General Practitioners: Workforce

Baroness Redfern Excerpts

Monday 5th March 2018 Lords Chamber

[Lord O’Shaughnessy]

I shall have to write to the noble Baroness with the specifics on GP flexibility. However, one of the reasons that GPs take early retirement to take advantage of their pension is that it enables them to work flexibly afterwards.

[Baroness Redfern (Con)]

My Lords, regarding the workforce, having pharmacists in GP practices means that GPs can focus their skills where they are most needed: diagnosing and treating patients with more complex needs. Does the Minister agree that this not only helps GPs manage demands on their time but helps to ease their workload, while patients have the convenience of being seen by the right professional, improving quality of care and ensuring patient safety?

[Lord O’Shaughnessy]

My noble friend is absolutely right. As well as our commitment to increase the number of GPs by 5,000, we also have a commitment to increase the number of GP practice staff by 5,000, including 1,500 pharmacists, who provide exactly the kind of support she outlined.

NHS: Cancer Treatments

Baroness Redfern Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Redfern (Con)]

My Lords, I thank the noble Baroness, Lady Jowell, for initiating this debate today—it is a privilege to take part and I thank her for her passionate, moving and very brave speech. I want today to support all cancer patients who wish to have the opportunity to be involved in clinical trials, as adaptive clinical trials are a promising way to develop new treatments by offering those patients multiple opportunities to test. Life expectancy has significantly improved but unfortunately in some cancer sites early intervention is more difficult; for example, as we have heard, brain cancer and pancreatic cancer, which my late husband suffered from. Those numbers are struggling to move. As we all know, cancer touches us all.

Today’s debate, however, brings attention to how important new innovative cancer treatments can offer life-changing outcomes. The NHS is working collaboratively with the life sciences sector to improve accountability and transparency in the take-up of innovation with the support of NICE, and that has to be welcomed. The NHS enjoys the benefits of SME contributions: many of the companies in the UK life sciences sector are small and medium-sized companies, so I am pleased that financial support has been given, with the help of the new £6 million government scheme, together with £34 million over four years provided to encourage and support those innovators to develop world-leading digital solutions. A good, supportive research environment in the UK is needed to ensure that the best research can be carried out to speed up the development of pioneering treatments, accelerating access to new medicine and benefiting from working with international collaboration on clinical trials: that must continue.

Flexible pricing mechanisms, such as outcomes-based pricing, would result in quicker decisions about approvals, with pricing based on a drug’s value to the NHS. Also, more emphasis must be placed on the genomic revolution to eliminate the one-size-fits-all approach to cancer treatment. I welcome NHS England’s steps to create a genomic medicine service to close the gap and ensure equitable access to molecular diagnostic testing for all patients across England. Good data sharing is paramount.

A cancer diagnosis can be, and is, frightening, distressing and confusing. As I said, it touches us all, whether it affects a loved one, friend or colleague. A much-needed shift in emphasis towards prevention and a clinical strategy march of medical science, together with a strong media campaign, must lead to increased longevity. Finally, cancer patients throughout their treatment are focused on staying alive as long as possible, so it is important that they are free to take more risks. I thank the noble Baroness, Lady Jowell, for her brave speech: this is about giving hope for everyone, all patients; it is about improving the cancer campaign and improving outcomes.

NHS: Staff

Baroness Redfern Excerpts

Thursday 30th November 2017 Lords Chamber

[Baroness Redfern (Con)]

My Lords, I thank the House for the courtesy of allowing me to speak in the gap. I thank the noble Lord, Lord Clark, for bringing this timely debate to the House today. I refer to my interests as listed in the register and as being a member of the Select Committee on the NHS.

