NHS: Mental Illness

Lord Alderdice Excerpts

Tuesday 17th July 2012 Lords Chamber

[Earl Howe]

My Lords, we have deliberately taken a generic approach to the NHS outcomes framework. That said, the framework for 2012-13 contains three improvement areas relating specifically to mental health: premature mortality in people with serious mental illness; employment of people with mental illness; and patient experience of community mental health services. Therefore, the noble Baroness is not quite right in what she has just said. Many of the indicators in the outcomes framework relate to all patients, including in relation to safety incidents, for example, or experience of primary care. Improving outcomes for people with mental health problems will be a crucial element of success.

[Lord Alderdice]

My Lords, five out of the six recommendations of this excellent report by the noble Lord, Lord Layard, and his colleagues emphasise the importance of IAPT, an excellent initiative begun by the previous Government, which is being built on by the coalition Government. However, from the time of the previous Government to now, I continue to receive reports that psychotherapy departments, particularly those that provide non-cognitive behaviour therapies such as art therapies, psychodynamic psychotherapy, group analytic psychotherapy and family therapy, are closing down or are unable to get contracts. Can my noble friend help me to understand why that might be the case since, while CBT is valuable and helpful in many circumstances, it is not the only approach to treatment that has been demonstrated to be helpful in those who need psychological therapies?

[Earl Howe]

I am very happy to take the advice of my noble friend, who is of course an expert in this area. Historically, it is true to say that access to talking therapies in the broadest sense has been very poor. That is why we have invested £400 million in rolling out the IAPT programme, which makes available a range of NICE-recommended therapies to a much larger cohort of people. However, I will take my noble friend’s point away and, if I can throw any light on the issue that he has raised, I will gladly write to him.

Health and Social Care Bill

Lord Alderdice Excerpts

Monday 19th March 2012 Lords Chamber

[Lord Owen]

My Lords, we have heard a lot of speeches and I do not intend to take long, but I reiterate—if any noble Lord has come in late to this debate—that they should again read the amendment. It makes it clear that what we are trying to do is find enough time—a matter of a few weeks—to hear the opinion of the tribunal that has found against the Government on the disclosure of the risk register. That is a provision within the Freedom of Information Act and follows the earlier decision against the Government arguing for the disclosure of the transitional risk register by the commissioner.

It is pretty unusual for the Government to find two such rulings against them, and it seems perfectly legitimate, before making a final decision—which I readily concede has to be made before Prorogation—to give the courtesy, let alone anything else, of hearing the judgment. It is almost as if we are afraid of the judgment.

In fairness to Professor Angel, we heard from the former Lord Chancellor about his credentials. People do not sit on the tribunal for freedom of information just on one case. They have made many different judgments; they know the issues. With respect to the former Permanent Cabinet Secretaries who have spoken, those who sit on the tribunal know the issues—I do not say as well as former Cabinet Secretaries, but they were looking at it from one side of the equation, the well-being of the Civil Service and the service and information they gave to Ministers. The Freedom of Information Act looks at it from a wider perspective. It looks at it for the good governance of the country as a whole. It urges people to look at why we have open government and greater transparency: because people find it much easier then to accept democratic decisions. This is about a democratic process.

[Lord Alderdice]

My Lords, I have listened carefully to what the noble Lord, Lord Owen, has said. My understanding from his earlier intervention was that he felt it important for your Lordships’ House to understand what was in the transitional risk register so that that would inform its debate on Third Reading. In the light of what my noble friend Lord Howe said—that it is almost certain that that material would not come into the public domain over the next few weeks, as I think that the noble Lord accepts—all that would come into the public domain over the next few weeks would be the reasons why the judgment was made, not the content of the transitional risk register itself. Therefore, I just want to be clear that the noble Lord is saying that all that your Lordships’ House could do would be to debate the reasons of the tribunal, not the content of the risk register. I am not clear how the reasons of the tribunal would inform our Third Reading debate.

[Lord Owen]

It is exactly the wording of the amendment,

“to consider the detailed reasons for the first-tier tribunal decision”,

if there is sufficient time. This is the issue of freedom of information. I have already openly admitted that Governments tend to restrict information and Oppositions want the maximum amount of information. That is the inherent tension which the Freedom of Information Act was established to try to resolve. It seems wiser to listen to those voices.

The noble Earl raised the question of constitutional issues. The Bill raises some serious constitutional issues. The Government have no mandate for the Bill. They specifically went to the electorate and said that there would be no top-down reorganisation of the National Health Service. That is considered by a lot of people outside this House to be a flagrant lie. That is one constitutional issue.

Health and Social Care Bill

Lord Alderdice Excerpts

Wednesday 8th February 2012 Lords Chamber

[Lord Alderdice]

My Lords, the noble Lord, Lord Patel, has characteristically underplayed his own grasp of this important area, but, as noble Lords have heard, he has on his own behalf and on behalf of the noble and learned Lord, Lord Mackay of Clashfern, and the noble Baroness, Lady Hollins, presented an elegant, informed and very persuasive case for the amendment, to which I have put my name. In many ways, there is not much to say other than to support him. However, when noble Lords say that in your Lordships' House, it is often because they actually have quite a lot to say, and I shall say a few words.

On 2 November last year in Committee, your Lordships debated three amendments which would have placed the responsibility on the Secretary of State, the national Commissioning Board and all clinical commissioning groups to regard mental health on the same basis as physical health. That is to say that they should give full consideration to all those suffering from mental illness in the same way as they would those suffering from physical illness.

One reason for trying to insert such a commitment into the Bill was that, despite the efforts of the previous Government—to whom the noble Lord, Lord Patel, is quite right to pay tribute—to address the needs of people with mental illness by allocating more money for talking treatments, on which the coalition Government have substantially built, as the noble Lord said with reference to the legal friend of the noble and learned Lord, Lord Mackay, out there in the real world, mental illness and problems of mental health do not get the same attention and concern. As we said in the debate in November, many people think of mental illness as a subset of illness, like cancer, diabetes, or whatever, but it is not. It is a quite different aspect. When you fall ill with something physical, something happens to you but your personality and your self are not affected; but when you fall mentally ill, the very essence of your self is affected. That is a very different business. It frightens people. They often turn away from paying attention to it because they are so troubled by it. The provision required is different. Often, much more than is the case with other illnesses, a whole range of services has to come together to provide treatment and support.

Our concern in that debate—which was supported by noble Lords on all sides of the House; no one spoke against—was that all the efforts until now have been less than fully successful in building up the regard and esteem in which mental health and mental illness is held. So the proposition for the amendments was not a belief that there was a particular technical flaw in the Bill which meant that mental illness would not be addressed; we are very much aware that it is addressed in the Bill. That is not the problem. The problem is: how do we find a way continually to bring mental illness to the attention of commissioners? The noble Lord, Lord Patel said, as was said in the November debate, that in times of financial pressure and austerity, the tendency is to pull back financial commitment from those areas where there is least pressure. When people are physically ill, they can often nevertheless continue to exert pressure; but when people are mentally ill, they often do not give due regard to themselves, never mind press for the needs of others who are suffering from similar disorders.

Our concern is not about those three specific amendments but the principle. The noble and learned Lord, Lord Mackay of Clashfern, went away and produced a single amendment. The noble Earl was kind enough to give a considerable amount of time to me and the noble Baroness, Lady Hollins, to discuss the question. A concern was expressed by him and some people in the department that if one included this in one place, one would have to put it in every place because otherwise the implication would be that it applied only to the issue to which it refers directly. I have to say that the noble and learned Lord, Lord Mackay of Clashfern, was wholly unimpressed with that argument. As he is a former Lord Chancellor, I think one takes that pretty seriously.

