Health: Folic Acid Fortification

Baroness Brinton Excerpts

Wednesday 2nd April 2014 Lords Chamber

[Earl Howe]

Because I have been told I cannot.

[Baroness Brinton (LD)]

My Lords, pending that decision, and even with the fortification of flour, the fact is that not all women planning to get pregnant will have the right level of folic acid. Are the Government planning a media campaign to encourage mothers about this? I mean not just the information on NHS pages but radio and magazine advertisements for young women so that they start to think about it when they begin to consider having their families.

Health: Local Healthwatch Funding

Baroness Brinton Excerpts

Wednesday 19th March 2014 Lords Chamber

[Earl Howe]

My Lords, I would say that it is not the role of the Government to dictate what local authorities should be doing. It is up to local authorities to make judgments about what are the needs and priorities of their areas. I would also say that there cannot really be any direct comparison between the money made available by central government and the funding provided to local Healthwatch. It is not the case that £10 million has somehow disappeared. It is, rather, that councils have made local funding decisions which mean that £33.5 million was invested in local Healthwatch last year. What matters here is the transparency. That is what we very much welcome. It enables local Healthwatch to hold local authorities to account for their funding decisions and thereby, perhaps, influence them to give them a bit more money if that is required.

[Baroness Brinton (LD)]

My Lords, in the light of the Minister’s response, what assessment have the Government made of the extent to which local authorities are meeting those needs?

[Earl Howe]

My Lords, we will not have a comprehensive picture of the impact that local Healthwatch has made until it publishes its annual reports later in the year. At the moment, we have anecdotal reports of some considerable successes around the country, but until we have those annual reports, it would be premature for me to make a general comment.

Mental Health: Funding

Baroness Brinton Excerpts

Tuesday 18th March 2014 Lords Chamber

Asked by

[Baroness Brinton]

To ask Her Majesty’s Government what steps they are taking to protect the provision of mental health beds and funding, in the light of their commitment to parity of esteem between physical and mental health.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, we are clear that acute beds must always be available for people who need them. Providers have a responsibility to listen to patients and to offer care in the community as well as in hospitals, when appropriate. The mandate to NHS England sets its specific objectives, including on mental health. It is for NHS England and clinical commissioning groups locally to determine how best to allocate funding in commissioning services to meet local need.

--- Later in debate ---

[Baroness Brinton (LD)]

I thank my noble friend for that Answer. Before these cuts come in April the reality is that it is already very difficult to find an urgent mental health bed. Ten days ago in Kent, no emergency level 4 mental health beds were available. Given that the cuts in mental health services are 20% more than for hospital trusts and given David Nicholson’s statement last week that NHS England will not review them, what specifically can the Government do to remedy the situation?

[Earl Howe]

My Lords, my honourable friend Norman Lamb has expressed his concern that the cuts to the mental health tariff have taken the form that they have. I can tell my noble friend that the department will be scrutinising the commissioning plans of clinical commissioning groups and the draft budgets of mental health trusts to make sure that they reflect the central importance, as set out in the Government’s mandate to the NHS, of making measurable progress towards parity of esteem. We know that there are regional differences in access and we are setting up a new national mental health intelligence network to provide comprehensive and up-to-date information about mental health and well-being.

Medical Act 1983 (Amendment) (Knowledge of English) Order 2014

Baroness Brinton Excerpts

Tuesday 11th March 2014 Grand Committee

[Viscount Bridgeman (Con)]

My Lords, I rise with some diffidence as the first layman to address your Lordships in this debate. I, too, thank the Minister for his statement and pay tribute to his department for the leadership that it has shown in securing from the Commission the remedying of what was a glaring and potentially dangerous anomaly in the 2005 directive. The Commission has produced a very satisfactory outcome.

I believe the United Kingdom is among the first member states, if not the first, to incorporate the changes introduced by the revised directive into legislation. I note that the order is headed:

“Health Care and Associated Professions”.

I hope the new language-testing arrangements will be incorporated as early as possible into other branches of healthcare—I have nursing in mind in particular. I think it is the experience of many that nurses from the EEA are almost invariably pleasant, caring and considerate. They of course play a huge role in this country, but I know that many patients have had difficulty in communicating and in making themselves understood.

