NHS: Health Improvements

Baroness Brinton Excerpts

Wednesday 26th November 2014 Grand Committee

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Lord, Lord Kakkar, on securing this important debate on a key issue that is essential if the NHS is to be in the forefront of health improvement in the next few years. The noble Lord focused on the larger strategic picture, but I want to focus more on the impact on the patient and the citizen. The title of the debate refers to both innovation and research. I want first to talk about where innovation and research are providing improvement in treatment and in health, particularly the benefits of the new academic health science networks, which use pure and applied research to create very strong links between hospitals, commercial organisations and universities. These regional bodies are providing a country-wide system to deliver innovation.

I declare an interest as an arthritis patient; I am grateful to Arthritis Research UK for a briefing that it sent me. It has joined with the Medical Research Council to fund the Centre for Musculoskeletal Health and Work. Led by Southampton University, this centre seeks to find ways to reduce the impact of conditions that affect muscles, bones, and joints on the ability of people who work: people like me. At present, musculoskeletal conditions are the biggest cause of workdays lost through illness, with 30.6 million days lost a year. The cost to the economy is significant. For people with rheumatoid arthritis, seven out of 10 are unable to work because of the condition within 10 years of diagnosis. So research that is both scientific and applied can not only make a significant improvement to the individual and their condition, but can also reduce NHS costs and offer the chance of their returning to work and taking an active part in our economy again.

In another example of research innovation, Arthritis Research UK has joined with the Medical Research Council and other medical research charities to invest £230 million in a clinical research infrastructure initiative. This initiative will involve 23 key projects at centres across the country, and will use state-of-the-art technologies to find out how differences in the cellular and molecular make-up of people affect how they respond to disease and to treatment. It will take us forward on personalised treatment as that develops over the next few years.

Innovation does not automatically mean clinical research. The Scottish Health Informatics Programme is a good example, which we in England would do well to emulate. In a report to the APPG on Medical Research, a case study points out that SHIP is a Scotland-wide collaboration between the NHS and Scottish universities which analyses and links patient records. Although currently a developing resource, data linkage has also been used in a number of health studies in Scotland, using anonymous linked clinical diabetes and cancer data to show that patients using synthetic insulin were at no greater risk of developing cancer than those using traditional insulin.

That should be contrasted with some of the very practical problems of not linking data, where each hospital has its own patient number and does not allow data to be transferred between hospitals as a matter of course. A patient who has to have regular blood tests before treatment may have their test carried out at a GP surgery; it is then sent to the local district hospital, which will e-mail the result back to the GP, who often has to sign it off before the patient or the other hospital is allowed to know the result. The patient has to speak to the receptionist, sometimes to the GP as well, and the receptionist again when they go in to collect the blood test result. Because in this example the patient’s treatment is at a regional hospital, not their district hospital, they then have to text their consultant with the result to ensure that the treatment can actually be carried out. If the results are delayed for any reason, when they arrive at their regional hospital treatment may be delayed while a further blood test is carried out, and there is then a backlog of patients seeking treatment. All this is because the NHS cannot allow the transmission by e-mail of formal results. I am told that it is to do with data protection but if the Scottish system can make it work, surely the NHS can as well. Will my noble friend the Minister indicate whether England and Wales will follow the example of the Scottish Health Informatics Programme and solve what seems to me to be a straightforward and simple problem rather than the intractable and expensive problem that it has become?

There is another important area of innovation that provides significant health and well-being improvements, and that is the involvement of the citizen and patient in understanding their own disease and treatment. The National Institute for Health Research launched its “OK to ask” campaign on International Clinical Trials Day in 2013. More than 150 NHS hospital trusts took part and 80% of respondents who were followed up said that it had definitely helped to raise awareness of the importance of clinical research. The National Cancer Patient Experience Surveys of 2012 and 2013 show that only one in three cancer patients is having a conversation with their doctor about research. There is a good body of evidence to show that patients who talk to their clinicians and understand their illness and the treatments that are available—or even not available—are less likely to suffer from depression.

