Homecare Medicines Services (Public Services Committee Report)

Baroness Morris of Yardley Excerpts

Thursday 2nd May 2024 Lords Chamber

Moved by

[Baroness Morris of Yardley]

That this House takes note of the Report from the Public Services Committee Homecare medicines services: an opportunity lost (4th Report, Session 2022–23, HL Paper 269).

[Baroness Morris of Yardley (Lab)]

My Lords, I am very pleased to introduce this debate on homecare medicines on behalf of the Public Services Committee. In opening, I thank all the witnesses who appeared before our committee for their time, expertise and co-operation with us. I thank the team who served us so well: Sam Kenny, Tom Burke, Claire Coast-Smith and Lara Orija. I personally thank all the committee members, who worked hard on this report and, I think, are pleased with it and determined to see it through.

I know that committee members will understand when I thank the noble Lord, Lord Blencathra, because without him, we would never have looked at this issue at all. I was aware of homecare medicines, I knew what an important service it is, but I had no idea of the challenges it was facing or how ineptly people were dealing with those challenges. We are grateful to him for that, but the problem that emerged was that we were not the only ones who did not know about the challenges: it seems that nobody running the service knew about the extent of the challenges either.

This is an important issue: it is a picture of how the NHS should be. It is a forward-looking service. It offers patients the opportunity to have medicines and treatments in their own home, to have choice and flexibility around their lives. It saves money for the NHS and patients, and it is something that needs to work, because it could be a vision of the future. It has increased in recent years. There are 500,000 prescriptions now, 2.8 million deliveries a year and, over the last 15 years, on average, a 10% increase in those using the service each year.

However, if you read our report, or you look at the evidence, there is one overriding conclusion that you are left with, and that is the difference of opinion between the different witnesses who appeared before us. What was frightening, almost scary, was that that difference was split into two clear groups: the clinicians and those who use the service, who talked about the many problems; and those who manage, run and regulate it, who did not seem to see any problems at all. How that lack of observation and communication has arisen must be something that the department sorts out before it can move forward.

Having said that, I feel it is a strange report. Of all the reports I have been involved with during my time in both Houses, I do not think I have ever seen an issue that I am more confident can be solved. We are not asking for more money; it is not politically contentious; it is not backward-looking, it is forward-looking; we just need somebody to grab hold of it, make the difference and make it work. This is not something that is an aspiration or something that has a 10-year forward look; this is something that can be done now. We can get it right and make life better for patients and for the NHS. In essence, homecare medicines is a market, and the hospital trusts, each trust individually, are the purchasers holding the money. They contract with two elements. One is the drug companies, the pharmaceutical companies; and the second is the homecare providers which deliver medicines and appliances to people’s homes.

What is perhaps unusual, but never mind, is that the contracts themselves are between a chief pharmaceutical officer in each trust and a large pharmaceutical company. Some 80% of the trusts have no contractual arrangements at all between themselves and the service provider, they just have a service level agreement. But that is not unusual; they are not the only part of the public sector that puts out a tender, monitors its performance, makes adjustments and gets on with it. However, if you look at what we know about the effective delivery of public services or private services, some elements have to be in place. You need information about what is going on. You need to agree performance indicators. You need to know how an organisation is performing against them. You need to know who is holding them accountable and you need to know who to go for when things go wrong. Not one of those things is in place in homecare medicine, and it is a service that is relatively small compared with many of the big public services that we run.

First, there is data, but—believe it or not—none of it is in the public domain; nor is it available to clinicians when they are advising patients on what to do. The National Homecare Medicines Committee, one of those which manage the service, collects 27 key performance indicators and passes them to the NHS, but they are never published or made available to anyone. Then there is a completely different set of KPIs between the pharmaceutical companies and the homecare companies which deliver the medicines on their behalf. There is no standard template across the country; every single one of those contracts can take a different shape. They are not published, the trusts and clinicians do not know what is in them, and they never know whether they have been achieved.

If that was not a big enough mess, on top of all of that—believe it or not—all the data is self-reported. That is not only a recipe for a service that does not work well but it means that no comparisons are possible when the NHS trust is spending money to place its contract. It has no information against which to judge either the performance of its present contractor or anyone else. Almost more important than that is that no information is therefore collected about how seriously patients suffer from service failure. No one in the NHS or anywhere else collects information about the impact on patients served by this poorly run service.

Secondly, there is no effective system of regulation. There are three regulators: the Care Quality Commission, the General Pharmaceutical Council and the Medicines and Healthcare products Regulatory Agency. They all inspect a different tiny part of the system; there is no one with overall responsibility. The problem is that this is not a high priority for any one of these regulators.

The Care Quality Commission does about three inspections a year. It does not collect complaints; there is no section in its books or charts for complaints received about homecare medicines. It has never chosen to do a thematic review and there is no evidence that we could find of a prosecution it has initiated. Whatever people who work at the CQC think about when they get up in the morning, it is not, “I wonder how homecare medicines is getting on”. When we asked those three regulators about the gaps in between the bits they inspect, they all said, “That’s fine, we don’t overlap—but there are no gaps in between”. That is not an effective system of regulation, and it helps nobody.

Thirdly, in a system such as that there would have to be infrastructure and support to go with it. Chief pharmaceutical officers in each NHS trust are busy people. They have a very demanding job, and the responsibility of sorting out the contracts with the big pharmaceutical organisations falls to those men and women. Everybody who came before has admitted that this requires specialist knowledge and that there is a huge amount of effort involved in managing the contracts and being aware of the impact on patients. The support and expertise that they would need to do that job is just not there.