There are many reasons why this is a matter of some urgency, but I will suggest just one. I think I am right in saying that the practice of putting great emphasis on patients’ notes goes back a long way in the UK; possibly more emphasis than some other member states, even those with advanced healthcare arrangements. It is therefore all the more important that nurses from the EEA are proficient not only in spoken but in written English, a point which the noble Baroness, Lady Finlay, made in connection with doctors. As one facetious journalist put it,

“the difference between a microgram and a milligram is a coffin”.

I hope the Minister can give your Lordships the assurance that progress is being made in extending the provisions of the revised directive right across the healthcare profession, not least with nurses. I hope that this will include the fitness-to-practise hurdle, which is so important in reinforcing the ongoing responsibility of the relevant regulators for their members.

[Baroness Brinton (LD)]

My Lords, I am also a layman so the noble Viscount, Lord Bridgeman, need not feel completely alone. However, I preface my remarks by saying that my grandfather was the dean of St Mary’s Hospital Medical School. I remember him trying to explain to me why a bedside manner was not just about translating medical language but was all about speaking and listening. The one point I would add to the many that have been made by noble Lords this afternoon is the one about communication. A technical knowledge of English on its own is not enough—it needs to be one that picks up not just the body language but the nuance, including of regional language. If a Yorkshireman says he is “probably alright”, you know that you would want to question him further, whereas somebody coming from overseas might take that at face value.

I leave the rest of the medical comments to the medical professionals, who have spoken amply in that respect, and want to speak very briefly on freedom of movement in the EU. My party certainly believes that it is vital but—in true liberal tradition—it is fine up to the point at which it harms other people. It has been quite clear, certainly with one very celebrated case but also with others that may not have hit the public eye, that the capacity to cause harm is now at a level where action needs to be taken. These changes are well overdue and I am very pleased that they will set a new framework for the General Medical Council and restore confidence in foreign doctors from the EEA, wherever they are from and whatever level of language they have.

I end on the point that proportionate language competence must not only be checked but be checked more frequently than the BMA perhaps would like, because language and communication skills can get rusty.

Contracting Out (Local Authorities Social Services Functions) (England) Order 2014

Baroness Brinton Excerpts

Tuesday 11th March 2014 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, I remind the Committee that in 2011 an order was passed by noble Lords under the Deregulation and Contracting Out Act 1994 to allow local authorities taking part in two pilot schemes to contract to outside organisations certain adult social service functions.

The House agreed to amend the original order in November 2012 to allow local authorities to continue this contracting-out activity in respect of the pilot programmes beyond the period provided by the original order. The pilots were: adult social work practices pilots and right to control pilots. The order before noble Lords today seeks to set out the policy intentions for general delegation of functions in relation to adult social care, and will in effect mark the end of the social work practice pilot programme.

I am presenting this order today, not to extend the social work practice programme itself but instead to roll out the general policy intentions for delegation of statutory functions in adult care and support. There are three main reasons why this order is required: first, to ensure that organisations set up under the SWP programme can continue to operate legally and carry out statutory functions on behalf of the local authority; secondly, to give any other local authority the power to delegate specified functions to a third party; and thirdly, to support our policy intention for delegation, bearing in mind the general power of delegation within the Care Bill.

I shall now set out more detail on each of the three points. The social work practice pilots were announced in 2010 and saw the creation of seven social worker-led organisations, which discharge the functions of the local authority in providing adult social care services. Five of these organisations continue to exist today. On a day-to-day basis, the pilots were independent of the local authority but worked closely with it and in partnership with other providers. The local authority paid for the services provided but maintained its strategic and corporate responsibilities though its contract with the social work practices.

We were looking at the pilot sites to test the potential benefits of the social work practices and delegation of statutory functions, and whether these innovative approaches improve outcomes and experiences for the people who use them. The intention of the programme was to bring people who need health and care support closer to those who provide the services they need by reducing bureaucracy, encouraging innovation and increasing the personalisation of services. The pilots were an opportunity to test different models to see what works well, and they were fully evaluated by King’s College, London.