I have one anecdote from 10 years ago—I apologise for the aged anecdote. When I was the deputy chair of the East of England Development Agency, we did some work with the Williams Formula 1 team. As its social responsibility action, the team that changed tyres in the pits was working closely with the Great Ormond Street Hospital operating theatre teams to work out how they might be able to improve their performance to speed up operations. Both Great Ormond Street and Williams have found it extremely useful because Williams learnt something from it as well. That is an unusual form of innovation—actually, I think it is good lateral thinking—but it works very well in other ways. I know that many people involved in the Williams thing now sell that expertise for management teams to work better as teams in the future.

We have had some good cases this evening to show that the benefit of innovation is much wider than we imagine. Not only do Parliament and government have a key role to play but so does the citizen and patient. We need to ensure that innovation and research is at the heart of the NHS as it faces the challenges of the 21st century.

Care Sector

Baroness Brinton Excerpts

Tuesday 25th November 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Baroness, Lady Kingsmill, on securing this important debate. I want my focus to be slightly more positive by picking some of the good examples in the sector, particularly in training and skills, to show that there is a way out of some the problems that the sector faces at the moment. However, I start by reiterating the point made by other speakers: the care sector has some of the most dedicated staff in the UK workforce, who have the incredibly responsible job of helping to look after the most vulnerable adults in our society.

The vast majority of the 1.5 million staff do it very well, but sadly the small handful who abuse their clients and our trust are the ones who capture the headlines. My mother had domiciliary care for a decade until she moved into residential care about 18 months ago. I have seen, at first hand, carers and their managers at work. During that time, nurturing relationships have been created and sustained and her carers have travelled with her on her difficult journey. In other visits and meetings outside the family, I have seen some less good practice but also some unusual places—I will come on to the healthcare assistants in geriatric wards and prisons later.

In the main, those services that are excellent are often unseen; problems, many of which seem to be appearing more frequently, are the result—I believe—of pressure from above which comes from two sources. The first is the still very small pool of people prepared to work in the sector, and the second is the funding packages for social care that cause organisations to take short cuts. Some local authorities now offer ridiculous hourly rates to organisations that do not cover travel time, annual leave and training in particular. I am afraid to say that the tri-borough in London is one of those and Bradford is another, so it is not just a London problem. I ask my noble friend the Minister: what can the Government do to ensure that the living wage and the overheads that healthcare organisations ought to be paying should be included in a contract from local government?

I want to reflect briefly on the social care workforce demographics for 2012, which I think is the most recent year for which we have figures, and Skills for Care’s report, The Size and Structure of the Adult Social Care Sector and Workforce in England, because some interesting points come out of them. I suppose it is no surprise that over 80% of the workforce are women but it is worth highlighting that for managers it is still 80% women, which is encouraging and shows that there is not a glass ceiling there. However, that is not reflected in the black and minority ethnic data, which show that 18% of the workers are BME but for carer staff the figure rises to 29%, while for managers it drops quite considerably. Will my noble friend the Minister say what support is being offered to junior BME staff by employers or Skills for Care to help them progress their careers and get through that glass ceiling?

Interestingly, the data also show that 82% of staff are British, 4.5% are from the EU and 13% are from non-EU areas. Given the debate that your Lordships’ House has just had, if UKIP wanted to repatriate non-British workers, we would have an urgent and immediate shortfall of 17.5%, which rises to nearly 20% among front-line carers.

There has been considerable focus on the qualifications of the care workforce over the past 10 years, much of it introduced by the previous Government and continued by the present one, and with some considerable success. There has been the development of the national vocational qualifications—NVQs—at levels 2 and 3, as well as the national occupational standards, where each standard is a unit of care that demonstrates that the worker can effectively look after that particular thing; it might be bathing an elderly patient or working with them to try to bring back some memories. At the higher level there is certainly work on dementia care as well.

