Health and Care Bill

Lord Stirrup Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Stirrup (CB)]

My Lords, I add my own warm congratulations to my noble friend Lord Stevens of Birmingham on his excellent maiden speech.

One of the most dispiriting and dislocating experiences that any large organisation can suffer is to be subjected to repeated waves of substantial reorganisation. It diverts attention away from the delivery of outputs and on to issues of structure and process, and just as, and often before, one set of changes is embedded, another looms. This leads to confusion, reduced efficiency and poor morale. So the Bill, representing another upheaval for the NHS, carries considerable risk.

I acknowledge that some of what it proposes goes with the grain of evolving practices in parts of the NHS and that it incorporates a number of welcome changes. The shift to a more integrated approach to health and care is long overdue, and the abandonment of the competition straitjacket will be cheered by the vast majority of practitioners. The question remains, however, whether such improvements could have been secured in a way that would be less dislocating for the NHS.

It is important to remember that a Bill such as this sets only a broad framework and that giving it effect requires a great deal of subsequent detailed work. At a time when Covid continues to stretch the NHS and the medical profession, perhaps even more so in the months ahead, does this represent the best use of scarce resources?

Turning to points of detail, in the time available I will touch on just one provision that the Bill does contain and two that it does not. Like other noble Lords, I worry about providing for increased political control over managerial decisions. I can understand how frustrating it might be for Ministers to have no control over decisions but nevertheless to have to bear the public and political consequences of them, but they need to ask themselves whether their closer involvement in the process is likely to lead to better decisions. I fear not. We have seen in the past that political priorities, often driven by dramatic headlines, are likely to be out of kilter with long-term health strategies.

While I am on the subject of strategies, I am disappointed that the Bill has nothing meaningful to say about planning and delivering the future NHS workforce. A quinquennial description of a system does not constitute a strategic response. Effective personnel planning has a simple equation at its heart: workforce equals the average annual intake times the average return of service. All three elements of this equation are crucial. The workforce requirement must be defined, and recruiting and retention must be appropriately balanced to maintain the right spread of experience and expertise. At the moment, we have no idea of the requirement, but we know that we are not training enough medical personnel and that retention is poor and getting worse. If we do not take urgent action to address these problems, none of the proposals in the Bill, no matter how worth while, will make a substantial difference.

The most pressing need is to improve retention. Defining the requirement and increasing recruitment are important but they will take some time to have an effect. Stemming and, if possible, reversing the increasing outflow of trained personnel will have the quickest impact on capacity. On a number of occasions, I have asked the Minister’s predecessors what actions are being taken to address the problem and received nothing but vague reassurances. Meanwhile, the situation has worsened. Will the Minister now undertake to set up an empowered task force to remedy this crucial situation?

Finally, I have pointed out in previous debates that the NHS is an ungoverned system in that it faces ever-increasing demand and ever-increasing technological opportunity. No enterprise can succeed in the long term unless it manages its outputs as well as its inputs. At the moment, the NHS’s outputs are varied on a haphazard and sometimes irrational basis, often through uncontrolled waiting lists. Unless and until we face up to the fact that the NHS cannot do everything, we will never have a properly governed system. Because of the imbalance between growing demand and opportunity on the one hand and inevitably limited resources on the other, healthcare is rationed always and everywhere. The question for us is whether we wish to devise a fair way of doing that or to continue with our present, incoherent system of force majeure.

The current Bill, like all its predecessors, has nothing to say about this. It therefore treats a number of distressing symptoms but does not address the underlying condition that threatens the long-term well-being of the NHS. In this regard, it is another missed opportunity.

NHS: Elective and Cancer Care Backlog

Lord Stirrup Excerpts

Tuesday 7th December 2021 Lords Chamber

[Lord Kamall (Con)]

My noble friend makes an important point. What matters is not just the amount that you put in but the way that you spend it. This is why the Government announced the NHS long-term plan to look at where we should tackle issues and the nature of waiting lists and, given that much of the waiting list is for diagnostics, roll out diagnostic centres to meet that challenge.