I welcome the statement by the Secretary of State for Health, Jeremy Hunt, that the Government recognise that it was not sustainable after seven years to carry on with the 1% rises or pay freezes. As we have heard today, we cannot expect NHS staff to go the extra mile if the money falls short; eventually, people will vote with their feet. So I am pleased to hear proposals for benefiting patients, from the announcement in the Autumn Budget of £6.3 billion of new funding for front-line NHS services and upgrades of NHS buildings and facilities to the creation of the “Homes for Nurses” scheme, giving a new right for the NHS worker to have first refusal on affordable housing, which would be generated through the sale of surplus NHS land, with an ambition that around 3,000 NHS workers would benefit. This is very much to be welcomed; our NHS staff are the backbone of the service, so it is important that we put first the people who are central to the delivery of high-quality care that is safe, effective, caring and responsive. I also acknowledge the 25% increase in placements for student nurses to increase the number of homegrown NHS staff, to reduce the reliance on expensive agency nurses, and to prepare ourselves for Brexit.

NHS staff need to feel safe and valued, with family-friendly policies, and there is a need to create a healthy morale to sustain a committed workforce. Factors that really influence staff retention include access to learning and development opportunities, a caring environment and a tough approach to violence towards staff. Retention of staff is a must, and the key to the sustainability of the NHS, while the fact remains that more has to be done to replace those who have left. I therefore welcome the launch of a new major programme to improve staff retention. It would appear—and it is regrettable—that more focus should have been on training the existing workforce, opening up the possibility of new opportunities leading to career progression. Training models in the health service have changed between 1947 and today, and will surely be radically different in 10 to 25 years’ time. We must not lose momentum on innovation and technology in order to have a continuous, dedicated and well-qualified workforce fit for the future.

Health trusts must also welcome learning from other hospitals, or look at mergers or working more closely together, sharing precious data in helping them raise their game in order that good leadership can drive continuous improvement in patient outcomes and productivity. We see staff working well in structured teams, fully engaged and supported to make changes to how they deliver that care, and able to make those changes to improve quality and productivity. It is essential that trust boards consider feedback from front-line staff. Trusts must make themselves great places to work, with job satisfaction, career progression and continual training as one. The importance of understanding what staff want cannot be understated.

Finally, I welcome, too, the Government’s endorsement of the NHS Five Year Forward View, funding it with £10 billion more a year for the health service by 2021. However, even with that funding, the health service remains under pressure, with more people than expected using the service last year. It is worthy of note that 2016-17 saw the NHS treat 2.9 million more A&E patients than in 2010. That is all thanks to our fantastic NHS.

National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017

Baroness Redfern Excerpts

Thursday 16th November 2017 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I am grateful to the noble Lord, Lord Hunt, for raising this issue. I am concerned about the additional barriers to care that may be faced by people with mental health conditions and learning disabilities. We know that such patients already face significant barriers to both mental and physical healthcare. For example, we know that people with psychosis already face significant barriers to both mental and physical healthcare. We know that people with psychosis face a mortality gap of 10-15 years, mainly from physical comorbidities. We also know that migration itself appears to increase the risk of psychosis, and the science behind this is developing rapidly.

It is not easy to divide, “immediately necessary” and “otherwise urgent” care, which is exempt, from routine care, which is chargeable. I speak from the standpoint of someone who has cared for patients with mental illness and with learning disabilities over many years as a psychiatrist, and also as a past president of the Royal College of Psychiatrists. The principle of early intervention to avoid a later crisis is widely recognised and promoted by the health service. Such intervention needs to occur very early. Identifying and intervening on low-level symptoms avoids escalation to more severe presentations that require intensive treatment and expensive admission to hospital. I am worried that the checks that have been put in the regulations will mean that patients, whether eligible or ineligible for free care, may wait longer and may need to be in crisis before they can access services. If this occurs, it will produce more suffering, increase risks and cost the health service more.

These costs do not feature in the Cost Recovery Impact Assessment, published by the Government in July. I am aware of examples of asylum seekers who arrive in this country with symptoms of post-traumatic stress disorder, and my concerns extend to the mental health of their children during periods of extreme uncertainty. Their mental health needs would not seem to meet the criteria for urgent care.