My officials have now seen the draft final evaluation report. On the whole, the evaluation was positive, finding some evidence that the SWP model could work well. Because each pilot was set up and operated differently, it was difficult to make generalised findings, but the evaluation found evidence of better continuity of care and co-ordination; a more personalised “offer” to people in need of care and support; opportunities for reducing bureaucracy, often through greater autonomy; and increased job satisfaction and empowerment for staff working in the pilots. Ultimately, the evaluation found that the success of the SWP was largely dependent on the quality of the contract and the relationship with the host local authority. It found nothing to negate our policy intention to make such powers available to all local authorities.

This order is crucial to allow the organisations set up under the SWP programme to continue to operate legally, subject to contractual arrangements with the host local authority. Not creating the order would mean that the functions would have to come back to local authority control, undermining the hard work and progress made under the pilot programme and potentially impacting on people receiving services through this route.

As the evaluation was largely positive, this new order seeks to extend the powers of delegation to all local authorities. We know from working closely with the Cabinet Office mutual support programme—a £10 million fund to support the creation and growth of public service mutuals—that several local authorities are already keenly watching the SWP programme, as they are also interested in gaining these powers. Others have contacted us about early adoption of such powers to support them in preparing for implementation of the Care Bill. The order will allow them and others to put in place necessary mechanisms to develop innovative service models, such as mutuals, to serve local populations in advance of the Care Bill. The findings from the SWP evaluation will be beneficial to all local authorities, and we shall publish them in full in due course.

This proposed extension to all local authorities is also consistent with the future policy of delegation of certain statutory adult social care functions. Clause 78 of the Care Bill provides for a general power of delegation of adult social care and has been developed through engagement with local government colleagues and wider social care stakeholders. Indeed, it has been part of the Bill from the very first iteration that we published. Furthermore, this clause has also been agreed by noble Lords and in the other place. The order therefore also bridges the policy gap until the Care Bill comes into force. Subject to Parliament, we plan for this to be on 1 April 2015. When enacted, Clause 78 will provide for a general power of delegation and the order will serve only for any transitional arrangements.

We know from working with the SWP pilots and through the evaluation that setting up a contracting-out process takes time. The order allows interested local authorities to begin this process now to assist them in preparing for implementation of the Care Bill, as well as providing security for the existing SWP sites. We are also currently working on statutory guidance to accompany the Care Bill, and the findings from the evaluation will be valuable in informing the guidance on delegation. We are working closely with adult social care stakeholders on the development of this guidance and will publish it for consultation in May of this year. This will also be useful for any local authorities seeking to consider use of this power in advance of the Care Bill being enacted.

In considering the need for the order, we have listened to the advice of representatives from the SWP sites, to ADASS and to colleagues from the Cabinet Office mutuals programme. In conclusion, we see the order as one that fully supports the aims set out in the Care Bill and the general adult social care reform programme. It will allow the continuation of existing innovative ways of working and the creation of new ones in order to benefit individuals and communities as a whole. I commend the order to the Committee.

[Baroness Brinton (LD)]

My Lords, it is encouraging that the results from the social work practices pilots are very positive. Phrases like “innovative”, “flexible” and “less bureaucratic” are very important to begin to change the culture in the way people work. It is also as important that the real personalisation of services is balanced by the job satisfaction of staff.

The Explanatory Notes that accompany the order are almost entirely positive. I picked up a slight nuance in the Minister’s comments. I wonder if there were any identifiable less positive or concerning features about which it might also be worth advising local authorities in how they are going to be commissioning work in the future. Apart from that, it is inevitably unfortunate that there is a short notice period that this is intended to cover, before the Care Bill comes in. At least there will not be a gap now, which is to be praised.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I should have declared on the previous order—and do on this order—my chairmanship of the Heart of England NHS Foundation Trust and that I am president of GS1 and a consultant and trainer with Cumberlege Connections. I am happy to support this order. I think it is the third time the noble Earl has been before the Committee to present such an order and, as I understand it, it is an interim measure until the Care Bill is enacted; the noble Earl has said that that is expected to be on 1 April 2015.