Procurement hubs serving NHS trusts often have no homecare medicines specialists. Each provider has developed a different system, with no single NHS system for providers to interact with. On prescriptions, they have to re-read the evidence to make sure that somebody is not making it up. Some 6,000 paper prescriptions go into the system every day on more than 1,000 different templates—it is no wonder that nothing that comes out makes sense. It is beyond belief that in 2024, some of those prescriptions are still sent by post.

That is the environment in which we expect trusts and clinicians to make decisions about a key service, on which they are spending public money and on which clinicians need good-quality advice to advise their patients on the decisions they should take. They are not faced with any KPIs that they can monitor; they do not know how one provider performs against the other; they know that there is no effective regulatory system, that there is an inadequate infrastructure to support them, and that no one is holding the ring to keep it all together. At the end of the day, there is no one in overall charge for them to turn to for help and advice.

It is not surprising that this leads to a system that fails everyone it seeks to serve. First and foremost, it fails patients. There is no complaints system and nowhere for people to go if something goes wrong. The things that can go wrong go very wrong and are very serious: the medicines do not turn up; the wrong medicines turn up; the medicines turn up at the wrong time; the medicines turn up, but the person who was showing the patient how to inject them does not turn up; or the medicines are out of date. The catalogue of what happens in an NHS service that puts safety at the top of its priorities is frightening.

The impact for the patients is also serious: they miss medicines, become more ill and need to go back to hospital and have operations. Because no data is collected about how much harm is done, I cannot stand here with certainty and say that people lose their lives—no one can—but what we can say with certainty is that people do not recover as quickly, and they are given extra burdens to deal with because the system does not work as it should.

It also has an impact on each NHS trust. If you are not getting the service from the homecare provider—and if you have no one to complain to because the providers do not have good phone systems with somebody who picks up the phone at the end who knows you—you will go back to hospital. You will go back to the consultant who gave you the prescription or to A&E, and you will ask for help. That means that every hospital in this country, which have already paid taxpayers’ money at a time of reducing budgets to the provider to deliver the service, will have to pay again to remedy the defaults in the service.

If you talk to any of the groups representing clinicians or patients, they will tell you the horror stories of how much they have to do to mitigate the weaknesses in the system. Crohn’s & Colitis UK told us that 10% of specialist nurses spend one day a week on the consequences of an inadequately delivered homecare service. The British Society for Rheumatology told us of one clinic where a nurse spends a quarter of their time chasing after homecare services. In Leeds, people have set up their own infusion unit so they can teach the patients how to inject the drugs. They provide the drugs out of their budgets to start them off, because it takes eight weeks for the provider to get their act together.

The other losers are the NHS and the country, because it is money wasted. It is the case that the NHS, the department and Ministers do not know how much money is spent on homecare services. We had four different estimates, between £2.9 billion and £4.1 billion, and I am still sure that no one knows exactly what it is.

Yet I remain an optimist. All that can be solved; it is a tragedy, but it is solvable. Part of the anger or frustration is that it has not been grabbed hold of and solved already. We might get somewhere if we put a system in place that has comparable data, if we get the regulatory system sorted out, if we put in support for procurement, if we move more to electronic prescriptions and if we put a named person in overall control, who wakes up every morning knowing that their job is to make sure this works all right.

I say to the Minister that we have been very pleased with the support and response that we have had from his department; it has been helpful throughout. They have not spelled it out, but I think that both he and the Minister who is no longer in the department were surprised at the lack of awareness of this service and the state that it is in. That is why I am an optimist: I know that we await a further report in the summer.

However, there is a tendency in government to turn to the existing structure and people to create something that is better—which is what I have worried about most. There is a lack of trust between those who have been shouting for a long time that things are badly wrong and those who have not heard them and have not done anything about them. My request to the department and the Minister is not just to do all these things but, most of all, to consult those who have the best experience of what has gone wrong and the best ideas about what could be done to make it better.

I very much hope that our report helps not just the department and the NHS to get this better but all the clinicians and patients who have not been treated as well as they should and have not had the support that they should for many years. That is the goal, and I think that it is achievable. I promise that my committee is absolutely determined not to let this go, by whatever means we can. I have no doubt that we will be back at this again. I thank the Minister and the department for the support so far and offer our every help in their future work.

--- Later in debate ---

[Baroness Morris of Yardley (Lab)]

My Lords, I thank everyone who has contributed to a very good discussion built on a very good report. I do not want to keep us long because I do not think there is a lot else to say at this point.

We have been through a number of hurdles, and I absolutely understand where the Minister is coming from—10 days ago, he was not aware of the problems, but that is a description of us all, apart from the noble Lord, Lord Blencathra. The first hurdle to jump was to get people in key positions aware of the problem, and that has been achieved. Secondly, I think there is a joint determination to do something about it and a feeling that it cannot wait. Thirdly, there is some agreement on some of the things we can do, and a willingness to have an open discussion on how we might do some of the more problematic things. I am particularly grateful to the noble Lord, Lord Allan, for stretching my mind and knowledge on what might be possible in terms of digital technology—things I had not even thought of.

The other thing that has been important today, which I was very keen that we do, was to get a next step. These good ideas fall between discussions, and things happen and no one picks them up again. I am therefore absolutely confident that I can speak for the committee in accepting the invitation to attend a round table after the announcement is made. I think that, from our point of view, that is a very good next step, along with the announcement of the person in charge and the further letter expected from the Minister’s department in the summer. Therefore, that is our next step, and I am sure that there will be more steps after that.