The point is that we must find some way in which to make it absolutely clear beyond peradventure that concern for those who have mental health problems is every bit as great and the responsibility on commissioners is every bit as great to ensure the proper provision of services. One reason why this comes up as the very first amendment Report is that we want to ensure that in all aspects of health care, mental health care is attended to: no health without mental health and indeed, as the Royal College of Psychiatrists’ report said, no public health without public mental health.

It is regrettable that the Royal College of Psychiatrists, of which I am a member, has over the past few days been saying that the whole Bill should be set aside. That is not really a helpful way of engaging in these kinds of questions. The college knows perfectly well that the Bill is not going to be set aside—in fact, it would not be at all helpful if it were. I have seen these kinds of situations in other places, with people polarising in an unhelpful way. I appeal to the Minister, to the Royal College of Psychiatrists and to others who are interested and concerned in this field to find a way to get together again before the completion of the Bill to ensure that the concerns that we are expressing are reflected in a cast-iron fashion. It is a question not of these particular words or of this particular amendment but of receiving solid assurances so that we and those who care for people with mental illnesses, as well as those who suffer from such illnesses, can be confident about the new NHS.

[Lord Walton of Detchant]

My Lords, in rising briefly to support the amendment so ably proposed by my noble friend Lord Patel and supported by the noble Lord, Lord Alderdice, I ask the Minister one very simple question. In Clause 1(1)(a) the Bill talks about the,

“physical and mental health of the people of England”,

and says that the health service must be “designed to secure improvement” in that health. What on earth could the objection possibly be to inserting in paragraph (b) at line 6 the unexceptional words listed in the amendment? They simply stress the crucial importance of mental as well as physical illness. How on earth could this be construed as doing any damage whatever to the Bill? It is something that I hope very much the Government can be persuaded to accept.

Health and Social Care Bill

Lord Alderdice Excerpts

Wednesday 21st December 2011 Lords Chamber

[Lord Bassam of Brighton]

Then I turn to Mr Wiggins. Mr Wiggins has been in the building 21 years. He served as a Grenadier Guard. I think he initially worked in the House post office team. If you chance upon Mr Wiggins, there is certainly a bit of the postie about him. I am not quite sure how you determine these things, but he is very good at delivering things. Before that job, he worked as an attendant in the House of Commons and he was a House of Commons doorkeeper, so he has what I am told is described as “end-to-end experience”. I am not quite sure what that means.

My last tribute of thanks goes to Terry Little. Terry Little joined the Pass Office in 1997 after a career in the Metropolitan Police. He worked in the Pass Office until 2001 and for the past 10 years has been a doorkeeper. He and all the other doorkeepers are there to protect us, to ensure that we do not fall over when we might, to ensure that the House is kept in good order and to ensure that when the day is done, we can safely depart the building.

Going back to Mr Wiggins, I am told that he is joining the Commons annunciator team. I had some difficulty with this because the word “annunciator” in my brief is spelt “annunicator”. We do occasionally have problems with the annunciator. I am sure that those problems will be easily abated, but let us make sure that our briefs are word perfect.

I wish everybody in the House a very merry Christmas and a very fulfilling new year. I look forward to our happy return.

[Lord Alderdice]

My Lords, Christmas time, like some of the other festivals in the year, is of great importance for many reasons, not least the opportunity for us to spend a little bit more time with our families and friends than is usual during the normal period of our work. They also provide markers during the year which remind us and enable us to say a word of thanks to those who work with us and serve us so extraordinarily well in your Lordships' House. We are enormously fortunate in that regard, as we all know.

There are some people who come to us at an early point in their career for a relatively short time—interns and young people who come to work here for a little while who then go off with their knowledge and experience and do other valuable and worthwhile things. Indeed, my noble friend Lady Williams and I were just talking about how pleasant it is to see some of these young people continuing on to do absolutely marvellous things for their community and their country. We have been fortunate that they have started with us. Others, as has already been noted by the noble Lord, Lord Bassam of Brighton, come at a later point in their career, perhaps having served Queen and country in various parts of the world. They come here as doorkeepers, attendants and in other jobs to provide us with order and security, comfort and great courtesy.

However, there are others who come to us through other organisations, and I particularly want to mention those from the Metropolitan Police. It is sadly the case, but it is the case, that we owe our security to them, and it is important for us to acknowledge that that continues and sadly in the upcoming year will undoubtedly continue to be a requirement for us, and we are grateful to them.

There are others who come to us at an early point in their career and spend much of their life working here with us. Some of them are in hospitality, some are in the clerking community and some are in the clerical and administrative community. They provide extraordinary stability for your Lordships' House, and an institutional memory which is itself of enormous importance, although I know that a number of noble Lords also provide some of that. Some stay with us for a very long time, and it is important that we acknowledge them. One in particular, Christine Bolton, has just completed 40 years of service to your Lordships' House. I think that merits particular mention. She is universally and very affectionately known as Chris. She joined your Lordships’ House as a clerical officer on 1 November 1971. For many years, she was on the staff of the Journal Office and was an early user of what in those days was known as new technology—first, using a database on a mainframe computer and then using word-processing software on eight-inch floppy disks. I think that a few of your Lordships still remember those kinds of things.

Chris is now in the Legislation Office where she has become the cornerstone of our procedures for handling private legislation. For myself and our office, when recently one of our colleagues was ill and special arrangements had to be made for a replacement, we should like to acknowledge how helpful, courteous and gracious she was. It was not just a matter of Chris doing the job and doing it properly but she did it with grace and courtesy, which is one of the reasons why she has become so affectionately known throughout your Lordships’ House. She is not alone and many others serve your Lordships’ House in this way but today is an opportunity to pay particular tribute to her.

We will now, I trust, take a break even from some of those letters to which the noble Lord, Lord Hunt of Kings Heath, referred. I trust that all noble Lords will travel safely home to the various parts of our United Kingdom, or to other places if they are fortunate enough to go away, and will have a good rest, relaxation, time with friends and families, and thorough recuperation because I fear that not only the duties within your Lordships’ House but the challenges that come from outside in 2012 may be substantial and significant. We would do well to be ready for them.

[Lord Laming]

My Lords, I think evidence of the effectiveness of the usual channels is that we have reached this point in the calendar at the same time as we have reached the completion of the long Committee stage of the Health and Social Care Bill. This Bill has received the kind of scrutiny for which this House should take great credit. It is in keeping with the function of this House that we scrutinise these Bills with great care. This Bill has certainly received great scrutiny in Committee. I certainly associate myself with the comments of congratulation that have been addressed to the Front Bench and to the others who have played such a big part in the Bill. There is of course much yet to be done.

Mention of one Bill does not exclude in any way the work that has been done on the other Bills that have come before your Lordships’ House. Each of the Bills that we have had, or still have, before us has an enormous importance to our fellow citizens. Potentially, they affect the lives of us all and all citizens of this country. Therefore, it is important that the House continues to fulfil its responsibilities with the care that I certainly admire greatly.

In that process, we are enormously assisted by some outstanding staff. The staff in this House not only help the work to be conducted in a most efficient manner, but they behave always with great commitment, courtesy and support for all that we do. This has been a difficult period because the Bills have been so demanding that it has meant a number of late nights, some of which have become early mornings. As has already been said so well, the House is remarkably well served by its staff. We find it difficult to convey words fully to express our gratitude to them and we are indeed fortunate.