One difficulty was that the focus of the previous Government was on NVQ level 3, the equivalent to an A-level, rather than level 2, which left many in the sector concerned about those staff with no qualifications at all. The data show that almost half the workforce are now qualified to level 2, which is great news, and over 15% to level 3, both of which are improvements. But 37% of the workforce have no qualifications at all. We want anyone in a caring role, or who is managing carers, to have the national occupational standard—NOS—qualifications to at least level 2 to guarantee a minimum level of understanding about the care that is being given, and for the safety of the clients and patients. Inevitably, the majority of people without qualifications are direct carers. I ask my noble friend the Minister: what incentives can the Government provide for small businesses particularly to help train their staff, especially those who have no qualifications at all, given that there is an excellent national framework and many employers offer these qualifications?

This raises a further point. The future workforce projections to 2025 show that the workforce will need to grow by 800,000 in the next 11 years. If we do not have training and recruitment plans in hand, we will not be able to provide the skilled workforce we need as our ageing society needs more and more assistance.

To end on a positive note, I mentioned earlier the geriatric ward in a prison, the number of which is increasing. One healthcare assistant I met was just beginning training to qualify as a nurse because her employer realised the benefit of a proper progression pathway. That is the way this business should be going in the future.

Health: Mental Health

Baroness Brinton Excerpts

Tuesday 28th October 2014 Lords Chamber

[Earl Howe]

I hope that the noble Baroness will agree that the five-year plan is truly ground-breaking in many respects. We have identified £40 million to spend this year to support people in mental health crisis and end the practice of young people being admitted to mental health wards. Another £80 million has been freed up for next year to ensure that waiting time standards become a reality, not just for those with mild mental health conditions but across the piece. I will write to the noble Baroness if I can glean any further information about those with a specific disability.

[Baroness Brinton (LD)]

My Lords, one of the worrying consequences of the shortage of mental health beds is the number of patients who leave mental health wards and subsequently commit suicide within a short space of time. If a patient commits suicide within a short period of leaving in-patient care, it should be regarded as a never event. That would provide real parity of esteem alongside parity of funding and ensure that patient safety is at the heart of every patient’s release.

[Earl Howe]

My noble friend makes an extremely important point. NHS England is currently reviewing the never events framework. My honourable friend the Minister of State for Care and Support will shortly be meeting NHS England officials to discuss the possibility of including suicide following in-patient care as a never event and how the new never events framework will support parity of esteem.

NHS: Five Year Forward View

Baroness Brinton Excerpts

Thursday 23rd October 2014 Lords Chamber

[Earl Howe]

Many food companies—not all, but many of the larger ones—have already taken steps, for example, to reduce the levels of salt and saturated fat in their products. We need to go further. This has been done by the previous Administration and the current Government on a voluntary basis. We think that that has worked well. Nevertheless, we have never excluded the possibility of regulation, where we think that it is justified. At present, we believe that there is sufficient scope to make progress without regulation, but that is a matter we will keep under review.

[Baroness Brinton (LD)]

My Lords, from the Liberal Democrat Benches, we also welcome the five-year report, particularly because it accepts that the business-as-usual model needs to move on. In particular, we welcome the public health aspects and the fact that strong democratic accountability with councillors and local authorities is providing substantial change in public health. Does the Minister agree with the report that there should be more enhanced powers for local authorities to develop this further? If so, can he guarantee that there will be cross-departmental discussions to make sure that there are more responsibilities, powers and funding?

[Earl Howe]

My noble friend has alighted on an area to which the whole Government will have to give very careful thought. It is not simply a matter for my department. This will entail cross-departmental scrutiny and agreement. However, on the strength of the performance of local authorities in grasping the public health agenda, as they have very enthusiastically, I am sure that we should look at that particular proposal very constructively.

Mental Health: Beds

Baroness Brinton Excerpts

Tuesday 29th July 2014 Lords Chamber

[Earl Howe]

My Lords, on the very last point, I do not have up-to-date figures, but I will certainly write to the noble Lord. However, on his main question, detention as a mechanism solely to secure access to hospital treatment would not be lawful. If hospitals or local authority staff think that that is happening or feel pressurised to admit people in that way, they should report it to their trust and, if necessary, to the Care Quality Commission. Sectioning under the Mental Health Act, which denies people their liberty, is a very serious matter. It should be done only when a person is a risk either to themselves or to other people and, as the noble Lord knows, it is a legal process. A patient cannot be sectioned merely to secure a bed.

