Health and Social Care

Baroness Finlay of Llandaff Excerpts

Thursday 24th November 2016 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

To move that this House takes note of the implications for the health and social care workforce of the result of the referendum on the United Kingdom’s membership of the European Union.

[Baroness Finlay of Llandaff (CB)]

My Lords, I am grateful to have been able to secure this debate. I will use the term EU collectively to cover the non-UK parts of the European Union and the European Economic Area, as only 230 health and social care staff come from the latter.

We spend about the same percentage of our GDP on publicly funded health as is spent on average by the 14 nations who acceded to the EU before 2004, yet an Organisation for Economic Co-operation and Development report published today shows that we are the sick man of Europe for doctors and beds. Our heart attack and stroke survival is mediocre, cancer survival poor, we desperately need more doctors—Germany has 50% more than us—and we need more, not fewer, beds.

Our struggling health and social care sector has unfilled posts, increased demand and funding pressures. Until now, reciprocity of qualifications and free movement has brought us Europeans, from the top-flight academics and clinicians with unique skills to the lowest-grade care workers. Now, with Brexit, we must decide what we want to negotiate for.

Twenty-nine major health and social care professional bodies, royal colleges, unions, employers and skills and learning organisations have formed the Cavendish Coalition to ensure a sustainable workforce supply and thereby maintain excellent standards of care.

Around 160,000 current NHS and social care staff are EU nationals—58,000 in the NHS and 90,000 in social care, which is 6% and 7% of the workforce respectively. Most are in posts that would otherwise have gone unfilled; they are essential to sustaining services and to our research enterprise. Unless we respect staff at every level and the NHS and social care become good employers, we will not attract the next generation here into the care sector.

Salary alone is not a proxy for worth. “Worth” is knowing that you are valued in society and respected as doing an important, complex and at times difficult job because you have unique skills. After Luxembourg, the UK is the largest net importer of healthcare professionals who qualified in other parts of the EU, particularly in some specialist NHS trusts such as the Royal Brompton and Harefield, where more than 15% of staff are from the EU.

Let me start with my own profession, doctors, of whom a quarter overall are non-UK graduates. Some 11% of registered doctors in the UK—just over 30,000—gained their primary medical qualification in another European country. That is one in 10 of our NHS doctors. We are so under-doctored that 40% of advertised consultant vacancies are unfilled, usually through lack of suitable applicants. Well over a quarter of current consultants report,

“significant gaps in the trainees’ rotas such that patient care is compromised”.

The very welcome increase of 1,500 medical student places will take a decade or more to feed through to supply specialists. In the meantime, we must continue to recruit from outside.

What about beyond medicine? Overall, the NHS vacancy factor is running at 6%, particularly in nursing. Almost a fifth of midwives in parts of London—it is 6% across the UK—are EU nationals. We rely on Europe. There is already a tension between safe levels of nursing staff and financial pressures against using agency staff. I know my noble friend Lady Watkins will address the nursing workforce further. Access to dentistry is also already a problem but I will not the steal the thunder of the noble Lord, Lord Colwyn. We rely on physiotherapists from overseas, 7% of whom are EU qualified. As service demand grows, so recruitment becomes more difficult. The Chartered Society of Physiotherapy—I declare my interest as president—has workforce modelling showing we need at least 500 extra physio student places each year for the next three years.

In social care, one in 20 social workers and more than one in 10 other professionals, particularly nurses, are from the EU, but the greatest crisis looms in domiciliary social care. Turnover rates are already incredibly high: currently well over one in three, 37%, leave their role each year. This churn leads to lack of continuity and concomitant problems. When will the current workforce be told they have indefinite leave to remain—with their children? We cannot continue to defer such assurance which must apply regardless of how long they have been in the UK.

This workforce provides care and support to aid people’s independence, and prevent ill health and unnecessary hospital admission. They care for people when they are most vulnerable. The mood music is positive but that is not enough. These people we depend on need legal certainty and we need that clarified quickly to mitigate the risk of staff leaving. Such rights, including any cut-off period post-Brexit, must be communicated in a way that actively supports community cohesion and reverses the detestable aggressive and xenophobic attitude seen in recent months. If EU workers continue to feel unwelcome and decide to leave, some NHS and social care services will simply have to put up a closed sign.

On staff numbers, I focused on the large number of EU nationals working here in health and social care but more than double that number are non-UK, non-EU staff. Blanket calls for tighter immigration controls overall will simply cripple NHS and social care at a stroke. Make no mistake: the current five-year rule for a permanent UK residence card would exclude thousands. More than a quarter of all adult social care workers are from outside the UK.

