating expenses down to percentages in the 20s. The noble Lord, Lord Howarth of Newport, has of course referred to children’s hospitals, where funding is even lower than that. Therefore the shortfall has to be found from appeals and other fundraising events, and £1 million a year is probably the bottom-line requirement. I suggest that there is degree of cynicism on the part of government in all this. This is not a party-political point—it is common to all Governments. Every Government know that in the end virtually every hospice always gets its operating costs funded from somewhere.

I therefore say to the Minister: what a marvellous opportunity for the Government to show their appreciation for this marvellous movement, which, as the noble Baroness, Lady Finlay, has reminded us, leads the world, by at least raising across the board the average percentage of support which they are able to give.

National Health Service: Sustainability

Viscount Bridgeman Excerpts

Thursday 9th July 2015 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I, too, associate with other noble Lords in thanking the noble Lord, Lord Patel, for this very timely debate.

I have, on many occasions, talked to visitors from overseas who have used the NHS and who have told me how impressed and indeed amazed they were by the fact that the treatment had not cost them a penny. Free at the point of delivery is the bedrock principle of the NHS and admired throughout the world, and I will have more to say about that. This sits alongside the unpalatable fact that it is generally agreed that, by 2020, there will be a £30 billion deficit, in addition to all the deficits running at that time.

I strongly favour a royal commission. Arguably, its most important effect would be to take the NHS out of politics to enable the whistle to be blown, as my noble friend Lord Mawhinney has said—though whether it can remain in that condition is a future challenge for abilities greater than mine. I suggest that its brief should address, among other things, the question of free at the point of delivery. This is not only an admirable ideal in itself but, over the past three or four generations, has come to be regarded as a fundamental birthright. In political terms, frankly, no party would dare to question it. However, with a royal commission, politically unfettered and drawing on many government departments other than health, there appears to me to be a once in a lifetime opportunity to address this issue. I suggest to your Lordships that such a commission would have the unbiased authority that would enable it to address the unthinkable of some form of selective contribution by patients for treatment—the noble Lord, Lord Crisp, has obliquely referred to this—moving towards the ultimate goal of a financially viable National Health Service.

The other point that I hope the royal commission would address has fortunately been answered already by the noble Lord, Lord Kakkar, who made the point of the need to address the national healthcare services in other OECD countries, and the noble Lord, Lord Crisp, has given some examples.

In 2002-03, general practices were offered a new contract—personal medical services—which offered better funding if they undertook more services. Those that took up the new contract tended to be the more entrepreneurial practices. In central London, to take one example, take-up was around 50%. The national policy has been to reduce PMS funding to that of GMS, the pre-existing contracts. I quote a doctor friend, who is one of the people concerned:

“They say that they will return any saving from PMS reviews to the local health area. There is no guarantee that that would substantially make up for lost funding. In one area I know of practices that stand to lose over £400,000 pa, which will cripple them”.

His own practice stands to lose over £300,000—we are talking about west London. He continues:

“At a time when primary care is being promoted as a means of achieving substantial savings, by enhanced and new ways of working, it seems counterproductive to make swingeing cuts in often the most innovative and high quality practices”.

I suggest to your Lordships that this is a very short-sighted measure.