National Health Service (Pharmaceutical and Local Pharmaceutical Services) (Amendment) Regulations 2017
Lord Hunt of Kings Heath Excerpts(6 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
That this House regrets that the National Health Service (Pharmaceutical and Local Pharmaceutical Services) (Amendment) Regulations 2017, in delaying the review of the regulations governing the provision of community pharmaceutical services, do not prevent the closure of community pharmacies resulting from the budget cuts in 2016–17 and 2017–18 and changes to the way the funding is distributed (SI 2017/709).
Lord Hunt of Kings Heath (Lab)
My Lords, I beg leave to move the Motion standing in my name on the Order Paper. I so do because I am very concerned at the reduction in community pharmacy funding, at the very time when we need this precious profession to take on ever more responsibilities. In opening this debate, I take the opportunity to pay tribute to Mr William Darling CBE, the youngest ever president of the Royal Pharmaceutical Society, who died earlier this year. I had the pleasure of working with Mr Darling over many years in the NHS; it was he who brought home to me the hugely valuable role that community pharmacies play in the UK. I, the profession and the public will be ever grateful to him for his immense services.
I should also say by way of introduction that the Secretary of State, under current statutory requirements, was expected to initiate a review of the pharmaceutical and local pharmaceutical services regulations 2013 by 31 August this year. He has not done so because, according to the Explanatory Memorandum, the Pharmaceutical Services Negotiating Committee sought to judicially review the Secretary of State’s decision on pharmaceutical spending and the department decided to await the outcome of the review. Let me say at once that I do not object to that at all or, therefore, to the order. What I object to is the way the department has dealt with the profession over the whole question of funding.
I find it remarkable that a Conservative Government are effectively undermining both patient choice and the role of SMEs in their approach. On patient choice, it was clearly stated by Ministers at a meeting of the All-Party Pharmacy Group last year that the intention was to reduce the number of community pharmacies in this country. Remarkably, the department feels that there is too much choice for patients in our high streets. In effect, the change to funding they are making is reducing the number of pharmacies. The judicial review ruled in the department’s favour, but nevertheless established the legal principle that it is the duty of the Secretary of State to always bear in mind health inequalities when making judgments. The problem in relation to community pharmacy cuts is that the department has not done so; nor does it deliver the more clinical and effective approach that it said it wanted in its letter to the PSNC back in December 2015.
Community pharmacies are the most accessible of all healthcare services. Last year, they had, on average, 137 visitors a day, gave 281 medical reviews and dispensed approximately 87,000 prescribed products. My concern is that the cutbacks or reforms will have a painful impact on thousands of people and therefore need to be thwarted as soon as possible. By reducing the contribution that community pharmacies can make, there is a risk of an increased burden on already pressed GPs and A&E departments.
I remind the Minister of a PricewaterhouseCoopers analysis commissioned by the PSNC in England in 2015. It estimated that community pharmacies contributed £3 billion in value to the NHS, its patients, the public sector and the wider economy. This included £1.1 billion in cash savings for the NHS, £600 million in benefits to patients and £242 million saved in avoided NHS treatment costs. It is rather short-sighted to undermine a profession that can give so much to patients and relieve some of the pressure on a system that, overall, is really suffering at the moment.
The majority of community pharmacies’ funding comes, of course, from the NHS and is used to fund their premises, staff and all other operating costs. My understanding is that this funding was reduced by 4% in 2016-17, with a further reduction in 2017-18, making a total 7.5% drop from 2015-16. Some pharmaceutical contractors claim that the payments to them have been cut by as much as 20%. We know that the Government have brought in some reforms—combining dispensing fees into one, a special funding scheme for pharmacies in isolated areas, a scheme for high-performing pharmacies and a pharmacy integration fund—and I welcome those payments. The problem is, they will not ameliorate the impending crisis faced overall by many community pharmacies.
One of the reasons given by the Government is that they think there are simply too many community pharmacies in some parts of the country. It often seems to me that the Department of Health lives in a world of isolation, ignoring general government policy. I had rather thought that the Government were in favour of consumer choice and therefore having more community pharmacy premises on the high street would be a good thing, not a bad thing. No doubt the Minister can enlighten me on the Government’s view on that matter.
One has to be clear that although Ministers have said they are worried about the number of community pharmacies, the reality is that those cuts will actually affect mainly the smaller pharmacies, which tend to be in the deprived areas. This is the real concern here. The fact is that there is financial instability in the sector. The reduction in NHS funding has led to pharmacies having to face worryingly high and unexpected wholesale bills if they want to maintain an adequate level of stock, which clearly they need to do. They face the potential prospect of banks withdrawing credit because income covenants have not been reached, due to the inability to find a source of credit to cover the aforementioned bills.
In a desperate attempt to keep the business viable, community pharmacies are reducing their services to patients. Because they are having to reduce their staff costs and make staff redundant, they are reducing opening hours and apparently cutting some free services, such as delivering prescriptions to the home, which particularly benefit older people and those with long-term degenerative conditions. We know that community pharmacies were under significant financial strain this summer. We are concerned that as we move into the winter, that financial strain will grow. Of course, it is mirrored by the pressure on the NHS at the moment.
Last year community pharmacies provided 950,000 flu vaccinations. There is a reason for this: it is very convenient. You do not have to wait until the surgery tells you that you can come in one Friday when it is able to give you a vaccination. You can go into a pharmacy and have it immediately. Already this year, community pharmacies have given out 500,000 flu vaccinations—a figure that could double by December. It is just one example of community pharmacies’ huge potential. They could do more—much more—if they were fully engaged in the kind of planning we need to see at local level.