I just want to say one thing, which is a note of caution —it was referred to, I think, by the noble Lord, Lord Willis. The Minister will have to make his own judgment, but I think the overriding impression in our committee was that it was really hard work to get those already managing the system to accept that there was a problem. It was really tough to get them to that stage, and I am not sure that they got there; they might have got there in their own minds, but they did not acknowledge that to us. Because of that, the committee has a concern as to how much they are going to push this forward, but, more than that, the clinicians and the patients have concerns as well. The Minister may want to reflect on that and do what he can in whatever decisions he takes.

My last sentence is this. All those things are good, but we have absolutely raised expectations of those who use the service, the clinicians and the trusts, and we cannot let them down because they do not deserve that. I finish by thanking everybody for their contributions, and I look forward to further discussions. I beg to move.

Motion agreed.

Emergency Healthcare (Public Services Committee Report)

Baroness Morris of Yardley Excerpts

Thursday 20th July 2023 Grand Committee

[Baroness Morris of Yardley (Lab)]

My Lords, I am also pleased to be able to contribute to this debate as a member of the committee. I pay tribute to my noble friend Lady Armstrong, who was the inaugural chair of the Public Services Committee and has led it through its first years. Indeed, this report was the last from the committee under her chairmanship. I overlapped with her only on this one report, but I could tell from the time I spent on the committee how much she had done to establish it as a very important committee in our House. I know that there have been a whole series of reports which will add to our debate and our consideration of some crucial issues facing society at the moment. On behalf of all committee members, I place on record our appreciation for the contribution she has made.

I am sorry that this debate is taking place seven months after the report was published. There was never going to be a queue at the door waiting to get in as the debate started, but I hope the appropriate authorities can take note of this.

Governments are always reluctant to use the word “crisis”, as lots of things flow from that. Our committee found that there was a crisis in emergency care, and we used that word. I think we produced sufficient evidence to say that there was a crisis.

Even if you do not take that point, it is interesting to look at the document published by the Government since then, the Delivery plan for recovering urgent and emergency care services, in which they describe what happened last winter and the state we are in. They said it was

“the most testing time in NHS history”,

that there were

“problems discharging patients to the most appropriate care settings”,

and that hospitals reached record occupancy levels. The document also says that patients were spending longer in accident and emergency departments and waited longer for ambulances, and that that has taken its

“toll on staff, who … work in an increasingly tough environment”.

The committee could not match the description the Government themselves gave of the state of the ambulance service and emergency services at key points during last winter. So, whether you want to use the term “crisis” or not, our joint starting point is that things were intolerable last winter and have been intolerable for quite a while. We are not confident that they are going to be any better this winter. To some extent, the challenge for this debate and for the Government now is whether they can use those experiences and the evidence we gave in the report to make sure that things are not as bad next winter and that we can move on.

Lots of things have happened since our report was published, and I want to refer to some of them. It is very difficult, given the time of year and the way the public debate moves on, to know exactly what progress has been made since our report was published in January. I know that some of the figures on waiting times for ambulances have got better. I do not know if that is because of the time of year or because of action the Government have taken. However, I noted with some concern the National Audit Office’s report from June this year. When it looked at recent performance, it concluded that patient access to services for unplanned or urgent care has worsened; that there is too great a variation in service throughout the country; that the NHS has not met operational standards; and that performance has worsened in terms of delays in transferring patients from one service to another.

That is where I think we are. There is joint knowledge and a shared platform of debate that there was a crisis last time, and some of the statistics were very worrying. The one bit of evidence we have from a third party—the NAO report—does not indicate that things are getting any better. The effect this has had on the public, communities and their confidence is well known. It is no exaggeration to say that people lost their lives because this service was not performing at a higher level.

I want to take six points from our committee which struck me, on reflection, go through them and invite a response from the Minister. These are the six areas that stuck most in my mind, and I would like some reassurance that progress is being made on them. First is the immense complexity and connectedness of all the different parts of the system. We talk a lot about the health service and social care and how they do not work together. However, when you look at the emergency services, it is not just those two that have to work together: it is the police and the fire service, and the attitude of the public.

That leads to the second point: it is very difficult to work out who has the ability to effect change. People want to change things. They want to change their bit of the service, but they cannot change other bits. What became evident during the committee’s deliberations is that there is no one leader who can solve the difficulty. That is a problem, but the system itself does not allow people to make changes that have to be made if they are to improve their bit of the service. There has been a really good example of that since our committee’s report was published: the decision of the Metropolitan Police not to attend mental health cases.

I know why the police have done that, because in the committee you would hear somebody tell you that some police officers are spending the whole of their shift sitting in A&E with a person who has mental health problems, whom they have been called to assist. I can absolutely understand why they have said that that cannot happen any longer. I do not believe for one minute that the head of the Metropolitan Police has not tried to solve the problem as well, but I suspect that he has concluded that he cannot get other bits of the system to shift or make the changes in social care, the local authority or the health service—he has to act unilaterally to protect the service that he is absolutely accountable for and responsible for delivering. That is just one example, but that has happened in the last few months. We find so many cases of that, where people knew what they wanted to do to make their bit of the service better but were powerless, because changes needed to be made elsewhere, and the structure that could have brought everyone together to make the changes just does not seem to be there.

My third point, and the point that the noble Baroness, Lady Armstrong, made, was that people are risk averse, and there is very little approach to shared risk. I was pretty appalled to find that some schools, as a matter of policy, called an ambulance every time a child had a head knock, even if the parents were there and were prepared to take their child to accident and emergency. I do not want to belittle the difficulty of taking decisions like that if you are a headteacher or a teacher, but something is wrong there, if mum and dad say that they will take their child to accident and emergency, and the school says that no, the policy is that they have to call an ambulance for every child who bangs their head. We heard similar stories in care homes with patients who had fallen. The public are risk averse to making decisions which on reflection, might perhaps be more sensible.