[Lord Stirrup (CB)]

My Lords, an exacerbating factor in the size of waiting lists more generally is the number of patients referred unnecessarily to secondary care specialists. One way of addressing this problem is to make more time available to GPs to investigate patients’ symptoms more carefully. Does the Minister agree that, in looking at the overall issue of waiting lists, we have to take into account the needs of primary care as well and not just secondary care?

[Lord Kamall (Con)]

The noble and gallant Lord makes the very important point that we have to look at the whole way we configure our system of healthcare in this country. Many things that were previously done in secondary care can be done in primary. In fact, some of the things that were done in GP surgeries can now be done in the community in diagnostics centres or even in pharmacies, as many people who have had their booster recently will acknowledge.

NHS Digital: Primary Care Medical Records

Lord Stirrup Excerpts

Tuesday 8th June 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, I agree with the noble Lord that the opt-out system deserves to be looked at. We are undertaking a review of the opt-out system to streamline it along the lines that he described. However, he peddles a slightly false impression. There are extremely detailed considerations in the IGARD minutes, available online—39 pages from the last meeting—which go into great detail on the arrangements for the sharing of each piece of data. On payment for the data, I remind him that—as I am sure he already knows—these are payments for costs and not payments for any kind of charge. All data is shared for very strict reasons to do with research and planning. There are no other reasons for sharing the data.

[Lord Stirrup (CB)]

My Lords, we urgently need better flows of clinical data between different parts of the NHS, but the public are understandably anxious, given the well-publicised data leaks and thefts of recent years, and particularly given that the proposed scheme is not limited to the NHS but includes external third-party commercial enterprises. Why have the Government done so poorly at explaining to the public the need for such information flows and the health benefits that they bring? Why have they not, at least in the first instance, constrained the sharing of data more narrowly, in order to build up the necessary degree of public confidence?

Covid-19: NHS Long-term Plan

Lord Stirrup Excerpts

Tuesday 15th September 2020 Lords Chamber

[Lord Bethell (Con)]

My Lords, I cannot commit to a social care plan before the end of the year. It will require a huge amount of political collaboration and I suspect it will take longer than the next few months. I remind the noble Baroness that we have a £600 million infection control fund to help social care through the winter.

[Lord Stirrup (CB)]

My Lords, despite additional Covid funding, many NHS trusts are having to cut back on crucial capital investment programmes because of increased financial pressure. For example, some hospitals are having to replace obsolete and ineffective scanners with slightly newer but far from up-to-date models. Does the Minister agree that when the NHS long-term plan is revised, it will need to include a recovery schedule from these perhaps inevitable but nevertheless damaging short-term responses?

[Lord Bethell (Con)]

My Lords, the Chancellor has made it clear that catch-up support for the NHS to recover from the impact of Covid is an important part of his financial projections. However, I remind the noble and gallant Lord that we are investing in 40 new hospitals. It is a massive capital investment and the impact on our healthcare service should not be underestimated.

Access to Palliative Care and Treatment of Children Bill [HL]

Lord Stirrup Excerpts

2nd reading & 2nd reading (Hansard): House of Lords & 2nd reading (Hansard)
Friday 7th February 2020 Lords Chamber

[Lord Stirrup (CB)]

My Lords, I support the Bill and I thank my noble friend Lady Finlay for her persistence in seeking improvements to this crucial but neglected area of care. My father spent his final days in a hospice, and while his death was, of course, a matter of great sadness, the care he received, mental as well as physical, helped not only him but his family to deal with an inevitable but always traumatic aspect of life. This last point is crucial. Death is an inevitable, inescapable part of everyone’s life, and we, as a society, should recognise that quality of death is an integral part of quality of life.

In considering human rights, we talk about the right to life. I have some difficulty with that notion, since we cannot guarantee life, but we can and should guarantee our citizens help with the experience that every one of them will have to undergo. This seems to me an important part of human rights. There is no doubt that in this country there are many areas of excellent practice in this regard, but it is also clear that much more needs to be done to level up our approach to palliative care. The Bill is an important step in that regard.

The Government’s response to previous attempts to introduce similar legislation seems to have been to say that primary legislation is not the best way to deal with the issue. Frankly, that would be a more persuasive argument had they taken the matter forward effectively through some other route. While there has been some progress, I am not persuaded that it has been sufficient.

