The Long-term Sustainability of the NHS and Adult Social Care

Baroness Meacher Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Meacher (CB)]

My Lords I, too, thank my noble friend Lord Patel for his thoughtful report. I will focus on primary care and consider the compounding challenges of the primary care workload, the GP workforce, the nurse workforce, the budget and the blame culture.

First, the GP workload has increased by 16% over the past seven years as a result of the ageing population, the shift towards community care for certain illnesses and the dearth of capacity in hospitals. As noble Lords know, there are fully 1 million more people over the age of 65 than there were a mere five years ago. This means a more complex and time-consuming workload. The fact is that 10 minutes just does not do it for an awful lot of patients these days. The cut of 11% in the social services budget in five years just makes matters worse.

At the same time as the workload has increased so dramatically, GP numbers are under threat. The number of GPs taking early retirement has risen sharply following the clampdown on GP pension pots, bringing the retirement age down by two years to 58 and a half years. This means a huge and growing waste of expensive, highly trained GP resources. GP practice closures have been at record levels recently, and things can only get worse—considerably worse. An RCGP survey found that 39% of doctors in England said that they are unlikely to be working in general practice within the next five years. I find that terrifying. Doctors warn that a town without any GPs has become a real possibility. GPs talk about not wanting to be the last person standing when all their colleagues have left. The main reasons GPs give for their plan to leave general practice early are stress and excessive workload.

The Government say that the answer is to bring in more nurses. Absolutely, if only it were possible. A recent Pulse survey showed that one in eight practice nurse places in the UK is vacant. The shortage is expected to get worse if the Government go ahead with the plan to make nurses pay for their training. The nursing profession is anyway facing a demographic time bomb with mass retirements. The average age of practice nurses is 55. The GP nurse crisis is also linked to the historic failure to invest in primary care nurse training, and the long-standing neglect of community care nurse recruitment—a bundle of problems.

In this situation, an appalling fact has been the decline in the proportion of the NHS budget going to general practice, from 10.7% in 2005-06 to a record low of 8.4% in 2011-12. How can any Government justify that in the context of a major policy shift towards community care? Yes, the NHS England’s General Practice Forward View, as others have mentioned, acknowledged at least some of the difficulties, and committed £200 million to some schemes. That is a small step in the right direction, but the need is for a serious assessment of the overall financial requirement of general practices to enable them to build the multi- disciplinary and multifunctional integrated organisations to meet the demand.

Another very significant problem in general practice, I have to say, is the blame culture. The sooner the GMC and the ombudsman adopt the airlines’ approach of learning lessons from errors—yes, terribly important—rather than crucifying anyone who makes a mistake, the sooner we will reduce the very high level of stress among GPs, and reduce the trend towards early retirement and quitting really quite early on in their careers. If a GP sees anything between 60 and 100 patients a day, which they do, the chances of a mistake must be high. Of course legitimate complaints must be taken seriously, but a lot of patients would be very happy if they felt that their complaint would lead to some improvement. A complaint undermines morale and takes many hours of a GP’s time—time that no GP has. Will the Minister agree to ensure that this issue of the blame culture is addressed?

I am very concerned that several witnesses to the committee talked about the anticipated drastic fall in GP and nurse numbers and the extraordinary fall in the general practice budget share, and came to the crazy conclusion that the general practice partnership model should be shaken up. Any top-down reorganisation of that kind would further undermine and demoralise general practice. No, general practice is transforming services, despite the pressures and lack of funding to facilitate change. These are the issues that need to be looked at.

The absolute priorities must be correcting the funding balance between primary and secondary care and increasing funding overall, as I think pretty well every contributor to the debate has said. The £50 billion figure is probably a useful guide, as mentioned by the noble Lord, Lord Prior. There also needs to be proper financial support to encourage the developments already under way in many areas—such as I have already mentioned, enlargement of practices, federation of practices, and crucially including psychological therapists, who could save GPs a great deal of time. That could be closely integrated with adequately funded social services. There are also innovations like the development of online services which I know the Minister supports. Then we have a chance of a sustainable primary care service. Can the Minister give an assurance that this is the approach that the department will take?

Children and Young People: Mental Health

Baroness Meacher Excerpts

Wednesday 28th March 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord hits on an important point. Not only is mental illness unfortunately rising in prevalence, but it is everybody’s responsibility to try to help young people who suffer from it. That is what lies behind the proposals in the Green Paper, which contains a number of elements. He is quite right: there is additional training that will be applicable for all teachers, in mental health first aid, for example. It will also make sure that pupils understand it, changing the PHSE curriculum for more focus on mental health and well-being. That is why the designated leads are so important, because they bring that together at school level. So I agree with the noble Lord that schools have a critical role to play in dealing with this problem of mental health.