A number of members of the staff of the House work behind the scenes and we never see them, but they are extremely important to all that we do. It falls to me to have the pleasure to refer to two members of staff, Esther Roake and Nelly Parker. Over the years they have been employed to clean the collection of books in the Library. They have done this with great commitment and enthusiasm. They begin their task in the Library, going from shelf to shelf, removing every book and dusting it, cleaning the shelf and then putting the books back, and when they have cleaned all the books in the Library, they move into the collections in the corridors and other byways of the building. Remarkably, at the end of the process they are ready to start again because by the time they reach the end, the books on the Library shelves need to be dusted again. They have done this task for many years with, as I have said, great commitment and enthusiasm and, amazingly, they both claim not once to have opened any of the books. They say the reason for that is that they do not have time to do so, unlike us. They have been very cheerful members of our staff, and Esther always had a generous supply of sweets in her pocket that she would share with those who stopped for a friendly chat along the way. We pay tribute to these two members of staff, who have now retired.

We also offer our warmest thanks to all the staff who work behind the scenes for everything they do. On behalf of the Cross-Bench group, I wish everyone a happy Christmas and offer all good wishes for 2012.

Health and Social Care Bill

Lord Alderdice Excerpts

Wednesday 30th November 2011 Lords Chamber

[Baroness Emerton]

My Lords, while workforce planning is to be a devolved activity at local commissioning level, this Bill states that the overall duty of the national Commissioning Board is to arrange the provision of services for the purposes of the health service in England. Therefore, it would seem appropriate that the national board undertakes to give guidance on a range of issues, as some have already stated, and I would like to see this amendment added. I declare an interest as recorded in the register, speaking as a retired nurse, not named, on the NMC effective register.

The commissioning of the nurses, midwives and health visitors workforce is complex. It covers the community and hospitals; projecting numbers to meet the training requirements; commissioning university places with the right numbers for the services to be provided; and establishing the right number in the right place at the right time. In practice, this requires skilled planners who understand 24-hour service and the different levels of dependency in each speciality, to effect holistic care in hospitals and the community. The economic situation we find ourselves in is already having an effect on workforce numbers. Only a week ago the Royal College of Nursing reported on the effects that the Nicholson £20 billion cut is currently having on services. The detailed analysis by the RCN of 41 trusts revealed that clinical posts were affected, or were planned to be affected. An analysis of the trusts in England showed that the reductions are not only contained within administration, management and other back-room offices, but also affect nursing. Registered nurses are being affected by the freezing of their posts, leading to lower staffing levels, the down-banding of high-grade nursing posts, the loss of specialist skills and those working in preventive services, and cuts in the mental health field, where demand for nursing is rising.

This spells disaster for patients and their families. We know that in Mid-Staffordshire the nurse staffing ratios were changed from 60 per cent registered and 40 per cent support workers, to 40 per cent registered and 60 per cent support workers, in order to make financial cuts, but at what expense? It does not need much intelligence to see that nursing care suffered and the effect was dire.

International research evidence clearly demonstrates that low nurse staffing levels correlate with higher patient mortality and morbidity. We know from evidence in the UK, the United States and Australia that the quality of patient care is affected by the ratios of registered nurses to support workers. The higher the ratio of registered nurses to support workers, the higher the quality of clinical outcome, providing faster throughput and reduced infection rates that in turn reduce readmissions. In addition, the patients receive safe care, and they favour it by way of experience.

To give an example, in a US study, every one patient added to the average hospital-wide nurse workload increased the risk of death following common surgical procedures by 7 per cent. There was a 31 per cent difference in mortality between hospitals in which registered nurses cared for eight patients each and those in which nurses cared for four patients each, taking into account the severity of the patients’ illness, comorbidity conditions and the level of technology and teaching status in the teaching hospitals.

A study in the UK in 2007 found that patients in NHS hospitals in the upper quartile, where nurses had the heaviest patient workload, were 26 per cent more likely to die overall and 29 per cent more likely to die following a complicated stay in hospital. The nurses in the hospitals with the heaviest workload were between 71 per cent and 92 per cent more likely to show negative job outcomes, burnout and job dissatisfaction, and to rate the quality of care on their wards as low and the quality of care in their hospitals as deteriorating. Similar evidence was produced in Australia.

The Bill works towards high-quality, integrated holistic care. Equally important as plans for the hospital workforce in nursing and midwifery are those for the community workforce: community nurses, midwives and health visitors. Last week, the Queen’s Nursing Institute published a report entitled Nursing People at Home, which demonstrated worrying trends in community nursing that could be remedied if more nurses were specifically trained, year on year, to work in the community. It recommended that there should be support for the newly qualified through preceptorship; that healthcare assistants should be regulated; and that commissioners of services should set standards for the qualifications of community team leaders. Likewise, the Royal College of Midwives launched a report last week into the state of maternity services in 2011, recommending that more births take place in midwife-led units and at home, that properly trained and supervised midwife support workers should be appropriately deployed and calling for a guarantee not to cut midwife training places.

There is a common thread running through the recommendations of all three professional bodies that, in essence, supports the amendment. There is widespread concern across the professions that, unless the national Commissioning Board issues guidance on staffing ratios, local commissioning of the workforce could lead to unsafe ratios of trained to untrained staff, resulting in unsafe care and increased cost to the NHS. It is a false economy to meddle with safe ratios. It would be more effective to move quickly towards a totally registered nursing workforce in hospitals, knowing that patients were receiving holistic, high-quality care, leading to shorter stays and reduced readmissions to hospital, resulting in bed closures and real savings.

There is no need for me to go in to more detail. The current situation is very bleak and we are in the midst of amending a Bill that aims to improve the health of the nation and provide high-quality care in hospitals and the community. The latest report and front-line survey by the Royal College of Nursing expresses concern, especially on the urgent issues that face the nursing profession if growing demand is to be met, with the demographic figures showing an urgent need for care of the elderly, the vulnerable, those suffering from long-term conditions and those requiring end-of-life care. We continue to trot out, at every opportunity, that evidence-based clinical care is essential. Will the Minister consider the inclusion of guidance concerning the issues raised by this amendment as a duty of the national Commissioning Board? I beg to move.

[Lord Alderdice]

My Lords, I have a good deal of sympathy with the thoughts behind the amendment in the name of the noble Baroness, which she has put forward in her usual forceful but thoughtful way. However, there is difficulty in some areas.

The amendment does not state so clearly but it appears to assume that registered and non-registered are the same as trained and untrained. I also draw your Lordships’ attention to something to which I have returned fairly regularly for more than 10 years, the fact that psychotherapists and counsellors are not registered. There is no statutory registration, and yet there are areas of care—for example, in alcoholism and drug addiction, child and adolescent psychiatry and psychotherapy, the care of some very disturbed patients—where psychotherapists, particularly trained ones, and counsellors are extremely important.

Many of these are people with very long trainings, much longer than would be the case, for example, for a nurse. They are well trained people and they are well supervised but there is no register and therefore they would fall foul of a proposal like this. Were it the case that all the appropriate people were not only trained but registered and that therefore one knew that those who were not registered were not fully trained and supervised, I would have a great deal more sympathy with the detail of it.

I have difficulty not with the thought behind this amendment but with the fact that it seems to some extent to ignore some quite important groups. My fear is that if we move down this road, in the new world the pressure will be further against the employment of people who have had substantial psychological training. It has been made clear to me—this is one of the reasons why I use this opportunity—that some of those with a high level of training and a substantial length of experience are already feeling themselves marginalised because the larger professional groups that have registers are using that to strengthen up the stance of their members, which is entirely justifiable and entirely reasonable.

I would be much more reassured and much more able to support the amendment if either it was very clearly and simply referring to trained and registered nurses or unregistered people who are working in nursing, rather than the more general statement which is in the amendment, or—perhaps even better—if my noble friend the Minister was able to indicate that the Government were going to make progress on the registration on those other groups that need to be registered; that involves in particular, from my point of view, psychotherapists and counsellors. However, I do have a good deal of sympathy with what the noble Baroness says.