Last night in your Lordships’ House we debated sustainability and transformation programmes. I do not think many STPs have mentioned the contribution that community pharmacies could make to providing services which, otherwise, other bits of the health service will have to. It is a pity because I believe this profession could provide much more support for the system and for patients in the future. I am worried about the impact of the financial reductions that have been made. I hope through this debate to at least encourage the Government to think again. I beg to move.
Baroness Jolly (LD)
My Lords, I am happy to lend my support to this regret Motion. For many years, pharmacies have been the lynchpin of our health service. Before the NHS was formed, the pharmacist was the expert who those without means went to for advice and medicine. With the advent of the NHS and a free general practice service backed up by free prescriptions, the role of the pharmacist began to change. The last couple of decades have seen further change. Pharmacists began to reassert their role of offering advice to customers, being commissioned locally and nationally for public health and medicines support.
In 2015 the Government proposed 6% cuts to the pharmacy service and suggested the ways in which this might be achieved, including a reduction in the number of pharmacies and the adoption of internet supply. This was solely a budgeting exercise and lacked any evidence base or indeed impact assessment. The Chief Pharmaceutical Officer suggested that we have 3,000 too many pharmacies without offering supporting evidence.
Apart from the pharmacy being a place where we collect our prescriptions and buy over-the-counter painkillers and cough medicines, the public ask advice from the pharmacist on things they would not trouble a doctor with. Women access emergency hormonal contraception, while needle and syringe programmes are managed, as is the supervised consumption of medicines.
Pharmacies offer specific public health services, support with self-care and medicines support, including checking prescriptions and the New Medicine Service. In addition, they arrange deliveries of prescriptions to patients. That might be stopping in some parts of the country but in Cornwall it is ongoing. In 2015, there were nearly 12,000 community pharmacists dispensing a billion prescription items to the value of £9.3 billion. They are funded by both local and central government to provide essential, advanced and local services.
The PSNC was so concerned at the lack of evidence base for the Government’s decision that it commissioned PwC to look at 12 specific services and determine their net value. In 2015, more than 150 million interventions were made, along with 75 million minor ailment consultations and 74 million medicine support interventions. They also served more than 800,000 public health users, for example with supervised interventions and emergency hormonal contraception. PwC determined that patient benefits totalled £612 million, that the wider societal benefits were £575 million, and that the NHS benefits to the tune of £1,352 million. There are other benefits to the public sector of £452 million. That is a total just shy of £3 billion of benefit which, in one way or the other, comes to us all from having community pharmacists. That is just the financial benefit and does not include the benefit of Joe Bloggs or Mary-Jane being able to walk in and ask their pharmacist a quiet, discreet question and get support, help and advice.
I suggest that when not only our GPs but our A&E services are under immense pressure from patients presenting with conditions that do not require prescriptions or that level of advice, this is not the time to take away from the high street the welcome and expertise of the neighbourhood pharmacist. Will the Minister persuade his colleague to stop, look at the evidence and protect these services which are so vital to the communities they serve?
Lord Hunt of Kings Heath
I am grateful to the Minister, and I echo the welcome given to the noble Baroness, Lady Jolly, in her position as Lib Dem spokesman on health. I thank the noble Baroness, Lady Walmsley, for her sterling work over the last couple of years—we very much enjoyed working with her, particularly when we combined to defeat the Government on a number of occasions. Long may that continue.
I very much welcome the response from the noble Lord, Lord O’Shaughnessy. The review is very important, and I hope we will have an opportunity to debate these important matters. I am not sure that he is really in a position to talk about the deficit any more. I would refer him, perhaps, to the comments of the former Chancellor, Mr Osborne, about who exactly was responsible for the financial situation that we as a Government found ourselves in. I shall not carry on in that mode, but I think the Government’s mantra needs perhaps to move on.
Efficiency savings are one thing, but cuts to community pharmacies are another. That is where we really disagree. On the issue of closures, Mr Alistair Burt went to the All-Party Pharmacy Group in 2015 when these proposals first came out and said that he thought that thousands of community pharmacies would close. There is no question that cash flow is a real worry. I am very interested in what the noble Lord said, and it would be good to know the outcome of those discussions, but I can tell him only that in the sector there was very real concern about this.
I come to SMEs. The risk is that it will be the very small multiple, individual community pharmacies that will be the most affected. I do not know whether the Minister knows, but in 2015 Matthew Hancock for the Government announced an ambitious target to get more small businesses working on central government contracts. The target was set that, by 2020, £1 in every £3 by government would be spent with SMEs. I guess that there is a question of definition here, of the extent to which that is regarded as a central government target or not. The point is that last week Mr Damian Green in the Cabinet Office announced that the target is being missed by a considerable margin and that it has gone from being a hard target for 2020 to an ambition for 2022.
What is happening here today is symptomatic of the Government’s approach to SMEs. They say that they are important, but the actions of individual government departments are to make it more difficult for them to do business. This is where I am concerned that the cumulative impact of these cuts will have a damaging effect on the small independents, which would be a great pity.