[Baroness Brinton (LD)]

My Lords, the survey referred to by the noble Lord, Lord Bradley, was of junior doctors in the Royal College of Psychiatrists. If it was somewhat anecdotal and they felt that they were unable to report it formally, can Ministers ask NHS England to ensure that there is a survey of how many doctors are having to use sectioning, to prevent this continuing?

[Earl Howe]

It certainly is important that we get to the bottom of what is really happening. We take this issue very seriously. The Care Quality Commission intends to explore the issue of people being detained in order to access psychiatric units in its ongoing review of emergency mental health care. The findings of that review will be published later this year. The CQC’s Mental Health Act commissioner regularly and routinely looks at the lawfulness of detention. In fact, the Care Quality Commission is currently developing a new approach to its responsibilities as a regulator of the 1983 Act.

NHS: District Nurses

Baroness Brinton Excerpts

Thursday 10th July 2014 Lords Chamber

[Earl Howe]

My Lords, we recognise the need for urgent action, and that it is required across the piece. We need to train more district nurses, and therefore training places have gone up both last year and this year. We also need to equip district nurses with technology. To that end, the nursing technology fund will address the issue that the noble Baroness referred to initially, which is the time that nurses have to spend with their patients. Technology can make time management much more efficient, and it is also good for the patient, who feels more in touch. NHS England and Health Education England have set up a workforce project which, as I said in my initial Answer, is designed to address not only workforce numbers but also the attractiveness of district nursing to trainees.

[Baroness Brinton (LD)]

My Lords, there has been a 47% reduction in district nurses over the previous 10 years. Does the Minister agree that if we are to have real integration of health and social care, then commissioners, NHS England and Health Education England should prioritise support for district nurses and community posts, not least to reduce the pressure on hospital beds?

NHS: Rural General Practitioner Dispensing

Baroness Brinton Excerpts

Tuesday 8th July 2014 Lords Chamber

[Earl Howe]

My Lords, I do not think that it is a question of opposing choice against the rules that we have in place. The rules are there as a result of very long-standing agreements between the medical profession and the pharmacists. I do not think that there is an appetite on either side to open those rules up for renegotiation. A balance has to be struck somewhere and the professions are content with the balance that has been struck.

[Baroness Brinton (LD)]

My Lords, given that half of patients who use dispensing GP services include at least one person over 65 and that one in six is a disabled person, can the Minister tell us whether the one-mile rule makes sense in very rural areas, where public transport may be very sketchy, especially as the one-mile rule is as the crow flies, not via the roads?

Health: Polypill

Baroness Brinton Excerpts

Monday 7th July 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, the name polypills is slightly unfortunate. When I heard about this, I immediately drew parallels with polyclinics, keeping it in the health arena, at least; but one of my adult children wondered whether this was veterinary medication for our avian friends. The principle, as the noble Lord, Lord Hunt, has outlined—I thank him very much for securing this debate—is that the polypill combines four medicines into one; three to lower blood pressure and one to lower cholesterol. Personally, I prefer the name that they have used in Australia and New Zealand, SPACE: single pill to avert cardiovascular events. It seems a neater acronym and explains much more simply what it does.

I thank the Library for its very helpful research pack, not least because it references the proposal that all over-50s should take it. This is some of the research referred to by the noble Lord, Lord Hunt. Some even suggest that those over 35 who have an at-risk profile might consider taking it every day. Indeed, Dr David Wald at Queen Mary University of London, after his trial, says that 28% of people will benefit by avoiding or delaying heart attacks. However the QMUL studies trial was only 84 patients; perhaps I should say “people”, since it was targeting people who were not yet unwell. Those results show that the blood pressure of around 12% of participants was reduced and 39% had reduction in cholesterol. All this is good, but to have a drug compulsory—because that is how it would be seen, even if it were voluntary—for anyone over 50 seems to me a fairly low benefit ratio.