My other area of concern is the accuracy of decisions to deny care to a patient. The exemption for,

“immediately necessary, or otherwise urgent”,

treatment is a clinical one, as stated in the Government’s impact assessment. However, the British Medical Association, of which I am also a past president, has asked for clarification on the procedure when a person is unable to pay, including what safeguards are in place to prevent further or serious harm to themselves or the wider public as a result of them being denied treatment.

I am concerned that the process of administrative checks alongside a clinical test of urgency will be burdensome, costly and rushed. Once information is on a patient’s summary record, it may be difficult to change it or to amend errors. Such circumstances could lead to a failure to identify those entitled to free care. This may be even more complicated in patients who have impairment of capacity, communication difficulties or other mental health conditions. Challenging administrative errors and information on digital records in the health service can be difficult for all of us, let alone those with impaired capacity, communication and learning disabilities, or autism.

What safeguards are in place to prevent errors in requiring up-front payment? Without robust safeguards, those most in need of care may be those least able to prove they have a right to it. I would support the suspension of these regulations for further thought, but if this does not happen, can the Minister tell the House what are the arrangements for reporting the impact of these regulations on the mental and public health of the population who are at risk?

[Baroness Redfern (Con)]

My Lords, I refer to my entry in the register of interests. The regret Motion at first appears to imply that charging overseas visitors is something new. The requirement for the NHS to charge overseas visitors has been in place for 35 years—but, unfortunately, compliance and recovery rates have historically been extremely low.

I thank the NHS workforce for the fantastic job that they do; they are now treating levels of demand not seen before. Do noble Lords not think it only fair that any overseas visitor using our NHS should make a financial contribution, just as we all do when we are on holiday abroad and possibly want to access medical help?

It is important to emphasise that NHS England, NHS Improvement and the department have published guidance to support the embedding of the regulations, producing an average price list so as to better inform and enable patients to look at the up-front charges for anyone not eligible for free NHS care. Those people can then make informed choices about their care here or at home.

I am informed that, in order to protect the most vulnerable and to protect public health, the department remains committed to ensuring that vulnerable groups are always able to receive free care and that no patient will be denied urgent or immediate healthcare, regardless of their immigration status or ability to pay. This includes all maternity care in every setting, including diagnostic, and the treatment of infectious diseases.

Back in July, the department introduced new regulations to support improved cost recovery and make it fairer and more efficient for both the patient and the healthcare system. It saw recovery increase from £89 million to £360 million—all being transferred back into our front-line services.

Finally, with careful monitoring and ongoing assessments and with better use of existing data sources to improve efficiency, we will be able to see for ourselves the financial effectiveness and value for money through this process. These figures will be published in the new year.

[Baroness Taylor of Bolton (Lab)]

My Lords, I first congratulate my noble friend Lord Hunt on initiating this debate. Like him—and other speakers—I acknowledge that the NHS is under significant pressure and that there have been charges for a very long time. However, I say to the noble Baroness, Lady Redfern, that, if there is a problem with cost recovery, these regulations are not the answer.

I am prompted to intervene in this debate because of an organisation in Bolton, my home town: a local group called City of Sanctuary. Its role is to create a culture of welcome and safety for refugees and asylum seekers. As a Member of the other House, I had a considerable amount of casework dealing with refugees, asylum seekers and failed asylum seekers, so I know that its work is extremely important and that it has a great deal of direct experience. It has raised concerns about vulnerable groups, particularly those I have mentioned. I note that this category is not mentioned by the Minister in his letter.

There are three points I want to raise. I have read the Minister’s letter to all Members with care and I thank him for it. He tries to be reassuring, but I am afraid that he does not allay all the concerns that some of us have on the basis of the evidence that has been presented to us.