The noble Baroness, Lady Seccombe, said that she was fortunate to live in Warwickshire, and I endorse that—it is second only to God’s own city, of course. I was delighted to hear about the opening of a new community pharmacy in the premises of a bank. That is good, and I welcome the four schemes to which the noble Lord referred. I have no objection whatever to that, but the problem is that overall the package of proposals reducing the funding will put many community pharmacies at risk; they will often be in vulnerable areas and will reduce patient choice. The point that I put to him is that I do not think we are making as much use of community pharmacies as we could.
The 2012 changes took many community pharmacies away from the table. With PCTs, they were more around the table. CCGs at first did not have the responsibility for community pharmacy contracts, although I think they have more influence now. But we have to be realistic: GPs are not always as supportive of community pharmacies taking on more work as one would wish them to be. Some of that is about finance, and where it goes. Alongside the issue of funding, which I hope will be reviewed, I hope the Government will see how we can ensure at a local level that community pharmacies are heard more, have more influence and contribute much more, because I believe they have the professional skills to do so.
Finally, it was a great pleasure to hear the noble Lord, Lord Deben, talk about the impact of this measure on the environment and climate change. We sometimes forget that the desire of the NHS to centralise many of its services can lead to more car miles. I hope we will take that factor into account in the future.
This has been a very good debate. One thing on which we are all united is the role of community pharmacies, which is a very good thing indeed. I beg leave to withdraw my Motion.
Hospitals: West London
Lord Hunt of Kings Heath Excerpts(6 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to my noble friend for bringing to the House’s attention the concerns of residents about the future of Charing Cross Hospital. Although my noble friend has focused on issues in west London, the kind of debate that we are having is reflected up and down the country, as each area develops its sustainability and transformation programmes. My noble friend Lord Warner has outlined some of the issues with STPs. I particularly share his view about the loss of a London-wide SHA in terms of trying to lead change in the metropolis.
If the Minister thinks that STPs are going to get this Government out of trouble on the NHS, he should think again. Essentially, the wording may be different but, actually, when you look at them, they are previous plans dusted down and regurgitated in new language. At heart they are based on the belief that think tanks have had for 30 years that, if you invest in prevention, community and primary care, demand for hospital care will reduce. The evidence for that is very thin indeed. The fact is that there have been any number of attempts to implement those kinds of programmes, but of course the investment has never been of the order required out of the hospital setting, because the programmes almost invariably rely on acute bed closures to fund future investment. That is particularly difficult in current circumstances. Clearly, that is the case in west London.
The STP document really goes back to the 2012 consultation. My noble friend described that; the proposal was to reduce the number of major hospitals in north-west London from nine to five in a programme called “Shaping a Healthier Future”. That was subject to a searching independent review chaired by Michael Mansfield QC. My noble friend explained to the House some of the conclusions of Mr Mansfield’s review.
Despite that, the STP has decided to plough on with the proposals before us tonight. It is clear, reading between the lines, that the STP’s overriding motive is financial. It says that a clinically and financially sustainable system cannot be delivered in west London without reconfiguring acute services. Although it says—and the noble Lord, Lord Warner, is right—that no planned changes are to be made to Charing Cross’s A&E services before 2021, the fact is, because of the decision over the land closure on the Charing Cross site, there is a risk that, once the public and staff become uncertain about the future of the hospital, people will leave, retention and recruitment will become more difficult, patient confidence will be lessened, and the hospital will become blighted. This is the real risk for Charing Cross.
What is happening in west London cannot be divorced from general concerns about capacity in the NHS. We have debated twice in the last week the King’s Fund report, which identified that we have fewer acute beds in this country than any advanced healthcare system. We could of course use them better—we know that we could improve the way that discharge procedures work—but the fact is that it would be very risky indeed to go ahead with further reductions in acute capacity when the number of patients, particularly frail, older people who need the kind of care that hospitals provide, is going to grow. The King’s Fund therefore concluded that further significant reductions in bed numbers are unrealistic, which ties in with the Naylor review that I think my noble friend referred to.
We have not had much opportunity to debate STPs, but I point the Minister to the recent IPPR report, which found a deficiency of leadership within STPs and that funding was the overwhelming pressure on them, to the expense of any other action that they take and, of course, that there are no statutory powers with which to deliver the reform agenda as a result of the fragmentation created by the 2012 Act. The King’s Fund analysis of STPs in February 2017 concluded that, despite all the warm words about new models of care, they are driven by financial imperatives. I remind the Minister that a survey of 172 NHS trust chairs and chief executives, carried out last autumn, found that achieving financial balance was seen as the most important issue in STP land.
It is clear that the north-west London STP is financially driven. The noble Lord, Lord Warner, referred to the London STPs as a whole and the “do nothing” deficit of over £4 billion by 2021. The figure in the north-west London STP puts its funding gap at £1.113 billion. The STP then goes on to make the highly questionable claim that, through a combination of normal savings delivery and the benefits to be realised through the STP proposals, this huge deficit can be turned into a £15 million surplus. I hope that Ministers realise that this is a fantasy. It is a requirement, because the system bullies STPs if they do not come up with financial balance. But I do not know anybody who thinks that this STP could deliver anything like a £15 million surplus by 2021—it is a complete and utter fantasy.
The STP goes on to talk about the need to transform general practice and for,
“a substantial upscaling of the intermediate care services … offering integrated health and social care teams outside of an acute hospital setting”.