The papers also describe a cost of “only 50p per day”. This sounds relatively cheap, but it is £15 per month or £180 per year. Even more than that, Dr Wald suggests that it could be sold over the counter and not as a prescription-only medicine. I do not know what the current rate is, but the per-patient allocation for medication in the NHS is not large, and anything over £100 starts to raise eyebrows. The pill would therefore be a substantial burden on the pharmaceutical bill, especially if it was to be used for the entire population over 50 rather than for those who need it.

Even if we accept that there is a good reason to give four tablets in one for healthy people, other considerations still need to be aired. The first is side-effects. The noble Lord, Lord Hunt, referred to statins —I suspect that we all know somebody who is on them—the side-effects of which can range from memory loss, muscle problems, polyneuropathy, acidosis, anaemia, cataracts, immune depression and pancreatic and liver disease. Even if you are lucky enough not to have a response to a single one of those drugs, mixtures of drugs may well have combination side-effects. I know from my own area of rheumatology that some people react badly when a mixture of drugs is taken, and they are instructed to take certain drugs in the morning and others in the evening to avoid such contraindications.

I am slightly unhappy about the reference made by the noble Lord, Lord Hunt, to the polypill being parallel to vaccination. I would much rather that people who were thought to be at risk, which could well be anyone over 50, went down the public health route and were asked to consider lifestyle changes, including stopping smoking, looking at their diet, having their cholesterol tested regularly and, most importantly, undertaking some activity. A lot of publicity was given two or three weeks ago to evidence showing that, for the population over 50, you do not have suddenly to become a Tour de France cyclist or a marathon runner and that steady walking that raises your exertion level a bit every day will do the trick.

I therefore wonder whether this “wonder drug” is not trying to solve too much in one easy go, but I am not alone. In an article that appeared in the Daily Telegraph on 19 July 2012, Dr Margaret McCartney, a Glasgow GP, was reported as saying that more evidence was needed before a mass programme was embarked on and:

“The history of medicine is rich with ideas that sounded great but either didn’t prove effective—or worse, did harm”.

Natasha Stewart, a senior cardiac nurse at the British Heart Foundation, was reported as saying:

“Research into polypills is encouraging, but there are still many questions to answer before this ‘wonder drug’ is prescribed … However interesting this potential new pill is, medicines are not a substitute for living a healthy lifestyle”.

The polypill sounds very enticing, but I am concerned about it for three reasons. First, it is already being described as a wonder drug long before extensive research and careful monitoring of side-effects, including those caused by combining four into one, have been done. As I said earlier, many people are already under strict instructions not to mix certain drugs because they interact. Secondly, the cost at 50 pence a day is not insignificant. To prescribe the pill for a large number of people who will not need it in the longer run seems futile. Like Public Health England, I would much rather see proper medical assessment MoTs being given at 35 and 50, so that people becoming more at risk can be given lifestyle change advice, have regular tests on cholesterol and other things that will indicate whether they are at risk, and can consider whether their level of activity is appropriate. My final concern is that, if the polypill is made available across the counter and not on prescription, some—perhaps many—may think that the pill alone will protect them without their looking at their own lifestyle issues.

Having been pretty depressing about all this, I want to end on a positive note. If further research at a statistically significant level can demonstrate the benefit of the pill, and if the Medicine and Healthcare products Regulatory Agency is satisfied with its efficacy, quality and safety, then, yes, I would welcome it, but there is too little for us to go out and be utterly positive about at the moment.

NHS: Better Care Fund

Baroness Brinton Excerpts

Thursday 3rd July 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Lord, Lord Kennedy of Southwark, on securing this debate about the better care fund. This is probably a timely moment to pause and reflect on new routes to integration in the health and social care sectors, but we need to do so with some caution. It is too early to see the implementation of the first round of approved projects to its conclusion, and of course both local council and health budgets are under serious pressure, as all speakers so far have indicated. We also cannot expect full integration without being honest about the cost. It will be interesting to see what emerges in the manifestos of all the parties in the run-up to the next general election.

Still, I am pleased that the coalition Government are determined to see a real start to full integration in health and social care. There has been much lip service paid to it over the years but a marked reluctance by everyone, from politicians in Parliament to local authorities, the NHS and front-line staff, to make it happen. I suspect that this has been for a number of reasons.