To pick up the point raised by the noble Baroness, Lady Brinton, I suppose it would have been helpful if we could have seen the draft of the final evaluation report at this point—it is now not going to be published until April. The noble Earl referred to some of the main findings of the draft final evaluation report from King’s College. He said that it was mainly positive although there were clearly some issues, which are identified in paragraph 7.6. Perhaps he might like to say a little more about that.

Perhaps I could also ask the noble Earl about right to control. This was considered in the previous order, and in this order a reference is made to the fact that decisions on the future of the right to control pilot scheme have yet to be made and hence no provisions are included in the new order in this regard. When we debated this on 20 November 2012, the noble Earl referred to the interim evaluation of the right to control programme, published in February 2012, which showed that disabled people were benefiting but there simply was not enough evidence to make a decision on a wider rollout. He went on to say:

“Clearly, an extension of the kind that we seek will give us more evidence. The early signs are positive but that does not provide the basis for a robust decision on permanent arrangements”.—[Official Report, 20/11/2012; col. GC 150.]

Has the department now given this further consideration? Can the noble Earl say why no decisions on the future of right to control have yet been made and when he thinks such decisions will be made?

Health: Multiple Sclerosis Nurses

Baroness Brinton Excerpts

Wednesday 5th March 2014 Lords Chamber

[Earl Howe]

My Lords, I agree with the noble Lord, Lord Dubs; there is no doubt that MS specialist nurses provide support that is extremely valuable for MS patients and their carers. They help to manage relapses and give advice, they act as a gateway into counselling and physiotherapy, and they help to minimise hospital admissions and reduce the need for consultant appointments. I do not disagree with the noble Lord at all. However, it is worth reminding ourselves that NICE guidelines on multiple sclerosis set out that after diagnosis, patients should be,

“put in touch with … a skilled nurse or other support worker”.

We expect those who work in the NHS to take account of NICE guidance.

[Baroness Brinton (LD)]

My Lords, given the Minister’s last response, is it not extremely worrying that currently 25 multiple sclerosis nursing posts are under threat of redundancy—about 10% of all MS nurses? Shifting back to generalist nursing care would be a waste of an extremely valuable resource in both health and economic terms, as has been outlined. What is being done to encourage hospitals to maintain this vital service, which can save clinical and out-patient costs, too?

NHS: NICE-appraised Medicines

Baroness Brinton Excerpts

Thursday 27th February 2014 Lords Chamber

[Earl Howe]

My Lords, this important class of drugs will be subject to a special evaluation process by the National Institute for Health and Care Excellence. That methodology has been worked through and over the coming months we will see NICE evaluating orphan medicines and medicines for highly specialised conditions to inform clinicians in the NHS and, where appropriate, provide a funding direction for those drugs.

[Baroness Brinton (LD)]

My Lords, perhaps I may follow on from the Minister’s answer to the noble Lord, Lord Hunt, on clinical commissioning groups. The previous year’s report on appraised medicines provided a very helpful algorithm of biologics for rheumatoid arthritis. Will NICE and other organisations involved in these specialist medicines follow a similar algorithm to make it even clearer to CCGs where they should not step out of line but must follow clinicians’ advice?

[Earl Howe]

It is important to distinguish between a technology appraisal, where, if favourable, there is a clear funding direction for the NHS—in other words, it must fund the drug if the doctor thinks that it is appropriate for the patient—and a clinical guideline, where NICE issues best practice advice for the NHS. There is no funding direction attached to that. However, clinicians are expected to take account of NICE guidelines in everything that they do.

Young People: Suicide

Baroness Brinton Excerpts

Thursday 27th February 2014 Grand Committee

[Baroness Brinton (LD)]

My Lords, I declare my interest as a co-chair of the bullying APPG and a patron of Red Balloon. I thank the noble and right reverend Lord, Lord Eames, for instigating this debate so that we can discuss the root cause of so many avoidable deaths in young people. He was quite right to quote PAPYRUS’s data on the number of attempted suicides by young people: one every 20 minutes. That is three during this short debate.

The 2012 government report Preventing Suicide in England identified nine categories needing customised care, including children, those with untreated depression, LGBT people and ethnic minority groups. Although I am pleased by the emphasis placed on children as a separate category, we do well to remember that children can fall into most of the other groups as well.