The current tier 2 visa system needs review. With a fixed quota of tier 2 work permits, applicants score more points for higher-paid jobs; it is not a level playing field. Financial services staff enter in preference to low-paid health and social care staff, yet we desperately need the latter. Will the Government undertake to urgently revise both the residence requirement and the tier 2 visa points for future health and social care staff?

We must continue to recruit and retain health and social care staff from the EU and beyond while we try to increase domestic supply. To fill vacancies, more specific occupations than just nurses and midwives need to be added to the Migration Advisory Committee’s shortage list. Yet a word of caution: we must not compensate for fewer Europeans by selfishly raiding professionals from developing countries. That would further destabilise our world.

The Medical Training Initiative is a mutually beneficial scheme, run by the Academy of Medical Royal Colleges. It gives junior doctors from all over the world the opportunity to work and train here under a tier 5 visa while giving trusts a high-quality, longer-term alternative to locums for filling rota gaps. Will the Government support extension of this proven effective scheme?

We need special arrangements for Ireland. Professionals flow freely between north and south across the land border. Many doctors in Northern Ireland graduated from a university in Eire. Are the Government looking to Ireland to be our friend at the table when we leave the EU, in the same way that Norway relies on Denmark?

In employment policy and practice we benefit from remaining in concert with Europe, not disconnected from advances that safeguard staff such as TUPE protection during service reconfigurations and the manual handling directive. The European working time directive is in UK law and junior doctors’ working hours now average 48 a week. No one should contemplate increasing hours post-Brexit but we could introduce more flexibility over rest breaks and work patterns to enhance work/life balance and improve training. This can be done if and only if there is no tightening of immigration numbers in health and social care.

The General Medical Council would like the opportunity to test the competence of all doctors coming to practise here from Europe, to check they meet the same standards as UK graduates and so better protect patients. To make this possible, will the UK Government amend the GMC’s powers as set out in the Medical Act 1983? Will regulation and training across professions be integral to Brexit negotiations?

Currently, medical and research staff particularly benefit from training experience in EU countries. Will the Government remember to keep the door open for UK doctors wishing to work in the EU once the UK is no longer a member state? It is not only doctors but nurses, physiotherapists and all our other professionals.

Let us not forget biomedical research, in which we have been a world leader. Our global collaborations keep us ahead of the field. To date, the UK has been a net beneficiary of European research funding. From 2007 to 2013, we received €8.8 billion but contributed only €5.4 billion. The Prime Minister’s announcement this week of an extra £2 billion research development spend is incredibly welcome but we need to be able to employ the right talent to optimise research output.

Overall, one in five of the UK’s academic community is an EU national, although more than three-quarters of the winners of the prestigious BMA medical research grants this year originate from other European countries. Brexit risks our being excluded from the Erasmus and Marie Curie research training schemes and from invaluable collaborative experience in communicable disease management at the European Centre for Disease Prevention and Control. We cannot exclude ourselves from this expertise. Infection and toxins know no political barriers. World epidemics are and will remain a looming threat to our nation’s health.

The impact of Brexit, with falling scientific recruitment and disrupted Horizon 2020 research, was reported in Nature in August. Is the Government’s plan that we try to remain part of EU research systems and contribute funds to the European grants schemes so that we can apply for them? Will the Government ensure that our future regulatory framework enables cross-border research and clinical trials, even though we may well wish to be more nimble in the newer research fields, such as genomics?

The challenges are huge. To grow our own we must attract people into health and social care. That means valuing staff at every level, both in the workplace and in society, for the complex job they do and the personal risks to which they are very often exposed. Society’s attitudes to the sick, the vulnerable and the frail must change, and those who care for them should have proper working conditions—not thanklessly be worked into the ground. Only then will we attract our school leavers into caring roles and only then do we stand a chance of being self-sufficient in health and social care. I beg to move.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, I thank everyone who has spoken in this debate. I wish I could go through each contribution individually but time will not allow that.

I am very sorry that the Minister thought the debate was a moan, because it really was not. I do not think anyone here has moaned; rather, everyone has laid out facts and figures to try to demonstrate the problem that we have to tackle. The Minister spoke of huge opportunities, and it is to be regretted that no one who campaigned to leave was here to spell out what those opportunities might be, which they could have done. I offered up a couple and asked a question about them, but got no response. I look forward to the Minister perhaps writing to me in future and answering them—simply about the GMC’s powers and so on.