First, there is the perception that there is financial competition between the two sectors, each worried about not losing funding to the other. Secondly, financial mechanisms are in place that inadvertently discourage integration. Reports from some areas show that this is a serious issue. Thirdly, which is the most important, the two cultures—social care, whether local government or private providers, versus health—could not be more different. I do not think that the NHS would define itself as naturally entrepreneurial; and it takes a long time to change its ways of working. There have been some major crises recently where we are now seeing wholesale changes in the way we work, as exemplified by the Francis report. The social care sector is a mixed economy, with public service providers working alongside large and small businesses and social enterprises—not just a different model to health but a different model within social care. Therefore it is completely understandable that dialogue at the start of this major project is difficult. But there is progress.

Before turning to that progress, I want to give you one story that absolutely illustrates why we need integration. The aunt of a friend of mine, who lives in Bradford, was receiving both health and social care support at home, which was important because it meant she could live independently. One of her issues was ulcerated legs, with one leg much worse than the other. The bad leg was being treated by the district nurse on daily visits. The better leg was checked and put into support tights by her domiciliary care worker. As a result of cuts made by the Labour-controlled council, all domiciliary care classed as moderate needs was cancelled, including hers. Can noble Lords guess what is coming? Under the local PCT rules the district nurse was not allowed to help with the better leg, so this elderly and vulnerable woman had to rely on a male elderly neighbour to put the special support tights on her leg last thing at night. You see, one leg was NHS and one leg was social care. That was until the better leg deteriorated to the point at which the district nurse was permitted to come in and dress that one too. Honestly, you could not make it up.

That is at the front line; it is not the district nurse but the person in the PCT who is setting down the rules. That sort of behaviour in commissioning makes an absolute mockery of integration. That is what I mean by the clash of two cultures. There are other stories of silo thinking. In some areas there is very little discussion between social services staff and health professionals such as physiotherapists and occupational therapists. Patients are referred by physios and OTs, but there is not a continuing dialogue. One physio recommended an electric wheelchair for a patient, on the basis that this would keep her fully independent, but the wheelchair department’s rules are so strict that the patient did not meet the stringent requirements. As a result, the local authority had to offer a carer to come in to help get her up in the morning, costing both the patient and her council much more money than an electric wheelchair would have cost.

That is enough of the difficult stories. Of course, there are shining examples: not just in Torbay, but in Cambridgeshire and other places. I ceased being a councillor in Cambridgeshire 10 years ago, but even then we had a joint trust between health and social services, as it was in those days, to really start to change the funding. The money was pooled and attitudes really started to change.

We need to hear what these good examples are doing, but also to understand why they work. Unless commissioners and finance directors understand the benefits of integration, there will be a reluctance to move away from the current model. The Bradford case illustrates the point perfectly. Three more minutes of the district nurse’s time would have prevented the better leg from deteriorating and thus costing the NHS more in the long run. Therefore, while there are any cases such as the Bradford one we are nowhere near integration. That is why the extra money from the Government for integration—the £2.7 billion to councils to join up with health and social care providers, as well as local authorities’ extra £100 million this year and an extra £200 million next year—is so vital.

I was delighted to learn from Lib Dem councillors at their annual conference last weekend that the LGA estimates that councils have more than match-funded the total money of £3.8 billion for next year, 2015-16, taking it to £5.4 billion. However, the cost of this means that councils are now spending 35% of their total budgets on social care. Therefore support from central government is essential and I do not believe that we can wait until next year for that to happen.

Personally, I somewhat regret the debate about NHS money being taken by local government. I am sorry to disagree with the noble Lord, Lord Turnberg, but I think that changes in practice will reduce the costs of acute care. Indeed, the noble Lord, Lord Kennedy, referred to amputations for diabetes sufferers in this regard. That is exactly the sort of invest-to-save cost that we should be seeing with the better care fund—for example, spending on preventive care to avoid trips and slips, and in ensuring appropriate support at home for patients being discharged to reduce the “revolving door” syndrome whereby patients return to hospital in a few days. Spending on all those initiatives would help to reduce the crisis in acute care and help to reduce the pressures on its budget.