This is just one aspect of a wider debate over the need to consider physical and mental care holistically rather than as a series of separate issues. Just as social care needs to be considered alongside and be consonant with the provision of health services, so end-of-life care should be a integral part of the way we provide for the physical and mental well-being of our citizens.

Yesterday the noble Lord, Lord Hunt of Kings Heath, initiated in this House a very good debate on the NHS and social care. In it, I said that we were asking too much from the NHS and that this was creating unsustainable pressure on the system. It might therefore seem rather perverse for me to support a Bill that asks it to do even more, but that is not my intent. I am quite clear that the NHS does not and never will have the resources to permit it to do everything it might, but choosing what not to do at random or excluding services because they were the last to be proposed is no way to run any public enterprise, let alone one of such importance.

The evidence shows that the approach of clinical commissioning groups to the provision of palliative care is very uneven across the country, driven, I assume, by budgetary pressures rather than by strategic decisions. This cannot be right, but it is no good simply blaming the CCGs for this. The lack of a proper strategy for the provision of healthcare in England is, as I suggested yesterday, at the root of the problem.

Nevertheless, something needs to be done in the short term to address some of the most serious deficiencies in palliative care. Given the excellent work done by hospices, and considering the burden they lift from the shoulders of our primary and secondary care systems, it seems nonsensical to deny them access to the pharmaceutical services available within the NHS and to patients being treated at home.

If difficulties in accessing palliative care for adults approaching the end of life are distressing and unwelcome, how much worse must they be for children and their families? Yes, we are all going to die, but we expect and hope that it will be the conclusion of a fulfilling life. The death of a child must bring with it an anguish that simply cannot be understood by those who have not gone through the trauma. I accept that parents undergoing such stresses will not always be the best judges of what is right for a child, but sometimes they will have insights crucial to the provision of the best treatment. Cases of dispute between families and medical practitioners will sadly always arise from time to time and resolving them satisfactorily will always be difficult.

I understand some of the concerns that have been raised with certain aspects of the present Bill, but these can surely be addressed in Committee and on Report. It seems indisputable to me that attempts to reach a conclusion to dispute through mediation must be preferable to immediate court action.

The Bill will perhaps require some amendment if it goes forward and it is no substitute for a proper, non-partisan debate on a strategy for the provision of holistic physical and mental care in England. But unless and until we have such a national debate, the Bill of the noble Baroness, Lady Finlay, is a good vehicle for addressing some important shortcomings in the present system and I support its Second Reading.

NHS: Targets

Lord Stirrup Excerpts

Thursday 6th February 2020 Lords Chamber

[Lord Stirrup (CB)]

My Lords, much of the context for this debate is set by the targets that NHS England has laid down for the delivery of its services. There has been much discussion of the appropriateness of these targets, but we can draw some general conclusions from the persistent failure of the NHS to meet them. I suggest that the most important conclusion is that we are looking at a system stressed beyond its capacity to adapt and at serious risk of catastrophic failure. One can cite specific weaknesses and institutional failings, an inadequacy of funding and the need for coherence across the care sector. All are valid points, but they miss the root cause of the extreme stresses in the NHS: there is no proper strategy for the provision of healthcare in England.

I say that because a proper strategy is not just about plans, nor just about resources; it is about balancing ends, ways and means. Part of that balancing act involves deciding on the ends that are achievable within the means available. That is the calculation missing today. We are simply asking too much of the NHS. This is not a problem that can be solved just by looking at the inputs. Healthcare is an inherently ungoverned system of ever-increasing demand and ever-increasing technological opportunities. The recent growth in pressure has already outstripped the new resources promised, but that is not surprising. Left to itself, demand will always exceed supply, wherever we set the level of funding. We have to exercise control over the outputs as well as the inputs. That involves making hard choices and taking political risks, which is why I am rather pessimistic about the likelihood of our grasping this nettle. I do not believe that any of the main political parties is courageous enough, but we should be under no illusion about the consequences if we fail to rise to the challenge.

The Government will point to their long-term plan and the proposed increases in the numbers of clinical staff. These are indeed welcome, but they are insufficient. The Minister will be aware that morale within the NHS is in a parlous state. Many clinical staff are exhausted, physically by the unrelenting demands placed on them but also, and perhaps more importantly, exhausted mentally because they see no light at the end of the tunnel; indeed, they see no end to the tunnel. They need some sense that the system will be brought into sustainable balance in the reasonably near future, but I fear they are unlikely to receive such reassurance. If that is so, I ask the Minister to respond to some more detailed concerns, which, if addressed, might at least help to stave off an impending collapse of the service.