The debate has demonstrated that there is indeed a gaping gap. We risk haemorrhaging staff. A perfect storm is brewing, as has been spelled out today. Yes, we need to train our own staff, but this is not just about training places; this has to go right back into schools and across society to change attitudes, as has been said, so that care is viewed as esteemed work to go into. Our research cannot happen unless the regulations and routes for collaboration are in place and wide open and people feel welcome. I am sad that we have had no assurance on that today.

The phrase “addicted to overseas staff” is absolutely correct. Perhaps this debate has demonstrated that cold turkey is going on, as we realise that they are not going to be there in future and we cannot carry on with that addiction. The heart of our country is indeed at threat. The prejudice that people have experienced has been ugly. We are at a tipping point if we are going to lose that 5% to 10% of qualified European staff, who are certainly feeling uncomfortable and getting cold feet about remaining.

To close, I simply wish to say that I do not believe this was a negative debate. People were trying to be very constructive and lay out the problems. Unless you know the problem, you cannot find a solution. We cannot simply come out with bald statements along the lines of, “Don’t worry, it’ll be okay in the longer term”.

I thank most sincerely everyone who contributed. I beg to move.

Motion agreed.

Mesothelioma

Baroness Finlay of Llandaff Excerpts

Thursday 27th October 2016 Grand Committee

[Baroness Finlay of Llandaff (CB)]

My Lords, I am most grateful to the noble Lord, Lord Wills, for securing this important debate, and the noble Baroness, Lady Couttie, for outlining the clinical scenarios that people face, often when they are young, as they suddenly realise that they have this devastating disease. More than 2,500 cases are diagnosed each year.

I will focus initially on the iceberg effect; we are seeing just the tip because of asbestos in schools and the worry about that. Some 94% of cases of mesothelioma are effectively preventable because they are associated with chronic exposure to asbestos in one way or another, and we know that three-quarters of our schools have asbestos in place. The number of teachers dying of mesothelioma has been going up from around three a year in the early 1980s to 22 in 2012 alone. That is a marker of developing mesothelioma following chronic exposure.

The Committee on Carcinogenicity of Chemicals in Food, Consumer Products and the Environment has pointed out that we do not know whether children are intrinsically more susceptible to developing mesothelioma following asbestos exposure. However, it seems that the lifetime risk if they are exposed at the age of five is about five times that of someone aged 30 who is exposed to the same amount of asbestos. Therefore it seems that exposing children is storing up problems for the future.

I would like to coin the term “pre-mesothelioma” for the number of people in the population who will probably go on to develop mesothelioma but have no idea about it at all. If we are undertaking research, we have to get to earlier diagnosis, so we have to find ways much earlier on of picking up the markers of transformation to malignancy in the areas where asbestos fibres are stored. At the moment we do not know of any actionable drivers of the disease in order to pick up and identify early markers. There are multicentre trials, as the noble Baroness has just outlined, but the problem is that they are very disparate. That is why there is a desperate need for a single centre in the UK to co-ordinate them. That reminds me of when I was a very junior doctor and the MRC co-ordinated trials into the leukaemias, and it was from those that some advances were made. There needs to be a driver with just about everybody being recruited into a trial if that is at all possible. Currently, patients have to find out about trials and they do not really know where to go. They want to contribute because they do not want the same thing to happen to other people. The other problem is that of course while the MesobanK is in place and the cell lines are coming along, they are not there yet. We need to identify how tumour surface antigens are expressed and detect better markers of early disease.

I remind noble Lords that 60% of patients diagnosed with mesothelioma are dead within a year; in other words, they are palliative care patients. I am afraid that some clinical commissioning groups are not commissioning specialist palliative care services adequately, not at a level that allows them to be integrated with cancer and chest disease services. That is essential to provide psychosocial support as well as support for the rest of the family, and to deal with the devastating symptoms of the disease. Those groups of specialists also want to research some of the effects of the disease when it is not curable.

Lastly, we need data. I declare an interest as chairman of the National Council for Palliative Care. I was very concerned to discover that Public Health England does not plan to carry on collecting a minimum dataset from specialist palliative care services. Without that data we will not know whether what we are doing is improving services for patients. It would cost only £200,000 to refresh the collection and data management process, which in the greater order of things is nothing. Without good data on the number of patients, the people who transform from what I would call pre-mesothelioma into mesothelioma, and the numbers that need palliative care services, we will have no idea whether we are improving.