Where integration is working well, there would not even be an issue about whose money it is, not least because the better care fund plans have been jointly signed off by not just local authorities but clinical commissioning groups and health and well-being boards. Plans have also had to demonstrate how local providers have been engaged. Adult social care services have to be at the heart of the integrated system, supporting health in everything they do by improving hospital discharge and bolstering reablement services.

We have to explode the myth that the better care fund was never intended to solve the financial problems in local government and parts of the NHS. That is one of the reasons why population changes are adding £400 million to council social care budgets every year and why, frankly, budgets must be looked at in this current year. Therefore, will my noble friend the Minister say whether the Government are looking at providing support for the health and social care sector before we even get anywhere near winter problems this year? That is absolutely vital.

I believe that the better care fund is right for the nation’s finances. Investing to save rather than saving to invest is the right thing to do. I believe that in the longer run we need a transformation fund to help the culture change and ease the impact of all the changes that we are talking about, but it must have targets, too, and peer support—something which local government is very good at. The introduction by the Labour Government of the Improvement and Development Agency really helped transform councils that were in trouble and helped with the ground-breaking changes in many council services. It would be good to see that stretched into health and other sectors, too.

In conclusion, I am pleased that the better care fund is now getting well and truly under way but am slightly concerned that NHS England seems to be changing the criteria for targets for the first round and hope that that will not delay the implementation of any of the projects. That must not continue. We will be nowhere near full integration until health and social care for older people in this country are fully funded.

Health Care and Associated Professions (Indemnity Arrangements) Order 2014

Baroness Brinton Excerpts

Monday 30th June 2014 Grand Committee

[Baroness Cumberlege (Con)]

I declare an interest as a fellow of the Royal College of Obstetricians and Gynaecologists, a vice-president of the Royal College of Midwives and a patron of the National Childbirth Trust and Independent Midwives UK. I have other interests that are in the Lords’ register. I thank my noble friend for introducing this statutory instrument so clearly and for meeting the noble Lord, Lord Hunt, and myself, when we discussed the issue of independent midwives.

Draft statutory instruments are not usually a very gripping subject, but this one is because it affects the livelihood of so many people. It is therefore being introduced as an affirmative resolution. Not many statutory instruments, when enacted, will ensure that a professional is denied the right to practice—denied their livelihood. However, I start from the premise that every practitioner should have professional indemnity insurance. Some independent midwives are possibly the only group reluctantly acting without it but not only do they recognise the need for it, they want it and are prepared to go to great lengths to achieve it. This statutory instrument has concentrated minds and focused on the practicalities to achieve it, and from that point of view I welcome it.

It has been a struggle because insurance bodies draw no distinction between midwifery care and obstetric care, and of course the service given by each profession is very distinct. Obstetric treatment is very often a high risk activity, whereas midwife care is much less so. Successive Governments have adopted a policy that women should have choice—choice in healthcare but particularly choice in maternity services. This policy has been very widely welcomed by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the National Childbirth Trust, which have listened to women and have fought fairly long and hard to achieve this choice. All the evidence that they and others have gathered shows that women and their partners want choice. After all, there is nothing more important in life than giving life and bringing up the next generation.

Over the years, choice has been eroded thanks to the closure of maternity units, but in some places midwife-led units or birth centres have replaced them. They are often under threat as well. I welcome midwife-led units because they are another form of choice but I regret the diminution of home births because that is a choice denied. I ask my noble friend: how many home birth services in the NHS are on temporary hold and how many have closed? I know that they are very detailed questions and I would welcome a written reply if that suits my noble friend better than responding now. I am asking these questions because Independent Midwives UK provides for home births. That is a government policy and one that has been strongly endorsed by NICE. Independent Midwives UK provides continuity by a named midwife throughout antenatal care, birth and postnatal care—another government policy. Throughout the NHS this has proved to be pretty unachievable because community midwives are drawn into the acute services whenever there is a shortage, and because there is frequently a shortage it happens frequently.