Well, every STP says that. The question I put to the Minister is: how on earth is this going to happen? Clearly, it expects general practice to take on greater responsibilities, yet only a few days ago the Secretary of State acknowledged the overload on GPs. Many practices are now closing their lists to new patients, many GPs are choosing to go part-time and others are retiring. I wonder how on earth this STP envisages that by 2021 the GPs in west London will miraculously suddenly develop a new drive and energy to provide the kind of additional services that are required.
What about intermediate or step-down care? Unbelievably, we hear that while these STPs talk about the importance of intermediate or step-down care, they have proposals to close community hospitals. Again, I ask the Minister: where on earth is the confidence that the STP will deliver what it says to bring down the deficit, reduce acute capacity—clearly, that is what it will do—and provide the kind of enhanced service that it talks about?
Ministers tend to hear what they want to hear, as we all do. However, the word on the street, when one talks to any senior person locally who is not in the earshot of one or other of the regulators, is that STPs are a mere flight of fantasy designed to get Ministers off the back of the NHS and give it a little more time until somebody comes up with something new that Ministers will latch on to as the next solution for the NHS. STPs will not work. We all know they are not going to work.
The risk is that Charing Cross Hospital becomes absolutely blighted. I agree with my noble friend Lord Warner, who says that in the light of previous experience, whatever the STP says about Charing Cross, if anyone thinks that all this is going to be done by 2021, they need to think again. The risk is that poor old Charing Cross will be stuck in this awful blighted position, good people will leave and it will become increasingly difficult to manage this hospital. That is why residents are right to be concerned and why we look to the Minister for reassurance tonight.
Medical Examiners and Death Certification
Lord Hunt of Kings Heath Excerpts(6 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord O'Shaughnessy
The noble Lord is quite right to highlight this point. There have been calls for medical examiners since the Shipman inquiry; those were also endorsed following the inquiry into Mid-Staffordshire. Our intention is to ensure that, with planning time, the system can be introduced by April 2019, which is why the consultation and the regulations needed to underpin the planning for the system will be produced in short order.
Lord Hunt of Kings Heath (Lab)
My Lords, I chaired a foundation trust where we trialled the medical examiner role. I commend to the House the value of having a senior consultant able to talk to relatives about concerns, drawing the attention of fellow clinicians to issues relating to practice but, above all, safeguarding the public against tragic and appalling actions such as those taken by Harold Shipman. Does the Minister expect every part of the NHS to be covered by medical examiners by April 2019, or is that the start of the rollout? I hope that it can be extended throughout the NHS by that date.
Lord O'Shaughnessy
The noble Lord is quite right to highlight the pilots; indeed, early adopters have followed in their wake and have provided a much better service. The intention from April 2019 is for the service to cover the entire country, but it is most likely to start in secondary care and then move out into primary and community care.
Care Homes: Hospital Discharges
Lord Hunt of Kings Heath Excerpts(6 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath (Lab)
My Lords, on behalf of my noble friend Lord Dubs, and with his permission, I beg leave to ask the Question standing in his name on the Order Paper.
The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)
My Lords, information is collected on the number of bed days occupied by patients waiting to be discharged from hospital. The latest available information estimates that on an average day in August this year, 1,574 beds were occupied by patients waiting to be discharged to nursing or residential care homes.
Lord Hunt of Kings Heath
My Lords, that is a big number. I understand that over the last financial year, about 2.3 million days were essentially lost because of transfer delays. We know the number of nursing home places has been reduced by 4,000 over the last two years; we know social services are under pressure; we know the health service is not using housing services sufficiently. Why does the health service seem determined, in its STP plans for each area, to rush into yet further plans to cut acute capacity when hospitals are under so much pressure at the moment?
Lord O'Shaughnessy
I am glad the noble Lord mentioned the number within a year. He will be interested to know, as other noble Lords will, that the number of delayed transfers of care went down year on year between August 2016 and August 2017. That is good news. That reduction has been caused by greater funding in that period and a greater focus on accountability, particularly for local authorities and trusts together. In terms of acute capacity, the number of beds has been relatively stable recently and NHS England has introduced a new test for any reconfigurations that adds a fifth category, looking at the number of beds available in any given area.
Health and Social Care
Lord Hunt of Kings Heath Excerpts(6 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
To ask Her Majesty's Government what is their response to the conclusion of the Care Quality Commission in its annual state of care report that 1.2 million adults are not getting the care they need as the health and social care system is “straining at the seams”.
The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, the Government are committed to improving the quality and availability of adult social care in England. The Care Act 2014 introduced, for the first time, a national eligibility threshold for care, and the Government are increasing funding for social care by £2 billion over the next three years to meet growing demand.
Lord Hunt of Kings Heath (Lab)
My Lords, two days ago, in answering a Question on this report, the Minister spoke of a 20-year search for consensus on the funding of long-term care. We had consensus about the Dilnot proposals, which capped the amount a person would have to contribute to their own care. The Opposition co-operated with the Government in getting the 2014 Act through Parliament and the Government announced the cap at £72,000, but then they postponed its introduction and in the election they effectively abandoned it. No explanation has ever been given to Parliament about why the Dilnot proposals have been abandoned.
Lord O'Shaughnessy
There has been a 20-year search for a solution to this problem. It was not me who said that; it was the chief inspector of hospitals, who said:
“I think the one thing I regret is that 15 or 20 years ago when we could see the change in the population the NHS did not change its model of care”.
This is something we have all grappled with, but we have not yet come up with the solution that we need. That is why, through this consultation, we will be looking not just at finance but at quality of care, variation and sustainable staffing to rebuild the consensus that we need to move forward.