Breast Cancer: Innovative Drugs

Baroness Finlay of Llandaff Excerpts

Monday 24th October 2016 Lords Chamber

[Lord Prior of Brampton]

My noble friend makes a perceptive point. There is always going to be tension between new drugs and affordability, although there are new drugs and new medical devices that can, in the long run, actually save money. The whole purpose of the Accelerated Access Review is to try to square the circle. There are three factors that we have to consider: first, we want a strong and vibrant life sciences industry in this country; secondly, we want to bring forward new drugs as soon as possible if there are big patient benefits; and thirdly, it must be affordable.

[Baroness Finlay of Llandaff (CB)]

Following the statement of the Academy of Medical Royal Colleges this morning urging caution over chemotherapy in advanced cancer, does the Minister agree that it is very important that, at the time of diagnosis, patients have a serious illness conversation and are prepared for what might come so that they are not hanging on with false hopes for drugs which might not be of benefit to them but can have treatments that are appropriately targeted to the individual patient and their needs?

[Lord Prior of Brampton]

The noble Baroness is describing good clinical practice. One would hope that that conversation would take place between a doctor and patient. What was disturbing about the report from the Academy of Medical Royal Colleges was its overall estimate that £2 billion a year was being wasted on unnecessary tests, drugs and the like. The issue that the noble Baroness raises is where people’s lives are prolonged right at the end but they are not given any quality of life at the same time.

Mental Health: Young People

Baroness Finlay of Llandaff Excerpts

Tuesday 11th October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I am obviously disappointed to hear what the noble Lord says about Merseyside; I cannot answer specifically on Merseyside today. We have the Future in Mind strategy, which pledged £1.4 billion of extra spending over the lifetime of this Parliament for children and young people. If it is not reaching the front line in Merseyside, we should look at that.

[Baroness Finlay of Llandaff (CB)]

Can the Government provide assurance that the phenomenon of suicide contagion is now being recognised? That is contagion both from personal contact with somebody who has attempted or committed suicide and through media reporting, where the higher the profile in the media, the more likely there is to be suicide contagion. That appears to be a linear relationship. Do the Government recognise that the best way to deal with the complex problem of suicide contagion among children and adolescents at school is to provide suicide screening within schools—for the precise reason that the Minister outlined, which is that many of these people are below what you might call the healthcare radar?

[Lord Prior of Brampton]

My Lords, the issue of suicide clusters and contagion is serious and real. By 2017, as recommended by the Five-Year Forward View on Mental Health prepared by Paul Farmer, every authority will have a multiagency plan addressing that issue. I agree with the noble Baroness that we need to do a lot more in schools. Interestingly, 255 schools are now part of a pilot scheme where there is a single point of contact within the school, so that when a child is feeling suicidal or has mental health problems, it is at least clear who they should go to to seek advice.

NHS: Junior Doctors’ Contract

Baroness Finlay of Llandaff Excerpts

Wednesday 6th July 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, 40% of junior doctors voted against this contract. That is a fact, but it does not alter the fact that it is disappointing and sad that so many junior doctors feel obliged to vote against. I am not downgrading that at all. I have not heard it said that it is not democratic. A significant minority of junior doctors have voted against the contract. We have a huge need to rebuild trust between the Government and the junior doctors. The vast majority of junior doctors are committed to their profession and the NHS and we want to rebuild with them the level of trust that always existed in the past.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise that the unrelenting pressures on junior doctors are reflected in this vote and that it is essential to restore relationships and demonstrate outreach to restore some trust, and therefore that an open mind towards negotiating even minor areas of adjustment such as timetabling of introduction would go a long way to restore deeply damaged and fractured relationships?

[Lord Prior of Brampton]

It is worth noting that the Royal College of Surgeons and the Royal College of Physicians, and I think most of the other royal colleges, have supported this contract. Many of the leaders of the BMA supported this contract. As I said, the Secretary of State has specifically said in a statement today that his door is always open when it comes to issues around implementation. The plan is to implement this contract after the first foundation year 1, when doctors complete their first four-month rotation in October and November.

Health: HIV

Baroness Finlay of Llandaff Excerpts

Monday 4th July 2016 Lords Chamber

[Lord Prior of Brampton]

The critical issue is: to whom do we provide it? The whole purpose of the trials that NHS England is now funding is to ensure that when we provide PrEP, we do so for those who can most benefit from it.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise that the number of new cases in London is not falling, despite all the public health measures, and that there is therefore an urgent need to address the continuing at-risk behaviours? Will the Government also consider a trial of PrEP in the prostitute population, in which heterosexual transmission can occur and who are often not spoken about in relation to HIV, partly because all their activities are underground?