The department’s new definition of continuity is co-ordination. A named midwife should co-ordinate the care, as my noble friend said previously. We should ask women what they think. Is co-ordination the same as continuity? Of course it is not, when in extremis women cannot even get their co-ordinator on the telephone 24/7 but they can with an independent midwife. Do they build a relationship with the co-ordinating midwife, assisting at that seminal moment of giving birth? No, because she is not there; she is too busy co-ordinating.

Independent midwives in all their forms—as social enterprises, employee-owned organisations, provident industrial societies with “bencom” status and so on—want to provide choice, continuity and care for women both in the independent sector and for the NHS. They are based in their communities and many provide services for vulnerable women, asylum seekers, those with mental health problems and so on, on a pro bono basis, but like the rest of us they cannot live on fresh air. They are seeking commissions with clinical commissioning groups. They are working towards direct referrals from GPs who welcome the continuity of knowing the midwife responsible for a mother who needs advice and support. Can my noble friend suggest ways in which the Government could support independent midwives, who are the professionals who not only support the Government’s policy but are the professionals who actually carry it out?

The NHS mandate, which sets the agenda for NHS England and which my noble friend and his ministerial colleagues shape, is an opportunity to ensure that alternative choices are there for women and their partners. Will he encourage the ministerial team to focus on this issue and enable independent providers of services to thrive, thereby enhancing government policies, giving women choice and providing the continuity that they seek?

In closing, I pay tribute to the Nursing and Midwifery Council, which has taken a very measured view of this statutory instrument, has listened and has tried to meet the needs of all concerned, amending its guidance as necessary. I look forward to my noble friend’s reply, in writing if necessary.

[Baroness Brinton (LD)]

My Lords, I completely endorse all the points made by the noble Baroness, Lady Cumberlege, and I am glad that there has been some give from the council to try to move this difficult issue forward.

I want to make a slightly different point. In these febrile days, when everything in the EU is damned, it is most welcome that this regulation comes from a new directive that is going to give patients across the EU the security of knowing that there will be indemnity and insurance available in every state. It may not be directly comparable but there will be something there. I am pretty sure that this will not hit the headlines but I see it as a major benefit to those of us who travel in Europe, as well as those coming to the UK. It is the sort of thing that is completely hidden from the headlines; it should not be.

On the difficult issue of indemnity insurance for midwives, I have been wondering, having come late to this debate, whether or not there is scope for NHS England, the regulatory councils and the insurance councils to try to work better together. The financial services industry talks frequently about the problems of insuring a very small service. This clearly is that, and it does not fit into an ordinary framework. Yet the midwives have been through exactly the same training as their counterparts elsewhere in the NHS and I am sure that clinical commissioning groups will demand that they have insurance cover. That is absolutely right. Therefore, the problem is in looking at this small cohort of midwives rather than seeing them as part of the greater group who have qualified under the same professional regulation.

I ask the Minister whether discussions will continue to ensure that no one could be denied service simply because they may not fall neatly into one of the categories. Again, I congratulate the Nursing and Midwifery Council on at least trying to find a solution to this difficult problem but it should not be said, as it is in paragraph 8.3 of the Explanatory Memorandum, that there is a balance that has to be made here and, as it affects only a few people, we should perhaps be prepared to let it go. I do not believe that we should.

[Baroness Emerton (CB)]

My Lords, I have one or two points to make. It is not very often I disagree with the noble Baroness, Lady Cumberlege, but we really have to focus on the safety of mother and child.

I am talking about independent midwives only, not the whole directive, because I support the directive. I think there is a problem in that the midwifery profession generally is the most regulated of the nursing professions. They are required to be relicensed every year. They are under a supervisory midwife. They are, if anything, more supervised than the nursing profession. I chaired the professional conduct committee of the previous regulatory body and the midwifery cases that came forward were, in the main, where things went wrong with independent midwives. Mistakes are made—I am sure we all accept that—but the problem is that very often they lack support out in the community.

In a situation where things go badly wrong, there is the issue of who is going to pay the compensation to the mother or baby who has to be cared for for many months or even years. The other noble Baroness—I am afraid I cannot remember her name—said that we ought to be looking at something to help the independent midwives, but how do we help a very small group among a very large number of midwives and try to support them when very often the compensation is enormous?