Health and Social Care Bill

Lord Alderdice Excerpts

Wednesday 30th November 2011 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, perhaps I can come back to that. On Amendment 160A, I am grateful to the noble Baroness for her support. I am not even sure that I got it right. I am also trying to get at the fact that so much is happening now without any consultation. The CCGs are essentially being decided by the system and then at some stage there will be a formal application process. I am long enough in the tooth in the health service to know about NHS consultation. Frankly, we all know that the traditional NHS consultations make the decision and then consult. I fear that, with CCGs, this is what is happening. While I welcome the support for the involvement of the public in a formal application, I find it perplexing that so much is now being decided and that the public are not involved at all.

I listened to the noble Earl before supper talking about this being bottom up. That is not what is happening. I do not think that he understands quite how much this is being driven by the centre. It is quite extraordinary. You can call it guidance, but putative CCGs are being given such clear steers about what will be acceptable. I feel that we will reach a situation where, at some point, it will all be a done deal and the consultation will simply not be realistic.

On the noble Baroness’s comments about making the regulations affirmative, I accept that, even if they are affirmative, there is a limit to what parliamentary scrutiny can provide—although that does provide some safeguards. I would be interested in debating the idea of giving the Health Select Committee a role, although excluding your Lordships’ House from it would be a problem. I say to the noble Baroness that I think it a pity that the House did not adopt my suggestion about a mandate for a kind of national policy statement approach. There is an argument for having a more interactive debate, if you like, about some of these matters. I very much take to heart her constructive comments on this and the Select Committee role. It could be a very useful debate for the future.

[Lord Alderdice]

My Lords, lest it be thought that we were all wholly of one mind on these Benches in regard to some of these proposals, let me say that I am much more cautious about the propositions. My noble friend Lady Williams of Crosby has described the propositions for consultation with patients as novel. She is quite right. When the noble Lord, Lord Hunt, says that he recognises NHS consultations from the past as decisions first and consultation afterwards, he recognises how the previous Government carried out their business. As somebody who was in the health service at the time, I was very familiar with it.

We must be realistic about some of the propositions that come forward for consultation. Think through what is actually involved in doctors coming forward with proposals to fulfil the requirements set down in legislation in all its various aspects passed by Parliament, and then being asked to consult with the patients as to what exactly they think. Think through what exactly that might look like for general practitioners and their patients—those patients who would choose to back the general practitioner in his application to go along with the proposals, or would start to run a campaign against their GP. Is there really a thought that this will be something that serves the interests of helping general practitioners and their patients to move forward together? It is an interesting and novel proposal from the point of view of debate in your Lordships’ House. However, I am not at all convinced that it has been thought through in terms of how one might actually implement such a thing, and in terms of working with patients and patients working with their general practitioners.

In psychiatry, for example, I think of how much discussion and consultation there has been with patients about who their sector psychiatrist might be, never mind all sorts of other important decisions about them. The fact is that it is not a way in which one can possibly run these things. It is important to have consultation with the public in general, but to try to divide it up so that patients are consulted on whether their GP should follow decisions taken in line with decisions that Parliament set down is wholly another matter. My noble friend was right to describe it as “novel”, but I am much more cautious about the proposal than she is.

[Lord Hunt of Kings Heath]

I thought that what the noble Lord said about the last Government was a cheap shot. I was talking about the NHS consultation in my experience over 40 years. It has not been a wholly satisfactory situation. It is quite remarkable what the noble Lord seems to be saying. The health service has strong corporate governance and strong processes for consultation, but suddenly we are bunging £80 million to GPs and they do not have to consult. Are they in such a mystical position that they do not need strong corporate governance; that we can trust them, even though some of that money will be spent with the GPs instead of on other parts of the health service? Suddenly we think that they are jolly good chaps and we can trust them. We can trust them simply to form these clinical commissioning groups, in which in theory they will have great power, and there is no consultation whatever. It is quite remarkable what the noble Lord is saying.

[Lord Alderdice]

My Lords, let us be clear. It was no cheap shot. It was a comment on how the previous Government carried through their policies. He will know very well that I sat on those Benches and asked the questions of him. I am very much aware of it. What I said had nothing to do with corporate governance. It was the specific proposal that GPs’ patients should be asked to express a view on the proposition that their general practitioner be part of a clinical commissioning group. As though there was some serious alternative to it, and that it was something that could be carried through willy-nilly without any potential disadvantage in the GPs’ conduct of the practice.

What I pointed out was that this is not something that has any kind of precedent; it was, as my noble friend said, “novel”. What I said about it was quite clear. It has not been tried and I am not persuaded that it is something that has been well thought through. It could be very divisive within a practice. That is not at all to say that other elements of corporate governance are not appropriate. I wholly support them and the proposal. I was addressing a specific issue and I notice that it was the one issue that the noble Lord did not respond to.

[Lord Hunt of Kings Heath]

So I as a patient have no right to say or comment on which clinical commissioning group my GP wants to join? It is nothing to do with me and just up to the GPs to decide? That is what he said. On the question of general consultation, let me remind him of the NHS plan. If this Government had done this properly, they would have published a Green Paper. They would have gone through a process of working with the health service, they might have spent six to nine months doing it and they would have got much greater buy-in. It shows that they have dealt with these reforms in a high-handed manner. The result is that there is no buy-in whatever and that is why the Government are in the trouble they are. I pray in aid the way that the NHS plan was dealt with and the fact that 500 people came together on a number of bases to work on the plan. That is why it had so much greater ownership.

[Lord Alderdice]

My Lords, I addressed one specific proposal, not the whole world and the whole conduct of the Bill. I addressed one specific proposal, and the noble Lord comes back and tells me, “Has a patient no right to express a view?”. Of course the patient has a right to express a view. There will be public consultation. That is not the issue. The issue is that the noble Lord produced a specific proposal. One of my colleagues found it novel and interesting. I find it novel, but I am not at all persuaded that it has been well thought through, and I am interested that the noble Lord jumped so immediately to defend not the proposal but his posture.

[Lord Patel]

My Lords, I thought that I might get up to say one sentence to stop this conversation from going further. My name is on several amendments, particularly those proposed by the noble Lord, Lord Warner, about competency. I have a simple question, which I am sure the Minister will be able to answer easily. What competencies do the commissioners have to demonstrate before they are authorised to become commissioners? I know that there will be guidance, but what competencies will be looked at that demonstrate that they can be commissioners? I am being very brief today because of being chastised for talking too long; but now I have evidence that suggests that I was not the worst, so I will carry on another time.

Health and Social Care Bill

Lord Alderdice Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Alderdice]

My Lords, I am grateful to the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel of Bradford, for bringing these amendments forward. I have been happy to put my name to them—and I thank the noble Baroness, Lady Finlay of Llandaff, who very graciously withdrew her name in order that I could show my support for the amendments.

Like the noble Baroness, Lady Hollins, I am a fellow of the Royal College of Psychiatrists, albeit I am a recently retired psychiatrist. I would like to support these amendments, but coming from a slightly different perspective from some other noble Lords. When I came into psychiatry many moons ago, we learnt that some 50 per cent of all hospital beds in my part of the United Kingdom were mental hospital beds. That is no longer the case, because there has been a great move towards community care—or at least having people with mental illness in the community, which is not always the same thing. It has many advantages, but one disadvantage is that people have lost a sense of the size and severity of the problem. They tend to think of mental illness as a bit like cancer or diabetes, or something of that kind—as another disorder, along with all the rest. But it is not; it is something quite different.