A major factor leading to suicide is bullying. It is shocking that 69% of children in the UK report being bullied. The National Centre for Social Research report on bullying showed that each year 16,000 children are out of school long-term with depression because of bullying, and that there are at least 25 confirmed suicides as a result of bullying, but there are probably many more that do not meet the criminal standard that the noble and right reverend Lord, Lord Eames, spoke of earlier.

Early intervention is vital. Most children do not suddenly decide to kill themselves. ChildLine says that there has been a,

“trend towards younger and younger children dabbling in self-harm, with a 50% increase among those aged 12 in the last year alone”.

However, even younger children are at risk. Last year nine year-old Aaron Dugmore hanged himself after being targeted by a gang of older bullies at his school simply because he was new. Ayden Keenan-Olson, aged 14, overdosed on prescription pills after homophobic and racist bullying by his classmates. He had reported up to 20 instances of bullying since joining his school but no action was taken. He eventually bypassed security settings on his computer to research suicide.

That raises the issue of online suicide forums and cyberbullying. Later this year, family-friendly content filters will be set automatically for new broadband users. However, most kids are so tech-savvy that they are able to bypass these settings in minutes. There is much more to fear from the “dark web” free of filters than from known, visible sites, so we must educate and support our young people to protect themselves.

The launch of Zipit, ChildLine’s first app for smartphones, is great news. It is packed with humorous tips for teens and advice to help them to cope with flirting and messaging, equipping them to protect themselves from online sexting, bullying and trolling. In the two months since its launch, more than 45,000 young people have signed up.

Frankly, CAMHS are struggling to deliver mental health services or reduce the number of young people killing themselves. Pressure on services can mean many months’ wait for urgent appointments, or having to travel 300 miles to get a bed in a tier 4 clinic. I heard on Monday of a child who had had to go from Birmingham to Glasgow for such a bed. I ask the Minister what is being done to speed up access to CAMHS facilities and to minimise the distances that must be travelled in instances of urgent child referrals. The coalition Government are rightly demanding parity of esteem for mental health services, but we have yet to see it happen.

I want to end on a more positive note, although it may not seem that way at the start. First Capital Connect asked to work with Red Balloon, a specialist bullying charity, after three bullied children threw themselves in front of trains. One was a 14 year-old ballerina and the second two were a young Goth couple who jumped together in front of a train. Red Balloon works with suicidal bullied children, offering intensive recovery and education support so that children can return to mainstream school and to their friends and society. However, only a handful of places are available nationally, and CAMHS beds are also limited, not to mention the constant problems around funding. My worry is this: does that reflect the value we place on these tragically short lives? Much more is needed to get early support to youngsters before depressive thoughts of death turn into the horror of young suicide, which affects family and friends for ever.

Care: Financial Services Industry

Baroness Brinton Excerpts

Wednesday 26th February 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Lord, Lord Lipsey, on securing this important debate that joins together progress in health and social care for the elderly and how our financial services can help deliver this from 2016—two years’ time—in the wake of the Dilnot commission reforms.

The rising cost of care, however, has become an increasingly worrying issue. Two years ago, the commission estimated that the cost of the reforms was approximately £1.7 billion. Inevitably with an ageing society and limited resources, the state does not have sufficient funds to meet the increasing demand of social care for the ageing and disabled population. As Bruno Geiringer noted,

“with demand for older people’s social care expenditure currently touching £8 billion and actual spending sitting at around £7.25 billion, the gap between supply and demand is alarming”.

In 2011, the amount spent on care and support was 1.2% of GDP. However, in the same year, the figure was estimated to rise to 1.7% of GDP after the implementation of Dilnot.

As we have heard from other speakers, currently, individuals are meeting costs by drawing down equity from their housing assets, purchasing insurance, or taking from their pension funds. Where they do not have access to these sources, many have to sell their property, while still alive, to fund their nursing care, but, frankly, this is such a hard decision at a very difficult time in people’s lives as they face reducing their independence and losing their home. It is evident that there is, or will be, a market for the financial services to support the older generation. With a cap on the individual’s lifetime contribution, this can be much more clearly defined than under the present system.