[Baroness Meacher (CB)]

My Lords, the Minister will be aware that young people with severe mental health problems can wait up to four and half months for treatment when a young person with severe physical health problems can expect to be seen within the day. Of course we all want equal treatment of these two groups. I very much welcome the Government’s plan to spend £1.25 billion extra in this area. However, does the Minister have an estimated average waiting time for young people with severe mental health problems once the £1.25 billion is in place?

[Lord O'Shaughnessy]

I do not have a specific time, but I point to two things. First, there are now waiting time standards for early intervention in psychosis and eating disorders. Those waiting time standards will become more exacting over time, but they are being met at the moment. The Green Paper also proposes a pilot of four-week waiting times for access to specialist services in the NHS. We have a long way to go—average waits are 12 weeks—so we are inevitably starting incrementally, but the ambition is that over time, we will roll that out as a nationwide ambition. However, I am afraid that I cannot give the noble Baroness a deadline.

Prescription Drugs: Dependence

Baroness Meacher Excerpts

Monday 19th March 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend has just given a much better and more incisive answer than I could have given. There is a distinction; the point here is that these are drugs that people have started to take because they have needed them. I should point out one area that is not included in the review; it is not looking at cancer and terminal pain, because we need to make sure that there is appropriate pain relief for people who are in the last stages of their life.

[Baroness Meacher (CB)]

My Lords, is the Minister aware of the very powerful evidence from the United States that one of the most effective ways of reducing dependency on opioids is to legalise cannabis for the relief of pain? Cannabis is far less addictive and far less dangerous, yet it is incredibly effective for large numbers of patients.

[Lord O'Shaughnessy]

I would definitely be straying into Home Office territory by commenting on that. I would point out that cannabis remains illegal in this country and that the PHE review’s scope is to work within the drug strategy set out by the Home Office.

Health: Flu

Baroness Meacher Excerpts

Monday 30th October 2017 Lords Chamber

[Lord O'Shaughnessy]

I agree with the noble Baroness about the role of community pharmacy. It is worth bearing in mind that some 88% of people are within a 20-minute walk of a community pharmacy, which is accessible for the vast majority. There are also 20% more pharmacies than there were 12 or 13 years ago. Pharmacies have a critical role to play and are there in the community, but companies come in and out all the time.

[Baroness Meacher (CB)]

My Lords, I talked to a very senior NHS consultant this morning. To my absolute amazement, he said that the latest research showed that compulsory flu jabs for NHS staff provide no significant improvement at all in patient health. This is rather striking and a bit unexpected. Does the Minister have any different research evidence?

[Lord O'Shaughnessy]

That is unexpected and would be worrying if it is true. That is not the information on which we have based our policy. Our information is that, for most people—though not all—flu jabs are effective in mitigating the risk of flu in care settings.

Mental Health Services: Children and Adolescents

Baroness Meacher Excerpts

Monday 17th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Baroness for highlighting this very important issue. She will know that ring-fencing funding for mental health comes up a lot. There has been increased funding for mental health, but there is more than one reason why ring-fencing is not used for clinical commissioning groups, including honouring the principle of clinical autonomy, and we do not ring-fence around particular disease areas. I should point out that CCGs are being monitored now to ensure that they are increasing spending on mental health, year on year, in line with the increases in funding they are receiving, which is £1.4 billion over the coming years. The noble Baroness is of course quite right in what she said about the specific issue of children under the age of 18. That is why, among other things, we have committed to introducing mental health first aid in all secondary schools.

[Baroness Meacher (CB)]

The Minister will be aware that the threshold for children and adolescents who have severe mental health problems is extraordinarily high and that they may have to wait months before getting any treatment, whereas children with similar levels of physical ill health will be treated within perhaps a day or days. Does he accept that we are still an incredibly long way from equality between mental and physical healthcare, and what does he plan to do about it?

[Lord O'Shaughnessy]

I accept the point that the noble Baroness makes. Unfortunately, we are starting from a low base, over many years, in mental health provision, and that is what we are trying to rectify. She will know that the Prime Minister is deeply committed to this agenda. Let me point to a couple of issues. First, there is the introduction of the first waiting time standards—and indeed there are positive early data on meeting those stretching standards—as well as an increase in the number of beds available for those suffering from the most severe episodes of mental illness.