The Minister says that the regulations require that up-front charging for non-urgent or immediately necessary care will become a legal requirement. That is the basis of these regulations. But there is an immediate problem with the definition of “non-urgent” or “needing immediate care”. I think particularly of those people, such as refugees and others, whose full medical history is not known, may not be available or may not be fully evident, or who may not have proper cognisance of it themselves. It can be a very real problem, I suggest, for both the patient and the doctor. The medical groups who have expressed concern about this have made a very strong case.

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

Baroness Redfern Excerpts

Thursday 19th October 2017 Lords Chamber

[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?

[Baroness Redfern (Con)]

My Lords, in debating this regret Motion I listened intently to the noble Lord, Lord Hunt. He agrees that more pharmacies should be more engaged and that people should have more choice. I agree with him, but in today lies an opportunity to acknowledge the unique contribution that community pharmacists make to the health and care sector by providing easy access to clinical advice. I refer at this point to my entry as listed in the register of interests.

We should acknowledge that the Government are spending over £150 million a year more on pharmacies than the last Labour Government did, with over 11,500 community pharmacies—up by 18% over the last 10 years—together with the growth in the service budget of 40% over the last decade, to £2.8 billion in 2015-16. We now see over 40% of pharmacies in clusters of three or four, which means that in some cases two-fifths of pharmacists are within 10 minutes’ walk of two or more others. So it is right and proper that the Government are having this review to make absolutely sure that no community, whether in urban or rural settings, will be left without a pharmacy.

I want to pay tribute to the people who work in those pharmacies. In many cases, they are located at the heart of our communities with trusted professionals on-site who reflect the social and ethnic backgrounds of their residents. They are not only a valuable health asset but an important social asset, because they are often the only healthcare facility located in an area of deprivation and play a critical role in improving healthcare. Maintaining community pharmacies is crucial to keeping older and frail people independent. Going forward, we certainly do not want to see those people forced to travel, potentially over long distances, to pick up vital medicines and receive health advice. I very much hope that many rural communities, where travel distances can be a lot longer, can receive some sort of protection to ensure that patients can still access those services.

In 2017, it is right and proper to support a better payment structure and to be more efficient in the allocation of precious NHS resources—particularly by payment for the quality of service, not just for the volume of prescriptions dispensed—and to support the continuous improvement of those services to patients. That in turn will relieve pressure on many other parts of the NHS, particularly with a commitment to a national minor ailments service delivered through pharmacies so that patients who need urgent repeat-prescription medicines will be referred from NHS 111 directly to community pharmacies, rather than a GP out-of-hours service. We need to move from clusters of pharmacies to protect access for patients through a new pharmacy access scheme where there is a higher health need in a particular community.

The NHS has to be much more integrated. Pharmacists can make opportunistic public health interventions and provide advice on healthy lifestyles, thereby preventing or delaying the onset of long-term conditions and fulfilling a commitment to support people to keep healthy outside hospitals within the wider health system and a more integrated approach.

Finally, with the NHS asking for a £10 billion budget increase, there is an overriding need to see reforms to make sure that every pound spent goes as far as it can for patients and for the taxpayer as well. This package of reforms will ensure much greater use of community pharmacies as a first port of call by more fully integrating working with the rest of the NHS so that more people benefit from the skills of pharmacists and their teams. I am pleased that the Government are investing £112 million to deliver a further 1,500 pharmacists in general practice by 2020. I hope this review of the regulations, although delayed, will bring about the beginning of a longer-term transformation of the sector, expanding it to provide public health services such as health checks and immunisations as well as dispensing and selling medicines. There is no doubt that we all want to see a strong future for community pharmacy, but only if we can move with the times, because any delay brings uncertainty.

National Health Service (Mandate Requirements) Regulations 2017

Baroness Redfern Excerpts

Wednesday 6th September 2017 Lords Chamber

The Minister could reverse that tonight by giving us a little help and announcing that he will make absolutely sure that, whatever the other pressures, the time that people in this country who desperately need an operation have to wait for it will be maintained at an outer limit of 18 weeks. That is not ideal and it is not what I would have wanted during my time as Secretary of State, but in a civilised society it is the maximum time that people should wait to be relieved of the pain, the disturbance and, above all, the fear and insecurity that comes with prolonged waiting for a necessary operation.