National Health Service
Lord Hunt of Kings Heath Excerpts(6 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord O'Shaughnessy
The noble Lord makes an excellent point. It is true to say that in this country we are very good at creativity and innovation but not always very good at spreading it round. In a way, that is one of the biggest challenges the NHS faces. I would merely highlight a couple of areas where the NHS is working well. The first is the test beds programme, which is working with industry, taking new innovations and spreading them round. Secondly, we have committed to publishing our response to the accelerated access review by the end of the month on how to make sure the most transformative drugs, devices and therapies are taken up throughout the system.
Lord Hunt of Kings Heath (Lab)
My Lords, can I ask the Minister about the sustainability and transformation programmes? Has he seen the report issued by the King’s Fund last week that said we have fewer acute beds in this country than almost any comparable country? It also pointed out that the plan of many STPs is to reduce acute care numbers even further. I fully accept that we could use our beds and discharge patients more effectively, but the King’s Fund warns that STP plans to further cut acute beds are unsustainable. Will the Government consider that?
Lord O'Shaughnessy
Simon Stevens, the head of the NHS, made an important point several months ago about reconfigurations. Any reconfiguration has to meet four criteria: clinical need, popular support and so on. He added a fifth, which was about taking out beds. Those STPs are judged on their ability to meet the changing needs of their population. If there are proposals to take out beds which mean that those needs will not be met, such reconfigurations will not be accepted.
Health: Sepsis
Lord Hunt of Kings Heath Excerpts(6 years, 7 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord O'Shaughnessy
The noble Baroness is quite right. Trusts are now incentivised to report incidences of sepsis and their performance against these quality standards. That is happening. Unfortunately there is still variation within the system. That is why the documents that came out yesterday are so important. For the first time, we have an operational definition of adult sepsis. Clearly, that is critical to making sure that it is spotted in time.
Lord Hunt of Kings Heath (Lab)
My Lords, the action plan is very welcome. It seems apparent that when patients come through, particularly from A&E, they are not recognised as having sepsis. Clearly, there is an issue about health service staff not recognising the symptoms or understanding the scale of the problem with sepsis. The Minister will be aware of a 2015 report by the national confidential inquiry which criticised the way coding is designed so that, in fact, sepsis does not appear as the prime responsibility for a death. The Government have been asked to look at coding. If it is not in the action plan, will the Minister look at this?
Lord O'Shaughnessy
That is absolutely right: there was an issue with coding. The noble Lord will be pleased to hear that from April this year NHS Digital published new guidance on coding for sepsis to deliver exactly the kind of improved reporting he wants.
Care: Older People
Lord Hunt of Kings Heath Excerpts(6 years, 7 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath (Lab)
My Lords, this has been a short but very interesting debate, and I am grateful to my noble friend and to the noble Baroness, Lady Greengross, for the way in which they have addressed the dilemma that undoubtedly faces us, not just in relation to deferred payments but more generally in relation to funding appropriate social care.
It was interesting that my noble friend Lord Lipsey took us back to the royal commission. Over nearly 20 years we have seen a continuing debate, any number of reports and some measures on the statute book, yet we still seem no nearer to solving the conundrum of how to fund social or long-term care. I have to agree with my noble friend: there are those who argue that social care should be free at the point of use but I regard that as a fantasy. It is very unlikely that over the next 20 years any Government will in reality be able to afford it.
The problem is that, even though Governments have accepted some proposals in principle, when those proposals are costed, in reality they step back from them, and we are left in a hiatus of a completely arbitrary and unfair system. The noble Baroness, Lady Greengross, referred to this problem, which is, if you like, a boundary dispute between such care being free at the point of use in the NHS and means-tested personal social care. Understandably, tensions often arise within NHS hospitals as families try to resist an individual who is receiving care which is free at the point of use in the NHS ending up in the care system, where a means test takes place. I do not think that anyone can say that we have a fair system. In my view, it is equally unfair that self-funders in care homes effectively subsidise local authority-funded residents. Speaking from where I am, I suppose you could regard that as a kind of regressive taxation. It is so arbitrary and so unfair that I believe it is very difficult to justify.
It seems to me that either we try to solve this problem or millions of people over the next 30 years will carry on living in what is sometimes abject misery, uncertainty and fear about their financial future and about their families, to whom they would like to pass on some income where they are in a position to do so. If one were putting odds on it, one would say that at the moment one sees very little likelihood of anyone coming forward with a cohesive package of things which can be funded, which is thought to be fair and which would get public support, although clearly that is what we seek to do.
The deferred payment arrangement is very disappointing. Clearly, David Cameron’s pledge was widely welcomed and was seen to be progressive. My noble friend talked about the increased estimate that the department gave, going from £4,000 to £12,300, but in any case £12,300 seems a pathetic amount. We seem to have a complete failure in the marketplace. There is no easy way for people to translate a housing asset into care home support while retaining the ability to leave some of their resources to their loved ones when they die.
A number of organisations have commented on what has happened to the deferred payment scheme. Clearly, bringing in such a tight means test undermined what we thought Mr Cameron had been offering. The point was well made by the noble Baroness, Lady Greengross, that we need, at the very least, to see how the scheme is working. I know that the Minister, in an answer to my noble friend in March, said that the department is continuing to monitor the success of this scheme and that an update of these deferred payment schemes across all local authorities will be available later in the year. I hope that he may be about to give us a progress report on that.
