Greater Manchester Combined Authority (Public Health Functions) Order 2017

Lord Hunt of Kings Heath Excerpts

Tuesday 7th November 2017 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

I beg to move that the draft Greater Manchester Combined Authority (Public Health Functions) Order 2017, which was laid before this House on 20 July 2017, be approved.

The draft order we are considering today, if approved and made, will confer local authority public health functions on the Greater Manchester Combined Authority as agreed in the devolution deals, and support Greater Manchester’s programme of public sector reform.

The Government have, of course, already made good progress in delivering their commitment to implement the historic devolution deal with Greater Manchester. Since agreeing the first deal with Greater Manchester in November 2014, we have passed the Cities and Local Government Devolution Act 2016, followed by a considerable amount of secondary legislation for Greater Manchester, including: establishing the position of an elected mayor; new powers on housing, planning, transport, education and skills; transferring fire and rescue functions and assets; and setting out the operation of the police and crime commissioner function, which transferred to the mayor on 8 May.

The draft order we are considering today provides a further significant step for Greater Manchester. Greater Manchester has identified public sector reform and population health improvement as priorities. This draft order provides for the conferral of certain local authority public health functions on the combined authority. Once the order is made, the combined authority will be able to exercise those public health functions concurrently with the 10 metropolitan district councils in its area.

The main new function is conferral of a local authority’s duty to take such steps as it considers appropriate for improving the health of the people in its area. The effect of the order will be to treat the combined authority as if it were a local authority, with the same duty to improve population health and the same consequential requirements to comply with guidance and the NHS constitution, and with the ability to enter into partnership arrangements with local authorities and NHS bodies.

Conferral of local authority public health functions will enable a Greater Manchester-wide strategic leadership approach to the delivery of agreed public health functions and commissioning responsibilities—for example, public health intelligence, health needs assessment and health protection. It will support a Greater Manchester-wide approach to tackling health inequalities, variation in quality and service improvement to promote fair and equitable access and to achieve an upgrade in health outcomes for the population of the wider city. It will also support strengthened collaborative decision-making for population health through the identification of city- wide commissioning priorities and intentions, underpinned by shared principles and common commissioning standards —for example, commissioning for whole-system sexual health and substance misuse services. Finally, it will enable population health to be embedded across the city’s health, social care and wider public services through the Greater Manchester strategy and the population health plan.

Noble Lords will want to know that the statutory origin of the draft order before us today is in the governance review and scheme prepared by the combined authority in accordance with the requirement in the Local Democracy, Economic Development and Construction Act 2009. Greater Manchester published this scheme in March 2016 and, as provided for by the 2009 Act, the combined authority consulted on the proposals in the scheme.

The consultation ran from March 2016 to May 2016, in conjunction with the 10 local authorities in its area. The consultation was primarily conducted digitally, including promotion through social media. In addition, of course, respondents were able to provide responses on paper, and posters and consultation leaflets were available in prime locations across Greater Manchester. As statute also requires, the combined authority provided to the Secretary of State in June a summary of the responses to the consultation, and the Secretary of State concluded that no further consultation was necessary.

Before laying this draft order before Parliament, the Secretary of State has also considered the other statutory requirements in the 2009 Act. He considers that conferring these functions on the Greater Manchester Combined Authority is likely to improve the exercise of statutory functions in the area, and he has had regard to the impact on local government and communities, as he is required to do. Also, as required by statute, the 10 constituent local authorities and the combined authority have consented to the making of this order.

In conclusion, the draft order we are considering today, if approved and made, will confer local authority public health functions on Greater Manchester Combined Authority, enabling it to play a key role in improving the health of the population in Greater Manchester. I commend the draft order to the House.

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I thank the noble Lord for his explanation of the order. As I am going to touch on oral health in Greater Manchester, I declare an interest as president of the British Fluoridation Society.

The order is unexceptional and we support it. It takes a sensible approach, enabling the combined authorities in Greater Manchester to undertake public health duties which at present fall just to individual local authorities. The Greater Manchester Health and Social Care Partnership has published a very interesting population health plan, which has a lot of very good things in it, and I commend the local authorities and the combined authority for what they are doing.