Health: Diabetes and Obesity

Baroness Finlay of Llandaff Excerpts

Thursday 30th June 2016 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness is clearly right that weight reduction can reverse diabetes. My father, for example, has lost weight and his diabetes has, effectively, been put into remission. There is no question that it works. However, it is very difficult to lose weight once you are overweight. The figure is that only one in 210 people with a BMI of over 30 can reduce it to a normal level; hence the emphasis that the Government are putting on explaining this to children and young people before they get fat. That is the critical place to aim. However, I entirely agree that greater access to structured education programmes is very important.

[Baroness Finlay of Llandaff (CB)]

I fully endorse that reply from the Minister, but will he also ensure that the guidance includes recognition of emerging research that children, if they never become obese, have a different type of fat—brown fat—which maintains a higher metabolic rate and therefore decreases their long-term risk of diabetes? The importance of avoiding obesity in the first place, particularly in children and in women, in pregnancy and post pregnancy, is the only way that we will stop this ever-growing curve of diabetes associated with adult obesity.

[Lord Prior of Brampton]

I entirely endorse the words of the noble Baroness, which I am sure will be reiterated in the obesity strategy when it is announced later in the summer.

National Clinical Director of Adult Neurology

Baroness Finlay of Llandaff Excerpts

Thursday 9th June 2016 Lords Chamber

[Lord Prior of Brampton]

I do not think that anyone is saying that the system was not working well enough. The argument that NHS England put was that it had to focus its resources on a smaller number of key national priorities—for example, mental health, cancer and learning disabilities—and that is what it is doing. It is poking the resource into a smaller number of well-focused and well-defined areas, but it can still get all the advice that it needs on neurology from the clinical reference groups and other sources.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise that the UK has only one-sixth of the number of neurologists that the rest of Europe has, which accounts for delays in diagnosis, poor outcomes for patients and wide variation in services? That needs to be addressed urgently for patients to have earlier diagnosis and better outcomes, and for their families to be better supported. Co-ordination of clinical and research efforts needs to be across the UK. I declare an interest at Cardiff University, where the amazing CUBRIC has just been opened by Her Majesty the Queen. It has the potential to transform neurological diagnosis in the UK, but there needs to be UK-wide effort.

[Lord Prior of Brampton]

Health is of course a devolved matter in the UK, but there is absolutely nothing to stop the devolved parts of the UK—Scotland, Wales, Northern Ireland and England—from working closely together on these issues. I do not think that the lack of a national clinical director prevents us in any way from doing that.

NHS England: Pre-exposure Prophylaxis for People at Risk of HIV

Baroness Finlay of Llandaff Excerpts

Tuesday 7th June 2016 Lords Chamber

[Lord Prior of Brampton]

All I can say in response is that NHS England has had independent legal advice that it does not have the power to commission this particular drug for this particular purpose, and for this purpose the drug itself is not yet licensed. It is not to do with any decision made on efficacy grounds for this drug; it is purely that they have received independent legal advice.

[Baroness Finlay of Llandaff (CB)]

Can the Minister confirm that that legal advice, as I understood it on reading it through, points out that there is weak evidence that NHS England does not have the power to commission PrEP? It says that NHS England does not have the power to fund PrEP but points out that under Section 7A, the Secretary of State has the power to delegate the commissioning of PrEP. Can the Minister therefore explain why, in the face of the evidence that has come through from the PROUD study and internationally, the Secretary of State has not used Section 7A to support NHS England? Is there a dispute going on between NHS England and Public Health England, and is this a fallout from the Health and Social Care Act?

[Lord Prior of Brampton]

I do not think that it is a fallout from the Health and Social Care Act. It is purely that the NHS specialist commissioning committee within NHS England has received clear independent legal advice, as I understand it, saying that it does not have the power to commission this product. That position may well be challenged legally, in which case it will be resolved one way or the other.

Obesity

Baroness Finlay of Llandaff Excerpts

Thursday 26th May 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, of course my noble friend is right that individual responsibility is critical to this. But we have to make it easy for people to make the right choices by providing the right information. Particularly for children, we have to make it easier for them and their parents to make the right choice.

[Baroness Finlay of Llandaff (CB)]

Has the Minister asked NHS England to tackle the problem of obesity among healthcare staff? It is very difficult for the public to get a public health message about losing weight from a member of staff who is, frankly, obese.

[Lord Prior of Brampton]

The noble Baroness makes a very important point. That is what lies behind the chief executive of NHS England’s decision to address the presence of unhealthy food and drinks on NHS properties, and to encourage staff to live a much healthier lifestyle.