I have had evidence from Royal London and some of the charities. Royal London, for example, looked at the inconsistency between local authorities. It said that despite access to deferred payment agreement being a legal right—I am not sure that that is quite how I read the Act, but we know what it is getting at, because it is in the Act—10 local authorities told Royal London they had not entered into a single agreement since the scheme was introduced in April 2015. That is a pretty poor show. I ask the Minister: in light of the work that we hope will be published later in the year, what are we going to do about local authorities which simply refuse to operate the scheme at all?
My final point comes back to the Government’s manifesto proposal, their retreat and the intention set out in the Queen’s Speech to consult on how we improve the social care system. I refer the Minister to the Care Act 2014, a marvellous piece of work. It was consensual, it came from Dilnot and we spent weeks in your Lordships’ House in a consensual approach, yet it is dead and gone. There are some bits in it that are good, still, and which I very much applaud. It is a puzzle that the Government have never explicitly said whether they regard the whole thing as dead and gone and that is why they put the new proposals in their manifesto.
What is the consultation going to be about? Will it be about making the scheme that the Government put in their manifesto slightly more generous—raise the level, reduce the floor—or are they prepared to actually look again at Dilnot, which everyone said was a sensible approach, even if the figures may not be the right figures? Of course, the Government’s rate was much less generous than the original Dilnot proposal, but at the end of the day, whatever information the Minister can give us about the consultation, which we hope can be comprehensive, would be very welcome.
The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)
I thank the noble Lord, Lord Lipsey, for bringing forward this debate. I know that he has been a tenacious proponent of deferred payments and of reform of the care system. I pay credit to him for that—it is very rare that we have a debate where I can thank everyone individually, so I also thank the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. Unfortunately, I did not have the opportunity to know Lord Joffe, but I know how much the House has mourned his passing and have noted the contribution he made. I want to acknowledge that as we talk about this issue.
We have had a bit of a trip down memory lane today, although others might call it Groundhog Day. We seem to be going over this issue repeatedly without properly resolving it. Of course it is not easy; the ageing population is probably the greatest social challenge, at least the greatest domestic social challenge, that we face. It is not one that we have grappled well with in the past, and that is true of Governments of all hues. That is for a number of reasons, including obviously the money and the changing nature of society, particularly working patterns. What has been highlighted by all noble Lords is the interplay between the taxpayer funded, free at the point of use National Health Service and a social care system that works on a different basis. It means that any attempt, whether it is a Labour-proposed national health and care service or through integration at STP level, is made very hard, particularly as things move. So I do not underplay the importance of this issue, and, of course, as we think about the narrower issue of DPAs, it has to be set in a context of what is happening elsewhere.
In the short run, more money is going into local authorities to try to provide the social care that is required. It is particularly focused on delayed transfers of care. That has some interplay with this issue precisely because of the concerns about moving from one part of the health system into another, something mentioned by the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. It is about the difference between continuing healthcare and social care and the quite radical consequences of the different funding situations for families that are necessarily trying to navigate through it at a time of stress. It is a challenge, but we are trying to address it through this additional funding.
In the long run, as noble Lords have pointed out, the intention is to bring forward proposals on social care reform for consultation. The objective in the consultation—I am glad the noble Lord mentioned the Care Act—is to achieve the widest possible consensus. It should not be a completely open-ended “what shall we do” process, but it should try to put forward some proposals that, inevitably in the process of consultation, will change but will try to achieve some kind of consensus. The noble Lord, Lord Hunt, specifically asked about Dilnot. There was a lot of agreement around Dilnot, but I still come across people who think that Dilnot was the worst thing that could ever have happened. There is a more nuanced picture. If anything, that just underlines the importance of taking care as we try to build a consensus.
Moving forward to the specific issue of the debate, which is deferred payment agreements, as has been outlined, they are a means by which individuals can access equity in their home to pay for care without having to sell it, meaning that they do not have to sell their home in their lifetimes. As the noble Lord, Lord Lipsey, pointed out, DPAs have been in existence for a number of years and the issue was addressed in the Care Act precisely to attempt to create a more thoroughgoing national system to replace what had obviously been quite a patchy one. Even though some elements of the Care Act have not been taken forward, in particular the social care reform agenda, as has been pointed out, the Government took the decision to move ahead with the implementation of DPAs in order to fulfil the pledge of the previous Prime Minister—to whom both he and my noble friend Lady Sugg owe their position in this House—that people should not have to sell their homes in order to go into care during their lifetime.
In terms of the actual performance of the scheme, we had a year of voluntary data collecting for 2015-16, although it is now compulsory. A helpful note tells me that the next iteration of the data is 2016-17, and NHS Digital should be publishing them towards the end of October. We will then have a really thorough look at what is happening. The previous year showed that about one-third of local authorities responded, so it was only a partial picture. Nevertheless, it was disappointing that fewer DPAs were agreed than had been anticipated. Indeed, the noble Lord, Lord Lipsey, pointed this out as likely to be the case in the debate on the regulations. I will come to what we can do about it, but these are of course a means to an end in themselves. This is why I am not convinced that having a target is appropriate because it is about enabling a choice and adding to the choices that are available for people by providing a means of deferring payment until after death. There are many reasons why people may not choose a DPA, and of course the private market is evolving all the time. But we need to understand why there were fewer DPAs than anticipated and to ensure that those who are eligible for them can access one. If there are local authorities where not one has been signed, that suggests that something is going wrong at the local level in terms of communication between the local authority, individuals and the social care sector. So we need to know why that happens.