I mentioned my interest in oral health. It is well known that Greater Manchester has very poor oral health. It is also well known that, at a stroke, this could be dealt with by the introduction of fluoridation in the water supply in the north-west. All I would ask is that when the order has gone through, Greater Manchester be gently urged, through the Minister’s good offices, that an improvement in oral health be one priority that the combined authority—and indeed the mayor, who I know is a passionate believe in fluoridation—might take on. I hope the Government will encourage them in the right direction.

The order proposes that for some interventions, there can be reductions in visits to urgent care, a reduction in the number of people with chronic conditions, and that 700,000 people will be able to manage their chronic conditions more effectively. But of course, this takes place in the context of a very rocky position for the NHS and social care. The funding gap and the demographic pressures on the health service are severe. Inevitably, this is going to impact on the effectiveness of what Greater Manchester can do on health and social care as well as public health.

--- Later in debate ---

[Lord O’Shaughnessy]

I thank noble Lords for their contributions and for their broad support for the order before the House today. As I outlined, it represents another significant milestone in the Government’s devolution agenda and I am glad that that has been welcomed across the House. I will try to respond to the various points that noble Lords have made.

Like the noble Lord, Lord Hunt, we support the idea of the population plan, which will clearly differ from place to place where there is this kind of devolution. I stress that an important and distinctive part of this plan is that it confers on the combined authority the same powers and responsibilities as a local authority. It is therefore about them acting concurrently, rather than in an overbearing way, or seeking to override.

I have been in your Lordships’ House long enough to know that fluoridation is an area of particular interest. I wonder only why it has taken so long for me to have to answer a question on it. This is a devolution deal, and it is therefore about those powers being taken locally and acting in concert. I do not think it is consistent with the idea of devolution for me to urge any combined authority to point in one direction or another, and it sounds like my noble friend Lady Gardner has been doing plenty of urging already. Any such move would have to be made in concert by all 10 of the local authorities and the combined authorities and be done through the usual processes of consultation and so on, with regard to all the responsibilities that attend on those public health powers. I hope that provides some reassurance to my noble friend Lady McIntosh.

[Lord Hunt of Kings Heath]

After the Strathclyde case and the ruling from Lord Jauncey, the then Conservative Government took legislation through both Houses of Parliament to make sure that fluoridation was legal and above board. That was based on evidence that has not been undermined since.

[Lord O’Shaughnessy]

I am trying to make the point that there is an established regulatory framework around such proposals. As noble Lords can tell, I am trying to avoid coming down on one side of the argument or the other. In the end, this is an issue both for local areas and for clinical opinion and research. On the broader position of public health, difficult decisions had to be made about local authority budgets as a consequence of the financial crisis and the deficit which it brought about. It is still the case that local authorities are getting £16 billion to spend on public health over the five years from 2015 to 2020. Alongside that, power and decision-making have been devolved to local authorities on using that money and combining it with other functions that have an impact on public health. One of these would be housing, the quality and condition of which has a huge impact on the public health of local people. You cannot both welcome devolution and say that local authorities should not have the power to act in different ways, so long as they comply with their statutory obligations. From that point of view, local authorities should not act outwith those obligations, whether in the case of contraception clinics or any other public health responsibility.

The noble Lord, Lord Beecham, asked about integration: I stress the point about pooling of budgets. As he will know, a chief officer for health and social care has been appointed in Greater Manchester. That person is an NHS England employee, because the NHS is a national health service and NHS functions have not been devolved. We are clearly trying to achieve greater integration of services, through the sustainability and transformation programme. We hope that doing this at a level where there is a degree of integration by the relevant local authorities will be fertile ground, and that it will provide evidence for and leadership in the move towards accountable care systems, which NHS England is now leading through its five-year forward view.

On the final point about information being spread to epidemiological centres, I again stress that this measure confers the powers of a local authority on to a combined authority, so it will absolutely have the responsibility to share data. Indeed, it will not be able to assume responsibility for any functions if the 10 local authorities do not want it to do so. Obviously, we hope that they will. Indeed, by committing to support this order, they have signalled their intention to do so. I reassure the noble Lord that there is absolutely no risk that these kinds of responsibilities will be watered down as a consequence of this order.

In conclusion, I hope that I have answered noble Lords’ questions and inquiries about the impact of this order on fluoridation and many other issues. It is an important order and I hope that all—

[Lord Hunt of Kings Heath]

I am sorry to intervene again but I have just reflected on what the noble Lord said about fluoridation. He seemed to say that he was not prepared to come down on either side. That sounds to me like a new statement of government policy, as traditionally government has been in favour of fluoridation.