Whenever any of us suffers from a physical illness, it feels like something that has happened to us that we have to respond and react to. But when something happens by way of a mental illness, what is attacked is our very selves, because having mentation is what it is to be a sentient, conscious, reflective human being. I am not talking about people feeling a bit down or depressed or reacting to circumstances or difficulties; I am talking about mental illness. Those differences have sometimes been misunderstood and forgotten, including by psychiatrists in recent years. What disappears, what is attacked and what is under pressure is the very thing that makes you a human being.

One case in which that is most commonly seen is dementia. When my grandfather died and I was consoling my mother, she said, “John, my father died two or three years ago. It was only the shell that passed away yesterday”. In truth, the person is gone. That does not mean that we do not care for the rest, but the person has gone. Whether it is an organic disorder, or an organic-related disorder like dementia, or a psychotic disorder such as progressive schizophrenia, or even a neurotic disorder such as obsessive compulsive disorders and anxiety states, it attacks what it is to be a human being. It is a very different thing. All sorts of aspects of the being are attacked—the volition, the will, the capacity to want to do things, disappears. The capacity to care for the rest of the self is often attacked. This means that the very kind of service that you have to provide for people with serious mental illnesses is quite different. Whereas it might be legitimate to say of many physical illnesses that we expect the person to come along and to understand that they have to make a bit of an effort, with someone who has a serious mental illness, whose very capacity to understand and to care for themselves and address those kinds of things, they are attacked by the illness itself, and that expectation must be modified and be quite a different thing.

That leads me to be very supportive of the notion in the noble Baroness’s amendment, which I share with her, that in the health service we need to understand the differences as well as the similarities and crossovers between mental and physical illness. Noble Lords have said that they have some optimism that the stigma is less of an issue now than it used to be, and they hope that we might get to a point where it will disappear. I am somewhat of a sceptic about that, because I think that there is something fundamentally different about having a physical illness, when you can feel the lump or the bump and reassure yourself, and mental illness, when frankly at times all of us have some uncertainty about our own stability in that regard—and with good reason. It provokes a very understandable anxiety about the very existence of the self, which means that there will always be a degree of fear about it that does not necessarily exist in physical disorders. I am always encouraged when people become more understanding, of course, and I am always encouraged by opinion polls that say that that is the case, but I retain a little uncertainty that we are really there.

When I was training I used to come over from Belfast to the Royal Free Hospital in London for supervision every month. Sometimes the consultant was not ready to see me, so I would sit down among the patients in the clinic. I remember when the consultant came out one day and said, “I’ve decided that you’re really quite stable, John”. I said, “I’m sorry, what do you mean—why on earth have you decided that?”. He said, “You don’t seem to have any anxiety about sitting among the patients in the psychiatric clinic”. The truth is that many of us have those kinds of anxieties. It is a different thing.

When it comes to service provision, there is a greater tendency to ignore, forget and set aside the need for the resources for people who are suffering with mental illnesses. One of my concerns, as we move into a time of increasing austerity—and I suspect that will be the case for quite a period of time—is that there will be a temptation to focus on those services where patients can be demanding, emphasise their needs and promote the requirements that they have. Those who suffer from mental illnesses will find themselves shying away and not necessarily having the provision for it. Therefore, to put on the face of the Bill that the responsibility is for people with mental illness and physical illness is an important preventive factor for the next number of years—we can easily judge them to be years—of financial and economic pressure.

It is not just that kind of pressure that exists. Over the last number of years, I have noticed with many of my colleagues in psychiatry that there has been a tendency to slip back towards the provision of care for those who have psychotic illnesses or organic mental states and to try to forget about those with neurotic disorders who may sometimes be dismissed as the walking wounded. They are severe debilitating disorders that destroy lives and damage families and relationships, but many do not get the attention now that they should. Putting it on the face of the Bill would help to keep it in people’s minds.

We are not necessarily talking about disturbances of personality. It is a different kind of a matter. I hope that when the Minister comes to reply he will understand that this is not merely a question of the needs of a particular section of the community or a particular disorder or group of professionals. It is about a particular aspect of being a human being, which affects all of us, inside and outside this House, and is extremely important for our health service to recognise and have always brought to its recognition—whether through the Secretary of State, referred to through Amendment 11, or the National Health Service Commissioning Board, referred to through Amendment 106, or at the level of a clinical commissioning group, referred to through Amendment 180. The issue is not with the precise amendments but the precise problem, which I hope that my noble friend the Minister will be able to reassure us upon.

[Baroness Whitaker]

We have heard very powerful arguments from all sides of the House in support of these amendments, from deep and distinguished professional expertise, which in turn is backed by the professional institutions. I know the Minister will want to pay heed to that.

I would like to offer a lay view. These amendments would redress a deep imbalance. The Minister may well say again, as he did in his letter to Peers who spoke at Second Reading, that the Government's good mental health strategy,

“makes clear an expectation of parity of esteem between mental and physical health services”.

And so it does. But that is not the same as making it happen.

The Minister may point out again,

“in law, the term ‘illness’ covers all disorders, both physical and mental, so it is perfectly adequate for any Act of Parliament to refer succinctly to ‘illness’”.

The trouble is that however enlightened the intentions in the strategy, and whatever parliamentary draftsmen may say, we live in a culture which has for centuries relegated mental illness to the realm of the weird, the unmeasurable and the stigmatised, as others have said. Even after the great advances of the last 150 years, neither the resources applied nor that general public understanding which supports political action is remotely adequate for a realistic approach.

What I have seen is that bouts of mental illness severely erode the ability to cope with the problems that life throws up. They do not mean that the sufferer has to be treated like a being apart but they crucially impair the ability to earn a living. How many of those with chronic mental illness hold down a job? They can irreparably destroy relationships, which I heard a lot about when I was on the board of the Tavistock and Portman NHS Foundation Trust, and as a consequence of this combination the sufferer often loses their home. This is devastating; it is arguably more serious than many physical illnesses in its consequences.

When I used to volunteer for Crisis at Christmas, probably over half the homeless people I met were mentally ill. Dedicated professional volunteers came and attended to their coughs and colds, their teeth and their toenails. They sewed their buttons on and gave the heroin addicts methadone but there was never even the most limited talking therapy. I have had colleagues who have kept their proneness to clinical depression secret, even when medication controlled it perfectly adequately, out of fear for the career consequences, and others whose alcoholism was treated as only a disciplinary matter—contrast that with diabetes or severe allergies. This damaging general culture can be changed only if there are enough professional resources to make an impact on it and if there is no excuse, by means of the words—or lack of them—in the statute, to treat mental illness less seriously than physical illness.

How is it that, in answer to the Question which my noble friend Lady Thornton asked on 3 October, the Minister was able to say that the Churchill Medical Centre, a GP practice, deregistered 48 patients with dementia and mental disabilities,

“due to the resources required to support those patients”?—[Official Report, 3/10/11; col. WA 102.]

Are patients deregistered because they have asthma or congestive heart disease? I think not. Osteoporosis units are funded—good—but local psychotherapy units, which so often have to deal with the residue left by more superficial, short-term and cheaper treatments, are not. Cognitive behaviour therapy, excellent for some purposes, is so widely offered exclusively that it tends to push out a range of other treatments. This does not happen in cardiology. Counselling is often the initial treatment of choice; cheap and with a lesser degree of qualification required.

I heard recently of a single mother, abused and abandoned by her partner, a drug addict, who was not really managing to cope with bringing up small children. She would have had a few weeks of counselling in her GP’s practice and medication, followed by brief interventions by clinical psychologists but, like many others, this did not shift either her depression or her behaviour. Her anxiety was too deeply entrenched for short-term counselling to make much difference or prevent her taking her negative feelings and distress out on her children. In fact, she was one of the lucky few. She had a small, local psychotherapy unit near her and she received huge support from her weekly meetings over a long period but that unit, the Camden psychotherapy unit, will shortly lose its funding.