Lord Hunt of Kings Heath
In the noble Lord’s very helpful response, he referred to the private market. He mentioned that not everyone thought Dilnot was the right answer, because one of Dilnot’s aims was, by capping costs, for the insurance market to come in when they have been reluctant to. I wondered whether part of the consultation would seek to answer the conundrum of what could make the insurance market come into this area more enthusiastically. Clearly, that would be one way that we could solve some of the problems.
Lord O’Shaughnessy
The noble Lord makes a good point. I do not know if that will be laid out explicitly. We have talked a little about the manifesto and how it was a movable feast over the course of a weekend. We ended up with a floor and a cap. At the point at which you have a cap, in theory, you have an insurable product. It depends whether it is insured by the private market or the state, but that was clearly at the core of the Dilnot design. There was lots of disagreement about how you could take forward that principle, but I think it useful so that, in keeping with the nature of the market, you have a mixed economy of funding.
We have been talking to local authorities to understand why people may not be accessing DPAs. There are a number of barriers, such as lack of awareness, interest charges and administrative fees. We are considering what actions can be taken locally and nationally to raise awareness and understanding of the scheme. One example of that is that is the wide variation in administrative fees charged by local authorities. Clearly, it is important that those fees are not set at a prohibitive rate, nor that local authorities are or seem to be profiting from the fees. They are meant to be covering costs. However, I think interest rates provide quite a positive picture, because the interest rate is around a third of that offered by the standard equity release scheme on the market. With wider awareness, that would prove more attractive than it has done.
Regarding the eligibility criteria, £100,000 is a magic fee in this social care debate—even more so after the election. That was the point that the noble Baroness, Lady Greengross, made about the reform proposal and widening eligibility. There are two points I would like to make on this. First, the Government’s aim in establishing the scheme was particularly to ensure that people did not have to sell their homes, rather than run down other capital. I know that that is more limited than noble Lords might like, but that was nevertheless the aim of the scheme.
The second point is that, in expanding the criteria, a local authority should in theory be able to recoup its costs, but there may be some costs in taking on a wider group of qualifying people. There is always a balance to be struck, particularly in cash flow terms, between helping a group who are by definition better-off people, and fairness to local taxpayers. That is one issue that needs to be considered.
The noble Baroness, Lady Greengross, asked in particular about the deep dive that happened. She will be disappointed to hear that departmental protocol is that these are for internal use only, so I am afraid I am not in a position to share that information with her. It sounds like she has the detail on what happened anyway, so I am not sure that that would necessarily reveal anything that she does not know.
To conclude, it remains a departmental priority to make the scheme accessible to all those who are eligible and would benefit from it. We will continue to monitor the scheme and, once the data are published, may look at some of the ideas suggested by noble Lords on how to give this scheme more momentum. Clearly, the intention of it is not to be de minimis, but to reach the original target and more people beyond that. We are open to ideas on how that can be achieved.
Finally, any DPA scheme must in the long run fit into the wider context of social care funding and provision. That point has been well made in this debate. As the proposals come out for consultation, considering the interplay of DPAs and the overall funding environment will be critical in whether reforms are successful. I conclude by thanking the noble Lord, Lord Lipsey, again for tabling this debate and other noble Lords for their contributions. I look forward to working with them on getting consensus on real reform in the sector.
National Health Service (Mandate Requirements) Regulations 2017
Lord Hunt of Kings Heath Excerpts(6 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
That this House regrets that the National Health Service (Mandate Requirements) Regulations 2017, and the associated Mandate to NHS England, do not require that in 2017–18 NHS England meets its obligation to ensure that 92 per cent of patients are treated within 18 weeks of referral; believes that failure to meet this target is a breach of the rights of patients outlined in the NHS Constitution and of the statutory requirement laid out in the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012; and calls on Her Majesty’s Government to publish the advice they have received on the legality of their actions (SI 2017/445).
Lord Hunt of Kings Heath (Lab)
My Lords, I am moving this Motion because I believe that NHS England is failing to comply with its statutory requirement to ensure that a minimum of 92% of patients wait no more than 18 weeks for treatment from their day of referral. I believe that the Government are clearly complicit in that failure.
Governments often drop inconvenient targets when they are not being met but it is a little more unusual to see them airbrush one out of existence without any public acknowledgement, let alone report to Parliament, as has happened with the 18-week wait. This is one of the key targets for the NHS. It is important for patients to be treated promptly, and the target is also important as an overall barometer of the National Health Service, which is reeling from underfunding, rationing and a Government who are intent on wilfully letting standards slip.
Why have the Government allowed this to happen? Surely it rests with their lamentable failure to deliver on the key standards set out in the NHS constitution. We should look at their record. The current four-hour maximum A&E standard has been missed for the past three years, with performance deteriorating every year. The 62-day maximum treatment wait for cancer has been missed every year since 2013-14. As for elective care, the 18-week standard has not been met now for 16 months. Therefore, the Government are so lacking in confidence that they have just decided that they will drop one of the targets. This first came to light in March when, in unveiling his progress report on the five-year plan for the NHS, Simon Stevens, NHS chief executive, admitted that patients can expect to face,
“longer waits for operations such as knee and hip replacements in a ‘trade-off’ for improved care in other areas”.