We see that with 111 services as well. The statistics show that the 111 person is more likely to say to go to the accident and emergency than they are anything else, because there is a risk-averse attitude there. With some of the targets, the attitude to risk is problematic. For those responsible for making sure that ambulances do not wait in the car park at the entrance to the hospital, the best thing to do is to get the patient into the A&E waiting room, because they have then met the target—but it has not solved the problem for the patient, who is now in the waiting room. Others want to get them out the other end, because their target is to get the accident and emergency casualty waiting room down to as few people in it as possible. So they push the patients out to somewhere else, where they wait to go into care or back into the community, and they have met their target.

There are so many instances where people behave in a way that shows that they are not connected to other bits of the service, and they are risk averse. They want to solve their bit of the problem and make sure they can show that their service is performing better with regard to targets. No one actually says, “Let’s put our risks together—let’s put it all together and let’s have some sort of target, which means that I in my bit of the system act in a way that helps you as well as me”.

The fourth point is that one thing that frustrated me, time after time, was that I sat and listened in the committee to the most wonderful pilots going on in different parts of the country. I thought, “Why have we got a problem? Why is anything wrong, because I have just heard the most wonderful example of what is happening?” Nobody knew why it did not happen elsewhere as well. Nobody knew who was evaluating it or who had the power to say that it should happen elsewhere, and that is a problem. So I say to the Government that, while I welcome some of the initiatives that they have announced in recent months—full service virtual wards, transfer of care hubs, and greater flexibility for clinicians—the key thing remains that they are all relatively confined things that are likely to bring about some success.

The key problem for me—and this is where I finish—is that, with the integrated care boards, who is going to make sure that someone can implement the plan that they have been charged with writing up? Could we do more so that the regulators actually make a judgment as to whether services are working together, as well as whether they are working for their own interests? Can the Minister perhaps reflect about whether he is absolutely confident that the people who need to make changes have the power to do so?

Health and Care Bill

Baroness Morris of Yardley Excerpts

Lords Hansard - Part 2 & Report stage
Wednesday 16th March 2022 Lords Chamber

Is it the Minister’s understanding that the Prime Minister will chair the Health Promotion Taskforce? If so—and this is the most important point for all of us on the committee, many of whom have been in sports policy for some 40 years—unless you have accountability to Parliament, you do not have the catalyst for change. With accountability comes the catalyst for change, and I simply ask the Minister to confirm that the Health Promotion Taskforce, covering the areas that the Select Committee has set out, will have teeth, not because it will be chaired by the Prime Minister but because it will be accountable to Parliament, so that Parliament can consider in detail the process, programmes, policy and direction in which we need to make significant advances to achieve improvements in wellbeing, health and sport, and the way that all three can work effectively together. I would like clarity on the commitment from the Minister, and I hope we will receive it this evening. I look forward to hearing from him, and I beg to move.

[Baroness Morris of Yardley (Lab)]

My Lords, I support the comments of the noble Lord, Lord Moynihan. I do not want to repeat points that have been made at this late hour, but I wish to emphasise that the arguments about the importance of sport and well-being do not need to be made again. Everybody from all parties, right across the House, understand their importance and the consequences of not getting them right. The good will has been there for years, but the ability to transform it into effective action has not, and lots of well-intentioned efforts in the past have come to naught. That is what is driving the committee that met under the chairmanship of the noble Lord, Lord Willis, and I agree with the questions that have been asked.

For me, it is a case of not relying on a cross-departmental committee to run this project. It has not worked in the past, and there is no reason to think that it would work in the future. Is there seniority? Is there someone with clout who can bang heads together? Is there someone for whom it is a very important part of their job, and who knows they will be held accountable? I agree with the noble Lord, Lord Moynihan, that the Health Promotion Taskforce does seem to offer hope. Clarity on that—letting us know about its leadership, and the presenting to Parliament of an annual report for discussion—would allay many of our concerns. I look forward to hearing the Minister’s response.

[Baroness Grey-Thompson (CB)]

My Lords, I draw your attention to my interests: I am chair of ukactive, and I have a number of interests in this area. I also sat on the Lords Select Committee.

I too am not going to rehearse the arguments we gave in Committee, but all the names added to this amendment have been involved in this space for many years. We have all been through various iterations of this, and we should be talking about physical literacy and physical activity, and slightly less about sport. That might be surprising considering my background, but as the noble Lord, Lord Moynihan, said, we have an obesity crisis and a generation of young people who are more likely to die before their parents, and there are a number of conditions that can be treated. Frankly, we have been tinkering at the edges of this for way too long. There have been programmes and lots of initiatives that have had some success, but if we are serious about the NHS and the health of the nation, we have to do things in a different way. I feel like I have been talking about this for about the last 30 years—the noble Lord has had a slightly longer time in sport than I have—but I will be interested to hear the Minister’s response in order to understand how we can genuinely make a change and stop going round in circles on this important issue.

Health and Care Bill

Baroness Morris of Yardley Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

In conclusion, I welcome the inclusion of housing in the Bill, as part of the integration of services to achieve health and well-being objectives. I support the amendments in the name of the noble Lord, Lord Howarth of Newport, in extending this to embrace the wider urban and green environment that impacts health and well-being. I also commend the noble Lord’s amendments that would give prominence in the Bill to the voluntary and community bodies of which, I maintain, those with housing objectives now represent an important part of the country’s social fabric. I support the amendments.