The challenge is that the financial services industry must take greater initiative in funding these reforms. Several key financial products, some of which have been mentioned, are possible sources of funding. The disability linked annuity works by reducing the income of an otherwise flat annuity, but then doubles or trebles the income once care is required. In marketing this product, customers need to be aware of the tax treatment of annuities because they are treated as pay as you earn under current pension taxation rules. The second source of funding is products linked to housing assets. Many people fund their social care by utilising a portion of their housing equity to meet costs by either downsizing or taking out loans that are secured on their house, payable on death. The third source is linked to insurance. There is an opportunity for critical illness or life insurance policies to cover care costs. Similarly, top-up insurance can also assist individuals in the amount they spend on general living.

However, no providers currently offer pre-funded insurance, mainly because there is a lack of demand for it. This is why pre-funded insurance products have failed in the past, and consequently are no longer available on the market. However, such products could fit the new profile needed to fund social care in the future. I ask the Minister, if these insurance products are indeed beneficial in covering care costs, how can the Government help the industry stimulate demand for the products? A potential alternative to the previous options is a deferred payment scheme. Under this, people could pay insurance fees after they have died. This works by taking a portion of an individual’s life insurance and applying it towards paying for care fees.

Despite the potential of these products, there are many concerns that have been raised by both the Dilnot commission and the Government. As I have outlined, some products exist but face low take-up due to demand-side barriers, including reputational issues, a lack of public awareness, and the cost and complexity of the products. I am sorry to say that reputational issues have led to a loss of trust by many people in financial services. Research conducted by the Chartered Insurance Institute in late 2010,

“found that one in five respondents will never trust financial services again and 72% of people have not very much trust or no trust at all in financial advisers and life insurance providers”.

The most serious problem is the lack of awareness of social care costs. In several consumer surveys it was noted that most individuals do not know how much they will be paying for care in old age. The Local Government Association says that it found in a survey that,

“63% of individuals wrongly estimated the average cost of a care home as less than £25,000 per year”.

It is imperative, then, that we address issues related to engagement barriers in an effort to encourage people to seek private sector solutions. We must increase marketing for the products and raise awareness on the amount that people are likely to have to pay in future for their social care. This must start early. Worrying about it when you are 55 is, frankly, too late.

The Government have already established an expert working group that will involve the Government, the financial services sector, local authorities and the care sector. It is exploring ways in which individuals can best be directed to truly independent financial advisers, and will build links with pension benefits and other services. However, it is shocking that out of 53,000 self-funders in residential care only 7,000 received financial application advice in 2009. This may be a possible explanation as to why one in four self-funders ran out of money and sought help from the state. Clearly, there is a necessity for the support of financial industry in the form of products and advice. The Department of Health expects the financial services industry to respond by 2016. However, that is only two years away and most financial products take between five and 10 years to design before they come to market, let alone general take-up. I therefore ask the Minister, if this is the case, then where are these financial products and where is the early launch of information and advice to reassure the public on the adequacy of these financial options?

To conclude, there are too many individuals unaware of the social costs related to healthcare and the ability of financial services to help them finance costs. Although there is broad consensus that action needs to be taken, there is also a real fear that the commission’s recommendations could be left to rot because of the lack of products. This issue must be dealt with now because the financial services industry has the potential to minimise the full-scale effect of these costs on the lives of the ageing and disabled population. Equally importantly, it will remove the lottery of how much people have to pay for their social care, which has been a scandal for years.

NHS: Patient Data

Baroness Brinton Excerpts

Tuesday 25th February 2014 Lords Chamber

[Earl Howe]

My Lords, I cannot agree with that. The GP surgery is where the records are kept and would seem to be the natural place for patients to go. They do not have to make an appointment to do that. If they are concerned, they can write a letter or send an e-mail to the GP practice and then have a conversation later if they would like to. I do not think this is a difficult process.

[Baroness Brinton (LD)]

My Lords, it is clearly illegal for pseudonymised data to be worked back and then aggregated with other available data. Can the Minister assure the House that the Government will consider increasing the penalties for infringing personal data, including prison sentences for serious breaches and a ban on the offenders and their organisations accessing any data for up to 10 years? This is because current organisations are often not taking seriously breach-of- data fines.