NHS staff clearly need some immediate relief from the pressures under which they labour today. The Interim NHS People Plan has made some proposals in this regard, but a number are as yet neither specific nor quantifiable, so when will a comprehensive and detailed plan of action, with milestones and accountable persons, be available? How will progress on these measures and their impact on NHS morale be assessed and reported?

At present there is a clear lack of adequate or timely maintenance of the NHS infrastructure, which—as we know only too well in this place—only builds up even greater and more expensive problems for the future. What steps are being taken to improve and sustain the fabric of the NHS estate, and how are capital investment and maintenance needs being measured, funded and reported?

The pressures on GPs mean that all too often they are unable to investigate the condition of their patients as thoroughly or deeply as they would like. This can result in them making more referrals than necessary to a secondary care specialist, leading to longer waiting times for all. A little more investment in the primary care end of the spectrum might result in an overall saving of time, money and staff morale, as well as a better service to the patient. Can the Minister say who, if anybody, is making such risk/benefit judgments, especially across the boundaries in the care system, and what power they have to allocate resources in ways that would give effect to such judgments?

The Prime Minister has indicated his intention to seek a consensual way forward on adult social care. My plea, echoing the noble Lord, Lord Bates, is that this be extended to the provision of care more widely, to include the NHS. The Beveridge report and the ensuing legislation to give effect to it were made possible perhaps only by the upheaval and dislocation of a catastrophic world war. I hope we do not have to experience similar turmoil before we can make Beveridge’s legacy fit to survive the challenges of the 21st century.

Breast Cancer Screening

Lord Stirrup Excerpts

Thursday 3rd May 2018 Lords Chamber

[Lord Stirrup (CB)]

My Lords, the Minister referred to IT and QA failings, and has recently been answering questions about data security. An independent review into the breast cancer screening programme is clearly important and welcome, but how confident is he that the sorts of failings he has talked about do not exist in other areas of the NHS? Given the fact that the QA process failed in the current instance for eight years to pick this up, how can he have any confidence at all in automated processes elsewhere?

[Lord O'Shaughnessy]

We must be absolutely cautious in our dealings with technology. Of course, technology is part of the health and care service now. It is in everything. Making sure that there is good quality assurance is critical to that. Clearly, we have uncovered a problem but we do not think that the problem is in other screening processes. We have had reassurance from Public Health England that that is the case, but we clearly need to investigate further. We also need to be alive to the fact that these systems are often under attack from other actors, and to provide that cyber resilience. So I am afraid that it is an ongoing process to provide that kind of resilience and quality assurance. It is a job that never ends.

Veterans: Mental Health

Lord Stirrup Excerpts

Tuesday 7th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I am glad to see that my noble friend is still in very good shape. It is important for me to point out that a link between mefloquine and severe and persistent psychiatric symptoms has not been established. What I can talk about is what the NHS is doing to make sure that there is proper treatment of and care for veterans and those serving in the Armed Forces. The MoD is now giving on a six-monthly basis a report to the House of Commons Defence Committee on its actions. As I said, that includes increased risk assessments and so on. This is constantly under review, not just in the government department but in the MHRA, which is the licensing authority with responsibility for drug safety.

[Lord Stirrup (CB)]

My Lords, the Lariam case is a severe one, and I understand that the manufacturers acknowledge the link on the packaging of the drug. More broadly, the Armed Forces covenant is an acknowledgment of the debt and duty that society owes to its veterans, but one challenge for those providing public services such as within the medical profession is to identify those who fall within the ambit of the covenant. Those who most need some of those resources and some of that help from public services are the least able to identify themselves. What are the Government doing to ensure that those who provide such services are fully aware of the status of those veterans?

[Lord O'Shaughnessy]

On the first point, there have been reviews at European level to improve the packaging and the patient information leaflets about any risk that might attend taking this drug or indeed any others. Status as a veteran is now recorded in the NHS and goes into the patient record.