Veterans: Mental Health

Lord Hunt of Kings Heath Excerpts

Tuesday 7th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I reiterate the point I made in my Answer: NICE guidance on the treatment of post-traumatic stress disorder is clear that clinicians should take into account a range of factors when seeking to make a diagnosis. That should include the patient’s detailed case history, including medicines taken and under what circumstances. Regardless of whether the person is treated while serving or afterwards, that should be on their patient record, be accessible for anyone giving them direct care, and influence any prescriptions of treatments given. I also point out to the noble Countess that veterans’ issues are now in the training curriculum for all GPs. That came out of the Armed Forces covenant.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the treatment of veterans is clearly important, but so is prevention. Will the noble Lord confirm that for the drug the noble Countess referred to, whatever geographical area you are in in the world, there is always an alternative? Will he also confirm that the Surgeon-General told the Defence Select Committee last year that he could not guarantee that every member of the Armed Forces had a face-to-face risk assessment before the drug was given to them? Have the Government now ensured that face-to-face risk assessments take place?

[Lord O'Shaughnessy]

For the drug in question, Lariam is the brand name and mefloquine is the generic name. There are indeed alternatives available, and only 1% of antimalarial drugs prescribed to the Armed Forces are of mefloquine. There are instances when alternatives are not available, which may be because of a particular response to individual drugs or because the prescribing details are different—mefloquine is given on a weekly basis, for example—but the proportion is only 1%. The Defence Committee set out several recommendations, one of which was that there should be face-to-face risk assessments before prescribing. That figure is now up to 89% of the total; for the remaining 11%, the problem may be about recording rather than their not happening. The rate is much higher than it has been historically.

NHS: Winter Staffing Levels

Lord Hunt of Kings Heath Excerpts

Thursday 26th October 2017 Lords Chamber

[Lord O’Shaughnessy]

We recently debated community pharmacies. Reforms have ensured that most people—more than 80%—are within a 20-minute walk of a community pharmacy. As a consequence of these reforms, there has been no decrease in the number of community pharmacies in England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the case raised by my noble friend relating to Essex goes to the heart of the problem of discharging patients from NHS hospitals because of the lack of support in the community from social care and the reduction in nursing home places during the last four years. Is the Minister as surprised as I am that, despite this, up and down the country the NHS, through its sustainability and transformation plans, is putting forward proposals to cut out community hospitals and community hospital beds? Will Ministers issue an instruction to the NHS so that this will not be allowed to happen?

[Lord O’Shaughnessy]

We have discussed the issue of nursing home beds. We also know that there has been an increase in the provision of domiciliary care packages which reflects people’s changing care needs. Figures published yesterday show that social care spending has risen by £500 million during 2016-17. I am sure this will be warmly welcomed across the House. On community beds, noble Lords should know that, in addition to the usual four tests for reconfigurations, last year Simon Stevens, the head of NHS England, said that there is now a fifth test—the bed test. There must be robust evidence that any proposed reduction in beds is because of a reduction in demand and not the other way round.

National Health Service (Pharmaceutical and Local Pharmaceutical Services) (Amendment) Regulations 2017

Lord Hunt of Kings Heath Excerpts

Thursday 19th October 2017 Lords Chamber

Moved by

[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?

--- Later in debate ---

To conclude, I can reaffirm and reassure all noble Lords about the Government’s commitment to delivering a modern approach to community pharmacy—one that promotes efficiency and the best use of NHS resources while maintaining access to quality services and good patient outcomes. Pharmacy will continue to be a trusted partner in delivering a world-class National Health Service and the Government are committed to working with the sector to help make this a reality. On that basis, I hope that the noble Lord, Lord Hunt, will feel able to withdraw his Motion.

[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.

Motion withdrawn.

Hospitals: West London

Lord Hunt of Kings Heath Excerpts

Wednesday 18th October 2017 Lords Chamber

[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

Wednesday 18th October 2017 Lords Chamber

[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

Monday 16th October 2017 Lords Chamber

[Lord Dubs]

To ask Her Majesty’s Government what is their estimate of the number of people currently in hospital waiting to be discharged to care homes when places become available.

[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

Thursday 12th October 2017 Lords Chamber

Asked by

[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

Tuesday 10th October 2017 Lords Chamber

[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

Thursday 14th September 2017 Lords Chamber

[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.