The trend for the full range of mental health treatments to be available only to the rich, or those who can wait a year or more, will be exacerbated if there is not parity of esteem between mental and physical illness. Noble Lords may not be aware that the treatment they or their family might expect is simply not available to more than a very few poor people. It must be emphasised again what is at risk when people's mental health is jeopardised. It is not only their happiness; it is their job, their relationships, their capacity to be effective parents, their resistance to drugs, alcohol and crime, and their home. It is of course also our economy, our well-being and our ease and peace of mind which are impaired. Explicit parity of esteem is essential to redress this cruel imbalance. These amendments serve that purpose. I urge the Minister to accept them.

Health and Social Care Bill

Lord Alderdice Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Newton of Braintree]

My Lords, I begin a very brief set of remarks by apologising to the House, and especially to my noble friend Lady Williams and to the noble Lord, Lord Hennessy, for not having been here at the beginning of the debate. The reason is perhaps apposite and might help to calm down the noble Lord, Lord Peston; I was at an NHS clinic in Braintree at lunchtime.

On the basis of this debate and looking at the amendment, I am with my noble friend Lord Mawhinney and a number of other noble Lords who have no objection to a preamble or general statement of principle. I will come back to that in a minute. However, if we need one, this amendment is not it, as the noble Lord, Lord Bichard, said. There is a case for the Government looking at a possible preamble or broad statement of principle, partly because, in my judgment at least, the views that the noble Lords, Lord Peston and Lord Owen, expressed—which would lead me, if I believed that they were true, to refuse to support the Bill—have raised fears and concerns among a significant number of members of the public. If we can reassure them by a preamble or statement of principle at a proper time, we should do it.

My noble and learned friend Lord Mackay of Clashfern did us a service by going back to the founding statement in the 1946 Act. I say to the Labour Front Bench that it may need a bit of tweaking—I have not studied it in the way that my noble and learned friend has—but going back to the statement of principles on which the NHS was founded would give people that reassurance. For me as a Conservative, and no doubt for the Liberal Democrats as well, it would do a real service by assuring people that we are not about destroying the NHS but about making it better and more fully equipped to fulfil its initial objectives. I hope that my noble friend will look at what my noble and learned friend suggested.

[Lord Alderdice]

My Lords, I agree considerably with the suggestion of the noble Baroness, Lady Thornton, that some of us might have a sense of déjà vu about the setting down of a list of principles pre-Clause 1. She is right that it is what opposition parties tend to do—and the response, as the noble Baroness, Lady Morgan, pointed out, is that Governments tend to resist them. Her Government were no different from how I suspect the Minister will be in this respect. However, I hope that when Liberal Democrats and Conservatives in the past put down such amendments, they were a little more careful about the wording.

As a number of noble Lords who are susceptible to the notion of a statement of principles pointed out, the statements before us are not very well put. The first states that the health service,

“must have regard to the principles and values outlined in the NHS Constitution”.

I have no doubt that if this had come forward as a government proposal rather than an opposition amendment, the Opposition’s place would have been to say, “Only having regard to the principles and values? What about all the other aspects of the NHS constitution? Will they not be set aside now that we have a subsequent piece of legislation?”. Legally, that would be a perfectly legitimate point. The second one identifies a number of principles—quality, equity, integration and accountability —and then speaks of the market, which is not a principle at all. It is a mechanism, as my noble friend Lord Ribeiro rightly said. Indeed, the noble Baroness then pointed out that actually a little care was lacking in the setting down of the original words.

--- Later in debate ---

[Baroness Jolly]

My Lords, it seems that we are now getting an outbreak of agreement that there should be a duty on the Secretary of State regarding education and training in the Bill. This is to be welcomed.

The noble Lords, Lord Mawhinney and Lord Kakkar, put it really well, and I will slightly paraphrase what they said. The delivery of high-quality patient care is absolutely predicated on quality training. It is also critical, however, that standards are set, maintained and monitored, not only for doctors and nurses—we have heard a lot today from very eminent doctors—but for allied health professionals.

There will, however, be a plethora of local healthcare providers: some within the NHS and some outside. We are anxious to ensure that the local responses to the delivery of training will meet these standards. We hope that proper checks and balances will be put in place to give some sort of national oversight on this. The noble Baroness, Lady Finlay, alluded to this in her remarks. I was going to carry on by giving a couple of examples about the need for co-ordination across providers and talking about these independent treatment centres. I will refer only to phase 1 and not to phase 2; we will have got it right by then.

There were complaints, certainly in my local district general hospital, that doctors were seeing only quite complicated operations and not standard ones. It was to do with hips there, and we have already heard about elbows or shoulders elsewhere. Similarly, the noble Lord, Lord Winston, cited hernias and I have a hernia example, which I shall not share with the House.

With this Bill, there is a wholesale need for a total change of culture within the NHS about the way we work. If we put patients at the centre it will create a huge need for training. It will be one-off training in the first instance but it will also need to be ongoing. This is something that I had hoped the Future Forum might be considering as part of its deliberation.

We are assured that the Government are keeping deaneries in place at present, but we share the anxiety of some of the royal colleges about their future. I have to repeat what others have said—and I heard it only this morning: there really is anxiety about this second Bill. The first assurance was that it would come in the next Session but now organisations are worried that the delay might be even longer. Therefore, we need something from the Minister that will help to focus people’s attention and give them confidence that things are in place.

I have spoken to universities and other providers of training. They need reassurance and certainty, too. They need to plan their staffing and, in this, they form part of the health economy. It is in no one’s interest to destabilise them. Can the Minister offer such reassurance on this?

We welcome the duty for Monitor to have regard to the need for high standards in the education and training of healthcare professionals. How will this interact with the potential for insufficient caseloads, in some circumstances, to train new healthcare professionals properly? How will national oversight of education and training be carried out to ensure higher quality? All these areas need to be teased out further, and we will come back to them on Report.

We all acknowledge the critical need for training and for standard setting. Can my noble friend give the House some reassurance that he will look at these issues again and, where possible and appropriate, consider regulation as a way of moving some of them forward in advance of the Bill?

[Lord Alderdice]

My Lords, I do not wish to repeat what other noble Lords have said very eloquently, but there are one or two issues which have not been referred to, to which I wish to draw attention. First, I pay my own tribute to the noble Lords, Lord Walton of Detchant and Lord Patel, and indeed other noble Lords who have kept fighting the good fight on education and training.

It is important, however, that we see this in as broad a fashion as possible. I am a doctor but I intend to speak mostly on non-medical education within the health service, since it has not, perhaps, received as much attention as it might. Like everyone else, I will undoubtedly speak from my own experience, which is, perhaps, a little different because it is in psychiatry and the psychological services. That is not just about treating patients; it is often also about training doctors in communication skills and the capacity to understand the psychological aspects of disease.

The noble Lord, Lord Hunt of Kings Heath, knows that I am not a recent convert to this question of trying to get regulation of psychotherapists and counsellors so that they can properly become part of an overall healthcare system.

[Lord Hunt of Kings Heath]

My Lords, I think it was in 1999 that I was converted, alas.

[Lord Alderdice]

Sadly, just a little late, but there we are. The point is that when we think of medicine and nursing, we largely think about people who are educated at public expense—partly within the healthcare system and partly within the higher academic institutions—and employed largely in the health services but, in some cases, outside. In the area in which I work, I am afraid the truth is that the health service has not tended to provide the training for these people. In many cases, psychotherapists, counsellors, and HPC-approved people such as art therapists and music therapists, have had to train at their own expense because the health service has not provided the training. Some of them have worked in alcohol and drug addiction services, which the health service uses; or they have been used in suicide and self-harm services, which the health service uses; or they have been employed in general practice or in psychiatry and psychological services, which the health service uses. The health service, however, has not paid for the training of these people.