[Baroness Morris of Yardley (Lab)]

My Lords, I also wish to support the amendments that have been moved by the noble Lord, Lord Howarth, and supported by other speakers. I do not want to make a long speech, but I want to add weight to the argument by standing up and offering support. I will not repeat his arguments, but I want to pay tribute to the work that the noble Lord, Lord Howarth, has done in this regard. He chairs the All-Party Parliamentary Group which produced a report that was pivotal in taking this debate forward. The work that he has done with the National Centre for Creative Health has given us an army of evidence on its importance.

The amendments seem to fall into two groups. There are those around social prescribing for people with dementia as the noble Baroness, Lady Greengross, said, and the notion of health promotion by creating a better environment in which we live and preventing illness. That collection of amendments is an idea whose time has come. There is an amendment for later consideration to which I have added my name, for which the same arguments are being made for sport and recreation. I think of this as the whole area of health promotion, which is looking at non-clinical providers of healthcare. I think these amendments follow on very well from the last group of amendments that was debated.

The noble Lord, Lord Scriven, talked about the aims of this legislation as being about promoting well-being, and the noble Baroness, Lady Cumberlege, gave a very good example of how a community centre that had doctors in it has become a medical centre, and the message that they gave. Every single one of us here could make the arguments that we have heard so far, either from our own example—from our own health and well-being—or from something we have seen.

I wanted to mention two things. First, I declare an interest: I am director of the Royal Liverpool Philharmonic Orchestra, and the work that it does with Mersey Care NHS Foundation is magical. It sometimes goes unnoticed outside the region, but people with quite serious mental health needs are finding their well-being is promoted. They are enjoying themselves and feel more part of the community.

My second example is some work I did in Derbyshire with a charity of which I was patron, First Taste. The artwork it did in a care home meant that the prescription of drugs for sleeping and other things was reduced. All those arguments can be well made but my problem is this: I would have put money on no one standing up and arguing against these amendments. If you could stop 50 people out there and find three who will argue against these amendments, I would say “Well done”.

The danger for this area of policy is that no one is against it, but not enough is being done to get it to the top of the agenda. Sometimes, when no one is against it, you do not have the argument that promotes it up the national agenda. Everyone says “Great”, “We agree”, “It will be a great thing” and nothing happens. The stage of this area of policy is that everybody is doing a little bit. It is in the long-term plan. There are examples of good practice. We have the evidence that it works and the Government are investing some money, but it is never going to be an entitlement or a policy that has been enacted nationally unless something else happens.

In all public sector policies—it is the same in education—the biggest challenge is scaling up good practice. We now have lots of examples of good practice. What we need, and what is behind this amendment, is to scale it up so that it is not just a case of happening to live near an organisation or where somebody is making this happen. The amendments that we have, which are to the general duties of the integrated care boards, will be a step forward in trying to make this a national part of our well-being service. You are entitled to it; it is there and offered to you, no matter where you live.

That is the big task now. It is not making the case for social prescribing or non-clinical providers having a role to play in health promotion, but how we scale it up so that it goes higher up the agenda of people who are developing policy and deciding how resources should be spent in an area. Years ago, this would have been seen as a fringe interest and people might have thought the noble Lord, Lord Howarth, was eccentric in promoting such amendments. It is evidence-based now. It is what people know works and I think it is what people want. We just have to find a way of getting it up the agenda and making it happen. These amendments will go towards that end.

[Baroness Tyler of Enfield (LD)]

My Lords, I rise briefly to support this suite of amendments put forward by the noble Lord, Lord Howarth. I know how passionate he feels about this issue and how much work he has done in this area over many years. The noble Baroness, Lady Morris, has just taken the words right out of my mouth; I was going to start by saying that social prescribing is a phenomenon whose time has come. I think that is right. People understand that the approach of social prescribing is really opening up opportunities for people to improve health and well-being through non-clinical avenues. That is what this set of amendments is all about.

This is particularly relevant for people with long-term conditions and complex needs, particularly those with mental health conditions, suffering from dementia or experiencing loneliness. The one point I want to make, which I do not think has been talked about yet, goes right back to our opening debate today about how the ambitions of this Bill will be achieved only if there is true integration across health and social care. My big plea is: please do not forget social care when we are looking at this issue. When I say social care, I am thinking both about people who have domiciliary care in their own homes and people in care settings.

Mental Health of Children and Young Adults

Baroness Morris of Yardley Excerpts

Thursday 16th May 2019 Lords Chamber

[Baroness Morris of Yardley (Lab)]

My Lords, I too congratulate my noble friend Lady Royall on the way she introduced this debate and on giving us the opportunity to speak on such an important issue. I accept all the points made about the lack of resources in the National Health Service, the queuing for CAMHS and the need to invest there. Having said that, I do not want to talk about that aspect of well-being and how we can support young people. If our approach is that we always use an external health model to deal with this issue, we will never actually solve the problem: if we are always treating the crisis, there will always be a crisis. Whatever Government are in power, CAMHS and other mental health services through the NHS will always be rationed to some extent. At the moment, we are seeing teachers in schools spending their time queueing to get their children into the acute services of CAMHS and the health service.

I want to put forward as an example an approach to go alongside that but not replace it, because I know that for some children that level of expert clinical support will be needed. Essentially, we need public health working through schools. As a parallel, in dealing with obesity we deal with the causes of obesity; we have dentists, but we deal with the causes of children having bad teeth.

My noble friend Lady McIntosh made an incredibly powerful and effective speech. But even if we had the sort of curriculum in schools that she would like—and I wish that too—there would still be a need to make school a place where the well-being and mental health of young people are supported. That is the job of adults, whether parents, family, community or teachers. It is for us to create an environment where more young people develop the skills and knowledge to have better mental health and well-being throughout their lives.