The Government have been rather coy about this but the reality is that, behind closed doors, they agreed with Simon Stevens effectively to downgrade the 18-week standard. However, they forget to tell Parliament and the public that they had done so. Remarkably, there is no reference to that in the regulations we are debating tonight. The mandate for 2017-18 is equally silent on it. It is true that on page 19 of that mandate there is reference to the 18-week wait as a goal for 2020. But when you look at the list of deliverables for this financial year, it is completely missing. All we have, on page 20, is a vague reference asking NHS England to “meet agreed standards”. We should compare that with the 2016 mandate which says that NHS England is “required” to meet the 18-week referral for treatment standard.
Let us go back to the NHS England document of 31 March this year, Next Steps on the NHS Five Year Forward View. Chapter 7, on page 47, states that,
“over the next couple of years, elective volumes are likely to expand at a slower rate than implied by a 92% … incomplete pathway target”.
Those are wonderful words, which basically say that NHS England has dropped the 18-week target. Everyone in the NHS knows that to be the case. Not only is that letting NHS patients down, I believe that NHS England and the Government are in breach of their statutory responsibilities. The key standards are pledged in the NHS constitution and are backed up by legislation imposing a duty on NHS England to meet maximum waiting time standards. I refer noble Lords to Regulation 45 of the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012, which is headed, “Duty to meet the maximum waiting times standards”.
In July 2015, the Government explicitly stated that the NHS constitution,
“reflects a series of fundamental standards, below which care must never fall”.
Part 3 of the handbook to the constitution states a number of rights, including the right to start consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions. Therefore, it is my view that NHS England and the Government are required in statute to seek to achieve the objects that have been laid down, including the 18-week standard. The 2017 mandate that we are debating tonight does not include the 18-week target as a list of deliverables or requirements in 2017-18. The question to the Minister is why? I put it to him that the Government essentially agreed with NHS England to fail in its statutory duty to uphold the 92% referral for treatment target.
Lord O'Shaughnessy
That is the truth.
Next year the NHS turns 70. As my noble friend Lady Redfern said, it has a unique place in our society. The mandate to NHS England for 2017-18 goes further than ever before to ensure that we not only continue to deliver the best care and support for today’s NHS patients but also deliver the reform and renewal needed to sustain the NHS for the future. We know there is more to do, which is why we have put our commitment to support NHS England and the NHS in delivering the five-year forward view at the heart of the mandate. We will continue to do so. I hope that I have persuaded all noble Lords, including the noble Lord opposite, that their fears are unfounded, and that the noble Lord now feels in a position to withdraw his Motion.
Lord Hunt of Kings Heath
My Lords, that is one of the most remarkable speeches I have heard in your Lordships’ House. I have to say that if the Government really think that the NHS is in the healthy position that the Minister says it is, I feel very sorry for them and sorry for NHS patients. Talk to anyone on the front line and they will tell you of the pressures, of the hopelessness of the changes the Government made and of the Brexit impact on staff. The NHS is facing a critical time and to have this litany, this list of so-called achievements, does no good at all to the health service or to the credibility of the Government.
I shall make only two points. The Minister said at the beginning that the Government are still committed to the 18-week target, but towards the end of his speech he quoted the same words as I quoted, which made it clear, as Simon Stevens has made clear and as is made clear in Next Steps on the Five Year Forward View, that actually the Government have given up on the 18-week target this year. They have said that,
“elective volumes are likely to expand at a slower rate than implied”
by the 92% target. That was an open admission that the target is no longer set in stone. Talk to any chair or chief exec in the NHS and ask them whether the 18-week target is a firm target in this financial year and they will say no. Of course the NHS faces pressures. In the days of my noble friend Lord Reid the demographic changes were taking place just as fiercely as they are now, but he made a dramatic impact in reducing waiting times.
My point is this: if the Government believe it is so difficult to manage the health service in such a challenging time, they should be open and honest and say that the target has been taken away; but they have not been honest, they have not been open and patients will suffer. My Lords, I beg to move.
End of Life Care
Lord Hunt of Kings Heath Excerpts(6 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord O'Shaughnessy
I thank the right reverend Prelate for making that point. In Scotland there are different funding environments. I am aware of the 50% funding commitment from the Scottish Government. We are trying to make sure that CCGs in England not only have the funding they need by increasing NHS funding in real terms but that they understand how to spend it well for end-of-life care, and topping that up where necessary with central funds. So there is a big spending commitment there and with the new accountability framework we have a way of holding those CCGs to account for their performance.
Lord Hunt of Kings Heath (Lab)
My Lords, the Minister has talked about a new accountability framework but the fact is that the work that has been done so far shows that CCGs are simply not implementing the guidelines. What is the point of NICE guidelines if we cannot be assured that they are going to be implemented? I refer him to the NHS England mandate for 2017-18, which talks about developing a set of measures on end-of-life care against which CCGs will be judged. Can he assure me that the NICE guidelines will be fully part of those measures?
Lord O'Shaughnessy
It is important to point out that the NICE guidelines are not mandatory in and of themselves. What matters is that there is high-quality end-of-life care provided at the local level and indeed that CCGs are judged on that care. They can of course do things differently and that is the point of the system: to trust that clinical judgment. The noble Lord is quite right that end-of-life care is in the mandate—that in itself is a relatively new development. I will come back to him on the specifics that he asked for about the extent to which those metrics will be included in the mandate.