When I see amendments that refer to the maintenance of education and training, I see an ambition that is too small. I see a sense of self-satisfaction—of, “We’ve got to maintain what we’ve got because it’s the envy of the world”, rather than, “Some parts of the world have been moving substantially ahead of us, and we have to do some work to catch up with them”. Therefore, I welcome the fact that there are amendments on this front, but also that the Minister has gone a little further. He is not just talking about the health service; he is talking, in the words of this amendment, about anyone who may be,

“providing services as part of the Health Service”.

He is also saying that the Secretary of State will need a greater area of responsibility to ensure a wider provision of training.

Even within those services, which have been provided for the training of doctors and others, I have noticed in recent years that it has become more and more difficult for doctors to continue to provide for their own continuing professional development—which is an aspect of education and training—and to be free to provide supervision and training for others. The pressure is on them to provide the direct clinical service, and not to be free to commit themselves to education and training. I welcome these amendments, particularly that of my noble friend the Minister, which say, “No, the Secretary of State will have to undertake this”.

I come to one final matter because I know the clock is going along. The noble Baroness, Lady Finlay, raised concerns about those who are outside direct healthcare provision having to demonstrate that they are providing training. I understand that entirely, and there is a lot to be said for it. However, one needs to be a little careful. In my service, for example, it was clear that the NHS was not going to provide care and treatment services, and it was not going to employ more people. So the question for me was this: how did I find a way, by using a small number of experienced and highly trained people, of creating a multiplier effect out in the community? The only way I could do it was by taking on and supervising some people who were working in the voluntary, community and other sectors so that they then had the capacity to train themselves or anyone else. I reduced the amount of clinical service I was providing directly by taking them on and supervising them. Then, effectively, I could treat a whole raft of people whom the health service was not prepared to provide the money for.

If we make it a rule that those often small NGOs and charitable groups have to account for the training of all sorts of other people, one simply makes it impossible for them to make their provision. So I understand entirely what the noble Baroness has said and I have a great deal of sympathy for the sentiment here, which of course is what is important, but I would simply caution against making such a strict rule that it becomes impossible for smaller providers who are not able to provide training—and could not pay the extra to do it. That would prevent some of us within the health service using them to provide the range of services which, until now, the health service has not provided. The Minister has been given some credit for this and I commend him and other noble Lords who have brought forward this proposal for the Bill, but let us build on it and try to be ambitious about what we can say in this Bill, never mind the one that might be coming down the road a little later.

[Baroness Finlay of Llandaff]

My Lords, perhaps I may briefly intervene to try better to clarify my concerns. I am not asking that small providers should have to account for all the education they provide. Let me give a specific example. If you have a hospice home care team, it is very appropriate that they should take nurses under training on placement. They can go out with the specialist nurses and learn about provision in the community. It will not cost the hospice anything, but the hospice management might feel that having students around is difficult because of regulatory functions and so on. All I am saying is this: if the management says that it will not take on students to learn about its excellent clinical service, it must justify why it is closing that educational door.

Similarly, if a group of physiotherapy providers dealing with back pain has an NHS contract, it would seem appropriate that it should take on physiotherapy students in order that they can observe and learn ways of managing back pain, which is what the group is primarily dealing with. Those students will get very good training. If the group says, “We do not want to take students”, then I suggest that it would be appropriate to point out in the contractual process that it needs to justify why it is refusing to provide education. Also, perhaps that group should not receive the full tariff because other providers will want to share their expertise for the greater good.

[Lord Alderdice]

My Lords, as I say, I understand the sentiments that the noble Baroness is trying to convey, but one has to be careful about generalising from one’s own experience, which might not necessarily fit everywhere. For example, a noble Lord said earlier that in a lifetime of clinical work, only a couple of patients had ever said that they did not want a trainee sitting in. I am afraid that psychiatry and the psychological services are a wholly different ball game. Whenever we were setting up for trainees, we had to warn them in advance that one in every three patients would not allow them to sit in on an assessment because of its personal nature. When you are living in a smallish community, as mine is, where people know people who know people, these things are much more of an issue.

It you make demands of some of the NGOs and smaller community services—demands that may be completely appropriate in a larger setting such as hospice care—that is quite a different thing. I accept absolutely what the noble Baroness is saying, but please let us not make a rule for everybody which may detract from some provision that is entirely appropriate.

[The Earl of Listowel]

My Lords, I am reminded by this debate of my experience 10 years ago when visiting a hostel for young drug abusers in Kings Cross and speaking with the mental health nurse there. She said, “I was placed here nine months ago with three other mental health nurses. We were given no support and I am the last mental health nurse working with these very needy young men”. She was doing an immensely important and demanding job. I do not know if she was not getting her line supervision from the NHS, although I imagine she should have been. I know that there is a concern that when health professionals are placed away from the mainstream of the NHS, they do not necessarily get the support they need. One issue that I would like some clarification on, perhaps in a letter, is that of continuing professional development and the supervision of professionals even when they are working in outreach services. When they are away from the mainstream health service, they should still be getting the proper supervision and support they need.

I said at Second Reading that one cannot legislate for the NHS to care for patients, but what one can do is nurture the people who work in the health service—the doctors, nurses and physiotherapists. One can give them the best training and the best ongoing support so that they are capable of caring and being considerate. What was happening with the mental health nurse I mentioned was that she was caring in the most adverse circumstances. She had everything stacked against her. She said, “We just did not get the support. It was not thought that we needed support to do this important work”.

Concerns have been raised about future pressures on the training and development of healthcare professionals. There is also the Nicholson challenge: a lot of money has to be shaved in a short time. There is concern about fragmentation. As my noble friend Lord Kakkar said, training is an expensive process and costs professionals’ time. It might be helpful to consider for a moment what has happened in the social work arena over the past 20 years or so. One has seen a lowering of the thresholds of entry into the social work profession and a diminution in quality. Many good people are working extremely hard, but it is widely recognised that there has been a diminution in quality. I am thinking particularly of child and family social workers. They have to assess a family and decide whether a child stays in the family or is removed, a decision that will quite probably have consequences for the rest of that child’s life. But the thresholds have been lowered so far that, until recently, one could get on to a social work course with two Ds at A-level. Current social workers talk about “old school social workers” who knew the law and were methodical in their approach, and how they regret their passing.

I am grateful that this amendment has been tabled and it is right that it has been given such priority. There must be no diminution. Indeed, we must strive to improve training and support for the development of our care professionals. A particular area of concern has been that of psychiatry. We have had difficulty recruiting sufficient psychiatrists, and I understand that nowadays most psychiatrists do not have English as their first language, which is a matter of concern. I would cite the area of child mental health professionals as well. I know that the Royal College of Psychiatrists has been working hard on this, but I wanted to light this up as an area of concern.

Finally, I recently visited midwives working in a hospital in central London. I was advised that they received only one supervision session per annum. That seems an extremely poor amount of supervision. Normally in the health service it is provided every one to two months. Supervision sessions provide an opportunity to discuss, among other things, the continuing professional development needs of practitioners. I may have misunderstood the position and there may be some other context for midwives, but I would be grateful if the Minister could write to me with a bit more information about how midwives are given the continuing professional development they need.

I look forward to the Minister’s response. This is a tremendously important debate that is key to ensuring that, in the future, patients in the NHS get the quality of care they deserve.