NHS: Working Conditions

Baroness Meacher Excerpts

Wednesday 5th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I can only reiterate that I recognise the pressures on the workforce. That is why we are recruiting more GPs and nurses. There are more than 50,000 in training, and we are aiming to get 5,000 more GPs into the NHS over the next few years. On the noble Baroness’s point about moving treatment out of hospitals and into the community, that is one of the core drivers of the STP process, which is about reorganising care so that it happens sooner and, ideally, in a preventive way rather than after the fact.

[Baroness Meacher (CB)]

My Lords, I think the Minister will be aware that GPs are routinely required to see, diagnose and treat 80-plus patients in a day. What plans do the Government have to ease that situation when it is still getting worse month by month and it is proving impossible to recruit GPs? In the meantime, until things improve, will the Minister have discussions with the CQC and the ombudsman about how best they should undertake their jobs, taking account of the horrendous pressures on NHS staff and on GPs in particular?

[Lord O'Shaughnessy]

The noble Baroness is quite right to talk about the importance of having more general practitioners. I have talked about the increases in recent years—there have been net increases of 5,000 over the last 10 years—and the fact that we are recruiting another 5,000 over the next few years. I do not pretend that it is easy to recruit them, but the numbers are increasing. One of the keys to solving this problem is through the new models of care. In its General Practice Forward View, which was published last year, NHS England demonstrated a renewed emphasis on general practice and reforming it. That is one way of ensuring that GPs can cope with what is of course an increasing workload.

End of Life Care

Baroness Meacher Excerpts

Tuesday 14th March 2017 Lords Chamber

[Baroness Meacher (CB)]

My Lords, I am most grateful to my noble friend Lady Finlay for initiating this debate. I declare my interest as chair of Dignity in Dying, the sister organisation of Compassion in Dying, which is a slightly separate charity. Ensuring that people have genuine, meaningful choice at the end of life is central to improving care. Over the past decades, much of our NHS has shifted significantly from a somewhat paternalistic model of care, where the doctor is assumed to know best, to one where the patient’s wishes are paramount. This trend was strikingly evident in mental health care, where I worked for about 25 years. End-of-life care is lagging behind far too often.

Ben Gummer MP, Parliamentary Under-Secretary of State for Care Quality, in his foreword to the government response to the review of end-of-life care pointed out that,

“our care of dying people is … variable, haphazard and at times shockingly poor”.

The Government’s response also says:

“We know that too many people are not involved enough in decisions about their care … care is not sufficiently focused on the person’s individual needs and preferences”.


That seems profoundly true.

Dying people must be aware of their legal right to plan ahead for their own care and, crucially, their right to exercise their choice step by step along the way. Polling shows the enormous job that lies ahead to achieve those objectives. According to a YouGov poll in 2014, 82% of us have strong views about end-of-life care, yet only 4% of us have made an advance decision or appointed a lasting power of attorney. The Macmillan briefing points out that 73% of people with cancer would prefer to die at home, yet only one-third actually do so. Healthcare professionals and providers still too often impose their own views about what is best for their patients. My principles for end-of-life care come very much from the five years I spent chairing a clinical ethics committee. The principles of compassion and patient choice dominated then and, for me, they dominate today. A very important tool for patients and their end-of-life clinicians is, of course, the advance care planning process. One key message from this debate is surely the importance of commissioners funding the promotion and implementation of that process.

What are the benefits of advance care planning? Why does it really matter? Research shows that, when people are able to make informed decisions about their own treatment and care, those patients are far more satisfied. A 2015 YouGov poll revealed that when a patient’s wishes are not documented, 53% are likely to receive treatment they do not actually want—a complete waste of money. Academic research shows the potential of patient choice to produce significant financial savings to the NHS, a reduction in unplanned hospital admissions and the length of time spent in hospital in the last 12 months of life when, of course, most hospital care takes place. A real culture change towards patient choice, which involves planning ahead, is not only better for individuals but absolutely vital if the NHS is to cope with the financial pressures ahead. It is disappointing that only a minority of sustainability and transformation plans have laid out clear plans for addressing improvements at the end of life. Can the Minister assure the House that NHS England will insist that plans which fail to address end-of-life care—and preparation for advance care planning in particular—will be revised?