I chair the Birmingham Education Partnership; in saying that I declare my interest in the register. Four years ago, we were approached by the clinical commissioning group in Birmingham. It wanted to do this sort of work and knew it did not have the access to the city’s children that we did through the schools system. BEP provided funding to work with schools on a public health model. With its resources, we have appointed a team led by a psychotherapist—a brilliant woman called Anna Robinson—and made up of a family therapist, a head teacher and a learning mentor. So far, the team has worked in 53 secondary schools in Birmingham, appointing a designated senior lead in each school. The job is quite simply this: to help those teachers identify vulnerable children as they come into school from primary; to develop training packages for teachers and all adults who work in the school; to work with external partners, as managed by our group, such as the excellent YoungMinds, the public health authorities and clinical commissioning groups; and, now and again, to bring together the leads from all the schools so that there is a community of interest and support for this work. We are working with 53 schools, and when we finish our fifth year of funded work we think we will be working with all 80 secondary schools in the city. We are now turning our mind to working with primary.

The examples that the noble Lord, Lord Storey, talked about, of some schools having support and not others, are what I experienced and are usual. As an ex-Education Minister, I know that the most difficult thing is not to find what works but to get it into every school. The real challenge is rolling out good practice. I am cautiously excited, if that is not a contradiction in terms, to have got this model into 80 schools in Birmingham in five years and to be all ready to move to the primary schools. I wanted to bring that to the attention of this debate as something I hope we can take forward.

I know that, after we started, the Government came forward with their Green Paper, the first aid kit and measures to work with schools. I applaud that and am grateful for it, but the worry of our team in BEP is that elements of this still use the NHS-based model. If I get over one fact in this debate, it is that that by itself will not work. It has to be a model that is wrapped round, runs through and envelops the life that children have in schools, so that attention to mental health is part of how we do our job and not something that we have to refer children to.

I will finish by giving four or five points that BEP has learned and wants to bring to the attention of this debate—I am merely chair of the organisation and pay tribute to the team. First, quick wins are possible and there is nothing wrong with them, but sustained work needs time and consistency. The fact that we are going into our fifth year of this project is an important message in itself. Secondly, these lead teachers need to be confident and well trained, and have good subject knowledge and the confidence to train others. They therefore need training on an ongoing basis that will bring them together and enable them to do their job. Thirdly, schools need to be supported by an integrated team with other skills and other professionals.

I will make two points to finish about things that are not around yet but which will come. Schools need to know who to go to in order to buy or get good quality support. This will become a market. There are lots of organisations—some good and some not so good—selling or giving services. We will get to the point where we as politicians can list the organisations and resources which schools can access to support this work, but we do not give teachers the information they need to make wise decisions about what they buy or access.

Lastly, our team made a point which made me smile: you have to work within the school year. The National Health Service does not work in line with the school year. If we are to bring professionals together to create in our schools an environment where children are given the skills and knowledge to create as good mental health and well-being as possible, we have to work around the rhythms of what they do.

As I say, I am not putting this forward as something that is guaranteed to be a success, but I am confident that it is a more than valuable and important contribution to the debate, which I am delighted we are now having.

Breast Cancer Screening

Baroness Morris of Yardley Excerpts

Thursday 3rd May 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord makes a good point. We are encouraging people to use the helpline. Indeed, the number will be written in the letter that is sent to women, whether they are offered a screening because they are aged 72 or under or want to refer themselves for a screening. At the same time, many women will be anxious and will want to see their GP, or are seeing them anyway. We recognise that. We have liaised with the Royal College to make sure that GPs are properly briefed on a potential increase in the number of women referring themselves so that they are able to cope with that and provide the necessary signalling.

It is also important to highlight that we are working very closely with the key cancer charities, such as Macmillan, Breast Cancer Care and Breast Cancer Now, and others to make sure that there is a proper, broad approach so that women, whatever their anxieties—mental health issues may have been triggered as well as physical ones—get the support that they need and deserve.

[Baroness Morris of Yardley (Lab)]

My Lords, I obviously share in the concern about what has happened. I want to emphasise a point that has already been made and make sure that it will be part of the review. It is unimaginable that some women realise that they have not got the recall for their regular breast screening appointment. As a woman, you are sort of aware when it is about to come around; if the letter had not come, some people—though not everybody—would have either contacted the helpline or gone to their GP. I am worried that the response was, “Well, the computer says you’re not ready for a screening yet”, so the person was not listened to. I am seeking some assurance that the inquiry will come back with an answer on what happened when women said, “I think my breast screening appointment is late”.

Secondly, I am not sure about the scope of the inquiry, which I of course welcome. Will it look at all the circumstances surrounding this incident or will it go further, for example by looking at other causes of the drop in the percentage of people taking up such opportunities, as well as the regional disparities, which have already been mentioned?

[Lord O’Shaughnessy]

As always, the noble Baroness makes a very incisive point. The inquiry must look at whether there were signals and whether they were missed. That may be at the macro level or the micro level, with individual women saying to their GP, “Hang on, this is odd, I haven’t got this”. The problem has arisen because of the interaction between the screening process, which is due to run until a woman’s 71st birthday, and the extension, which was meant to run from a woman’s 71st birthday to the end of her 73rd year but was taking women into this clinical trial prematurely and randomising them. Hence, women in their 70th year did not get anything. It was the interaction of the two. It is technically quite devilish. A 70 year-old woman might or might not have known that she was due to have another one. This is one of things we have to get to the bottom of because, as the noble Baroness said, although this is about technology and computers, ultimately humans are at the centre of this problem.

The inquiry is primarily focused on the incident itself, but I imagine that if, during the course of its work, it finds out or establishes that other issues need to be pursued, such as increasing screening rates variation and so on, it will have the freedom to make those recommendations.