Health: Cardiology

Lord Alderdice Excerpts

Monday 24th October 2011 Lords Chamber

[Lord Alderdice]

My Lords, given that the review of paediatric cardiac surgery services presented earlier this year suggested a requirement for 400 or 500 cases per year, which is a level that cannot be provided in Northern Ireland so the service there would not be allowed to continue, can my noble friend reassure me that the Department of Health has been in discussion with the Department of Health, Social Services and Public Safety in Northern Ireland to see what the Department of Health here can do to ensure that paediatric cardiac surgery services are available to the children and young people of Northern Ireland?

[Earl Howe]

As my noble friend knows, the children’s heart surgery unit in Belfast is not part of the Safe and Sustainable review as it is the responsibility of the healthcare systems in the devolved Administration. It is for the Northern Irish health service to take a view on the safety and sustainability of those services and to consider the recommendations that flow out of the review in this country. We will, of course, share the learning from our experience in England, but I emphasise again that this is a matter for the NHS, and not Ministers, to resolve.

Health and Social Care Bill

Lord Alderdice Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Alderdice]

My Lords, when one comes near the end of a debate in which almost 100 Members of your Lordships' House have spoken, one has a good deal of time to think about what one might say when the time comes. I must first start by declaring an interest. From the time I left college until March last year, I worked in the health service, first as a junior doctor, then as a consultant psychiatrist and then as an executive medical director of South and East Belfast Health and Social Services Trust, one of the largest health and social care trusts in Northern Ireland. I retired at the end of March. During that time, when I came home from work I did not stop talking about the health service because my wife is a consultant histopathologist. If my children felt that when their aunts and uncles came at least that would be a relief, it was not. All of those who work outside the home in my generation, on both sides of the family, work in healthcare: in academic medicine; in laboratory medicine; in general practice; in dermatology; in psychiatry; and in child healthcare. It runs through our family’s veins in this generation. When I retired last year at the age of 55, I did so with a very heavy heart because in the early years I could see that in the area that I was committed to—people with mental and emotional disorders—every year I could look back and say, “There was a little bit of improvement this year. Things are moving forwards a little bit. There was a little bit of better care for the people who need it”, but that was not the case in the last years.

The noble Lord, Lord Owen, in a very powerful speech, rightly said that the health service will always be a rationed service because there is an endless possibility of using resource, but he then went on to say that people trust the health service because it is always fair. I wish that were true. For those who live at a considerable distance from the metropolis, for those who have certain kinds of disorder, for those who are very young, as we heard yesterday in terms of child and adolescent services, and for many of those who are old, there is not an entirely fair distribution of resources, so we must always be thinking about how we can make it better, and I know noble Lords would not disagree with that.

The sense for me was that things were not improving. The sense was of low spirits. It is an anxiety that I detect in the many people who have contacted me by e-mail and letter and in the many speeches in your Lordships' House in this debate. Why are people so anxious? Is it just because every time there is talk about making any change in the healthcare system people get anxious? Look what happened to Hillary Clinton and President Obama when they tried to address the healthcare requirements in their country and, frankly, make it better and a little bit more like what we have been privileged to have in our country—yet they found that people were terrified even by improvements in service. Perhaps that is part of it. My noble friend Lord Fowler has identified how every attempt by parties on either side has always been met with anxiety. Some people would suggest that we are receiving this deluge of messages because campaigning organisations now have the capacity to deliver them with enormous sophistication and speed. Maybe there is some truth in that, but it would be wrong to think that it did not represent a real anxiety and concern.

Why are there these anxieties from, for example, clinical colleagues? We need to go back a little. When general management came in, it was not Roy Griffiths’s intention to move away from involving clinicians in management. He subsequently made that clear in the early 1990s. He did not want a separate profession of managers, but I am afraid that many of my medical colleagues, and other clinical colleagues too, said: “We do not need to get involved with that. We will just get on with the clinical work, which is really what we want to do”. It is a seductive argument. Many managers also thought that it was much easier to manage if these people did not keep coming up with difficult clinical conundrums for them to address.

Over many years it got to a point where many doctors and other clinicians felt that they had no way into the management. That was one of my problems. I was left on an evening with a psychotic, suicidal patient whom I knew could not be managed in the community, but as a doctor I could no longer admit them to a hospital bed without going through an administrator who knew nothing about the patient and nothing about the situation, yet was telling me I had to keep them in the community and manage them however I could.

That has left doctors in such a position that—even though the previous Government put lots more money into the service, for which I commend them, and increased the salary of doctors, for which I guess they are to be commended to some extent—it did not improve output and efficiency. It did not even improve the morale of doctors. Most people of my age—I am 56—want to retire early from the National Health Service because they feel impotent to make the kind of changes that they want.

How do we address that? We find a way of bringing back together clinical involvement and the management of the service. Management is not a dirty word, but clinical experience and involvement is necessary if it is going to be good and effective. Not everybody will welcome that. It is much easier for a doctor just to go to his clinic and have no sense of responsibility for the implications of his clinical decisions, either for his particular patient or for all the rest of the patients and community. However, I am afraid it is the responsibility of clinicians to do that. It will not be easy for managers. I am sure they are happier whenever clinicians stay at bay, but these are issues that have to be addressed. We have to face their difficulty if we are to have a better health service.

Another dilemma was that things became more and more centralised, with more targets, regulations and directives coming from the centre, to address these problems. But many of them cannot be addressed from the centre. You have to involve local people—patients, carers and elected representatives. That is why the purpose of this Bill is to get clinicians back involved with management, localities, patients and carers through health and well-being boards, HealthWatch and other facilities involved in the process. And yes, colleagues should also compete with each other, not on the basis of price but—as the noble Lords, Lord Warner, Lord Darzi and Lord Birt have made clear—there is a value in people measuring themselves against their medical and clinical peers to see whether their performance and the production of their service is the best it can be.

I see the noble Baroness, Lady Thornton, shaking her head. She approached me some time ago in the run-up to this Bill to ask if we could get together and have some workshops and seminars to make noble Lords aware of all the issues. Some colleagues said it was a trap and I should not get involved—that the noble Baroness was trying to split the Lib Dems off from the Conservatives. I said I did not believe that and that she genuinely wanted to achieve familiarisation with all the issues, almost as a kind of do-it-yourself pre-legislative scrutiny. We got involved together and it was useful work. So when she said in her opening speech in this debate that there were a series of things she welcomed and would go on to discuss in Committee, I thought it was absolutely wonderful. Then she said that she would support not having a Second Reading. I thought that it would be a bit difficult discussing them in Committee if we did not actually get to a Committee.

However, that is what we have to do. We have to get to Committee to make sure we make the best possible Bill. What would happen if it was tossed out? What would be the message to the people in the health service? No clarity, no direction, no possibility of actually approving it on the Floor of Parliament. Some people have said that we do not need a Bill and many of the things could be done away from the Floor of the House. However, then there would not be good scrutiny or the facility for proper debate that people could engage with. Some of these changes also require legislation. It is extremely important.

The noble Lord, Lord Owen, and a number of colleagues have said that a number of constitutional questions need to be addressed. That is true. There are constitutional questions that have not been touched upon. Noble Lords would not expect me to ignore the fact that, when the health service was founded, there was a United Kingdom with a single health service and a little side-bar to Northern Ireland. Now there are four health services. There have been constitutional changes that have to be addressed, but this debate shows us that the richness and understanding of the whole House is needed to address these constitutional questions. As the noble Lord, Lord Owen, made clear, it is not possible to determine how long a Select Committee might meet and it could drag things out over a considerable period.

I appeal to colleagues that we get on with our business, which is not to defy the other place but to scrutinise the legislation ourselves together on the Floor of the House. I have one final request to my noble friend. It is crucial that he makes clear when he speaks that the Secretary of State—not someone else—will retain the responsibility and the accountability and be the ultimate guarantor of a National Health Service that we can all be confident in, not anxious about its future.