It is encouraging that the Government asked for advance decision-making to be central to the remit of the National Mental Capacity Forum. A recent study by the charity Compassion in Dying again emphasised the importance and benefits of making advance decisions. The report received widespread public support. Patients need information if they are to make informed decisions. Compassion in Dying recently commissioned qualitative research interviews with dying people. The results are worrying. One respondent—we will call her Sally—had ovarian cancer. She said:

“There are so many people out there who are certainly not getting the information they need from the professionals they’re dealing with, not about benefits, not about prognosis, not about symptoms, not about support, not about end of life care or the choices. Nothing. Nothing, unless you bring the subject up”.


The Government’s response to the choice review pledged that people would be able to have honest discussions about their needs and preferences. Clearly, this is often not happening. Commissioners need to ensure that doctors are trained to have difficult conversations with patients, and that doctors understand that patient choice is not a luxury add-on to good care but central to it.

Failures of the 111 Helpline

Baroness Meacher Excerpts

Tuesday 26th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, one would expect the doctors concerned to make that presumption in the case of a very young child. But the noble Baroness makes a valid point and I am sure that NHS England will take it on board.

[Baroness Meacher (CB)]

My Lords, does the Minister agree that this tragic case occurred in an environment of incredible pressure on GPs and others within the NHS, with a growing blame culture and huge numbers of patients—they have to see 60 to 70 in a day very often? We all have to accept that things will go wrong if we leave GPs, in particular, working under those sorts of personal pressures and so on. We know that 30% or so will leave the profession in the coming years. Will the Minister meet with me to discuss what he might do to alleviate some of those problems? That could be very helpful.

[Lord Prior of Brampton]

My Lords, unquestionably there are huge workload pressures on GPs. There is no doubt about that. I do not think they were a primary cause of this particular tragedy, but I will be happy to meet with the noble Baroness to discuss that.

NHS: Clinical Commissioning Groups

Baroness Meacher Excerpts

Wednesday 16th September 2015 Lords Chamber

Asked by

[Baroness Meacher]

To ask Her Majesty’s Government what assessment they have made of NHS England’s management of clinical commissioning group allocations under the current funding formula.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, decisions on clinical commissioning group allocations are taken independently of government by NHS England, in order that such an important issue as funding is made objectively and free from perceived political considerations. The Government set some broad principles to which they must conform. NHS England’s decisions are informed by the recommendations of the independent Advisory Committee on Resource Allocation.

--- Later in debate ---

[Baroness Meacher (CB)]

My Lords, I thank the Minister for that reply. As he will know, the Secretary of State is responsible for ensuring that NHS England allocates resources fairly across the NHS. Is the Minister aware that, at present, allocations to clinical commissioning groups are hugely variable in relation to the Treasury manual formula? For example, west London receives 31% more than the formula, while Hounslow receives 9% less than the formula, representing a discrepancy of some £110 million from one trust to another in relation to the formula? Despite some recent improvements, does the Minister share the concern expressed by the National Audit Office about the failure to end this unfairness—and, indeed, even the lack of any timescale within which to rectify this matter? Will he give an assurance to the House that within five years there will be a resolution?

[Lord Prior of Brampton]

The noble Baroness raises a very important issue. I think that she is raising issues not about the actual formula but about the speed at which NHS England reached the target levels of the formula. She points to the discrepancy of west London, which is 31% over the formula. I can tell her that NHS England is committed by 2017-18 to bringing all those under the formula by more than 5% up to that level. It will also be encouraged to address the issue of CCGs that are above the formula.

National Institute for Health and Care Excellence

Baroness Meacher Excerpts

Monday 13th July 2015 Lords Chamber

[Lord Prior of Brampton]

NICE has not been instructed to cease its work on safe staffing standards; on the contrary, it has been asked by NHS England to provide it with appropriate guidance.

[Baroness Meacher (CB)]

My Lords, the noble Countess rightly raised the amount of time that nurses spend filling in forms and ticking boxes. Is the Minister aware that much of this work comes from the rather microregulatory requirements of the regulatory bodies, and indeed NHS London? There are some very precise measurements, and if those were monitored carefully government Ministers and NHS England would know well whether services were being managed properly. Would the Minister consider revisiting the degree of microregulation of our health services?

[Lord Prior of Brampton]

I am not entirely convinced by the argument about regulation when it comes to managing wards. My own observation is that when you have strong leadership from strong ward sisters, ward managers or charge nurses, many of the problems that we identify seem to disappear and there is very high staff morale, low absenteeism and little use of agency staffing. So much comes down to local leadership, and sometimes regulation is used as a scapegoat.