NHS: Antiphospholipid Syndrome (APS)

Baroness Morris of Yardley Excerpts

Monday 9th March 2015 Lords Chamber

[Baroness Morris of Yardley (Lab)]

My Lords, I am delighted to be able to contribute to this short debate on getting greater awareness of antiphospholipid syndrome in the NHS, particularly among GPs. I declare an interest: I am chairman of the Hughes Syndrome Foundation, and I am very pleased to be so. I test positive for antiphospholipid but have had no more than minor symptoms. Where I am unusual is that I had a GP who spotted the signs early on, for which I am grateful. We need to get to a position where that story of early identification, and therefore no great illness other than minor inconvenience and minor treatment, becomes the norm, rather than stories such as the one that my noble friend Lady Drake finished her speech with.

The first point to make is that this is not a rare condition; few people have heard of it—it has a very complicated title, which does not help—but it is not rare. One in six miscarriages and instances of thrombosis, and probably most heart attacks, DVTs and strokes in people under 50, can be put down to antiphospholipid syndrome. Converting that percentage into cases, if you say that 10% of DVT clots can be attributed to APS, gives a figure of 3,000 events in the UK a year. So although this has only relatively recently been identified, it is not a rare condition. I bet I can say that almost all of us know someone who is APS-positive but we do not know it. The problem is that they will not know it either.

APS is essentially a success story. It was identified in 1983, and since then remarkable progress has been made in clinical and scientific research. PubMed is an international directory of worldwide scientific research. When we at the foundation looked at the publications in 2006, relatively recently, there were 20 published research papers. By 2014, that had grown to 602 published research papers each year. There are international collaborations under the banner of APS research, and recently at UCL here in London the UK Antiphospholipid Syndrome Society was formed, bringing together haematologists and rheumatologists—APS specialists are usually found in those departments—to collaborate and continue with research.

About 18 months ago we at the Hughes Syndrome Foundation realised that one of the things our patients were saying was that they did not know where the consultants were. We put together a directory of consultants in the UK and found that there are 100 consultants in hospitals in this country. So there is a growing body of evidence about antiphospholipid syndrome, and it has worldwide recognition.

It is not just that we know more about APS; the treatment is successful as well, as my noble friend Lady Drake indicated. There is no cure, but it is treated with anticoagulant medicines. The effect of that on women who have had previous miscarriages is that the success rate of 20% before 1990 among people with APS is now over 80% today. I think noble Lords can imagine what that means to women who have had three or more miscarriages, are treated and then have over an 80% chance of delivering safely.

Given this success story—success in identifying and researching the condition, relative success in being able to treat it—it is incomprehensible that there is such poor awareness of the condition elsewhere in the National Health Service and among GPs. Quite frankly, it is a lottery as to whether a diagnosis is ever made. Good-quality international work on this shows that on average patients wait three years for a diagnosis. We at the foundation put out a questionnaire to our members and found that a third had waited over five years for a diagnosis, and if you read their stories of going from consultant to consultant and from doctor to doctor, with no one recognising that this might be the cause, it is easy to see how early identification would make a real difference to them.

It matters that there is early identification, not only because treatment can be preventive—it might not cure the condition but it can prevent the worst effects of antiphospholipid syndrome being experienced by patients—but because once it was identified, more appropriate treatment could also be given. This is part of the problem: GPs or experts sometimes say, “Ah well, we’ll spot the thrombosis anyway. We don’t need to test for APS. Once the thrombosis happens, we’ll treat it as well as we can”. The point is that the treatment for thrombosis, for example, is different for those who have APS and those who do not. If you have thrombosis, you are likely to be put on warfarin for a period of three to six months. If you have thrombosis and APS, you need much longer-term treatment than that and will probably be on an anticoagulant for the rest of your life. Identifying APS as a cause of other conditions matters because it is the right thing to do, but also because it might determine the type of treatment that is given.

I suspect that the Minister’s experience in debates such as this is that people come forward and say that they want to bring the benefits of research and clinical progress to as many people as possible, and the debate then centres on the cost of drugs or the availability of specialised equipment. We all understand the difficulty that the National Health Service experiences in trying to afford bringing all the advances in medicine to patients who need them, but that is not the issue that we bring to this debate today. APS testing is relatively inexpensive: £25 for the two tests that are needed. As my noble friend Lady Drake said, the two simple blood tests can be requested by a GP. The barrier to testing is not a lack of resources or expensive equipment; the issue is that we have a disjuncture between what is happening at the clinical research level and how it is being acted on, particularly among GPs. I do not blame GPs for this. It is not surprising, given that there is so little planned structure for making GPs aware of the signs of the condition or its treatment. There is nothing in the NICE guidelines. It is not included in GP training, and even GPs who are aware of APS lack confidence in knowing how to treat it and to take it forward.

As a non-medical person, I think I understand how this has grown up over the years. APS affects all parts of the body, so every expert, every clinician, needs to be aware that APS might be a cause or a contributing factor, but because of this it has too often been seen as a second-order condition and has not been the first thing that specialists look at. Given the growing body of knowledge and evidence about APS and its treatment, it should now, 30 years after it was first identified, be seen as a condition in its own right. It needs to come in from the edge of medical awareness and be seen as part of mainstream diagnosis and treatment.

Some years ago, the Hughes Syndrome Foundation received a grant from the National Lottery and was able to send leaflets to GPs to try to raise awareness of the condition. It has just got a new leaflet and intends to do that again, but frankly that is not what should be happening. We are very happy to send out leaflet after leaflet, but we need a bit of help from the established part of the National Health Service that is meant to raise awareness among GPs. I therefore join my noble friend Lady Drake in her request to the Minister to say what else can be done to raise awareness among GPs.

I do not know what the Minister is about to say, but I suspect he will tell us about the things that already happen and that have been put in place to raise awareness about APS among GPs. All I can say is that it is not enough. It is not working. Too many people who have APS are still not having it identified as quickly and early as possible. They are not having the treatment that they need and the preventive treatment that can keep them well. All of us would want to overcome this problem with a £25 blood test. I am grateful to the Minister for his courtesy in asking us in advance about the issues that we wanted to raise, and I look forward to his response.

Queen's Speech

Baroness Morris of Yardley Excerpts

Thursday 3rd June 2010 Lords Chamber

[Baroness Morris of Yardley]

My Lords, I join others in congratulating the noble Lord, Lord Hill, on his appointment. His really is one of the best jobs in Government, and as long as he can withstand the surfeit of good advice from former education Ministers who are in this House he will do very well. I am sure that he will enjoy it. I also congratulate the noble Lord, Lord Hall, and the right reverend Prelate the Bishop of Guildford on their maiden speeches. It was a delight to listen to them and I also look forward to their further contributions.

New Governments are always inevitably about change; that is what the electorate has asked for and invited, but inevitably there is some continuity as well. I very much welcome the fact that, from what we have already heard from the coalition Government, many of the most successful initiatives of the past Labour Government—Teach First, schools supporting other schools, Sure Start, early years, federation and clusters—will still find a home under this Government. I also welcome one or two policy announcements that I have heard. In particular, on technical schools—or colleges or academies, as they seem to change their name as the policy develops—I congratulate the noble Lord on the work that he has done with our former friend on this. They are a change for good and I would certainly offer my personal support from these Benches in any way, as he knows that I have done so far. I am delighted that they, too, have found a home. I also welcome the review of the accountability framework, which is long overdue. I suspect that only a Government new in office could do that, not one who were part way through.

I want to concentrate today on the main themes of the education part of the Queen's Speech: academies, free schools and teacher control of the curriculum. Unusually, we have another opportunity on Monday to discuss the first Bill, so I shall not go into detail now. Rather, I shall look at some of the underlying principles that have been seized and which shape the education part of the Queen's Speech debate. At the start of their term in office, I suppose that every Government will have to decide what are going to be their levers of reform. In what will they place their trust to bring about the changes they want to see, and which they have promised the electorate?

This coalition Government have made two key errors—quite serious and fundamental errors—in those early decisions. From the Queen’s Speech and the speeches that we have heard so far, we can see that they, like many other Governments, have seized on two things to guide their reforms. First, there is structural change, changing the legal status of schools and their governance and, secondly, embracing independence—in this case, freedom from local councils or a nationally prescribed curriculum. We have now had more than five decades of continuous change in education. We should be able to look at the evidence of what works and build on that, rather than having this pendulum which swings from one set of policy ideas to another.

There is no evidence at all that structural change leads to successful education reform, yet politicians always go into structural change as a first and last refuge. You can list the types of secondary schools that we have had from 1945 onwards, from secondary moderns and grammars to communities and academies. Some of them have appeared more than once; they fade and come back. Despite what the Minister said, there is no evidence that academies are successful schools, but they are not a failure, because it is not the status or structure of a school that will determine its success.

There are many good academies and I pay tribute to them. I, too, pay tribute to Mossbourne Academy, which is mentioned more than any other school in both Houses of Parliament, yet I also look at the rest of the London schools. Most of the 100 secondary schools in London that receive from Ofsted the category of outstanding schools are not academies but local community schools. In Tower Hamlets, of the 15 secondary schools in the most deprived borough in our country, five are categorised by Ofsted as outstanding. Let us pay tribute to them. Not one is an academy; they are all community schools. I welcome and praise academies where they are successful, but there are failing academies. There are academies in special measures. In the south of England, there is an academy which has just been returned to local authority control because it is not successful. Changing the legal status of a school will not transform the opportunities for its pupils and the young people there.

The same is true of independence. The Government are confused about who runs schools. As Margaret Eaton, the Conservative LGA chair, has said, “Councils don’t run schools”—they run themselves. Many of the freedoms that are now going to be offered to the new swathe of academies are mirages or illusions of freedoms. Many are already on offer for all schools, no matter what their status. One reason that they tend not to take and embrace those freedoms is a fear more of Ofsted than of the local authority.

It is time that we did indeed build on the evidence of what works, and every bit of evidence—none more than some research that came out of the University of Bristol in the past few months—shows that the key to individual success is the quality of teaching and of leadership within the school. The research from Bristol shows that the difference in performance between the top 25 per cent of teachers and the poorest 25 per cent can amount to 0.5 per cent of a difference at GCSE. That is why there are good and poor academies, good and poor local authority schools, good and poor church schools; it is because they are not all blessed with excellent school leaders and teachers.

When a new Government come in, they choose the levers that they will depend on to lead their reform over the following years—the flag-bearers of what they want to do. I am disappointed that this Government have chosen structural change and illusory freedom. They should have chosen to say, “The quality of teaching is what will make the difference and our policies will serve that end”. The quality of teaching makes the most difference to the children from poor backgrounds and disadvantaged areas. I look forward, over the coming months, to hearing more about government policies that will help with that. So far, I am afraid that I am a little sad that this Government have almost reinvented the wheel, by seeking one more change in governance and in school status, with some more academies in the hope that that will bring about the reform that we all need. We should learn from research and from the evidence of what works. That does not lead us to more academies, with local authorities being squeezed out of the provision of education.