[Baroness Redfern (Con)]

My Lords, I rise to speak on this regret Motion tabled by the noble Lord, Lord Hunt, who I am sure, like me, together with all users of the NHS, will acknowledge that the NHS has a unique place at the heart of our society and is by some distance the institution that makes us most proud to be British. However, it is regrettable that the NHS has become a bit of a political football year-in, year-out.

I would like to talk about the many positive areas in the NHS and about how people are working very hard to move towards these targets. Yes, pressures, including seasonal pressures, are all in the mix, yet despite these pressures the NHS approaches its 70th year delivering outstanding care, and it is important today to acknowledge and thank all staff who work in the health service, as well as encourage and support a healthy morale for our future workforce. As we all know, the NHS depends on a strong economy. A strong NHS can contribute to the growth of that strong economy, especially in health and life sciences, not just now but in the future.

We see plenty of pluses. We are getting healthier but we are using the NHS more, with life expectancy rising by five hours a day, as the noble Lord, Lord Reid, alluded to. The need for care in a modern NHS continues to grow apace. The number of people aged over 85 has increased by 40%, and the number of patients receiving elective treatment grew from around 14.2 million in 2012-13 to 15.7 million in 2016-17—an increase of 11%. That is a fantastic result. Calculations indicate that over the next 20 years we shall see the percentage of people over the age of 85 double. I note also that the total number of people on the elective waiting list in April 2012 was 2.5 million. By March 2017 this had increased to 3.7 million—an increase of 51% and another fantastic result. I note also that when Labour left office, including Members on the Benches opposite, more than 18,000 people were waiting more than 52 weeks to start treatment. Now, the figure is under 1,700.

Only last year, the CQC in-patient survey showed continuous improvement over the past five years, with 62% of respondents saying that they were satisfied with the running of the NHS. NHS funding is being increased and we will see over £0.5 trillion being injected from 2015 to 2020, but with more cash injection the NHS must show that it can spend that cash wisely and efficiently. Therefore, I look forward to a strong and sustainable NHS fit for purpose and fit for the future, where all parties can work together, so that we have a safe, patient-focused health service that is the best in the world.

[Lord Clark of Windermere (Lab)]

My Lords, the noble Baroness is absolutely right to sing the praises of the National Health Service, and she is quite right to point out that we are undertaking more operations than we have in the past. She is also right to say that, as we grow older, more of us will need the health service. That is a fact that we have to face and accept and about which we have to persuade people—who do not need much persuading—that something has to be done. My noble friend Lord Reid and I served in the Blair Cabinet and we spent hours trying to bring about the political will to make sure that waiting times, which caused so much grief and pain in the 1990s, were cut. So we are talking about political will.

There is an interesting public opinion poll produced by YouGov and published today on behalf of the Royal College of Nursing. It shows that 72% of the general public believe that the NHS lacks sufficient staff to enable them to do their job properly. When we talk about altering waiting times, it is worth remembering that healthcare is a labour-intensive industry in all its aspects. We all know that, and we all know that the NHS achieves what it does only through the dedication and commitment of the staff and the hours that they work, from the consultants through to the nurses, the healthcare assistants, the porters and everyone. We have to try to assist them because they are getting towards breaking point. The Royal College of Nursing has balloted its members and is talking about taking industrial action. Therefore, we look to the Government to have the political will to act.

I accept that there is no magic wand. This Government bear a lot of responsibility because they were the key partner in the coalition that cut the number of nurses in training after 2010. The onus is now on them, and they are beginning to increase the numbers, but they must do more. However, it obviously takes a long time to train consultants, doctors and GPs. There are shortages everywhere, including a shortage of 40,000 nurses. I do not know the figure, but there is a shortage of GPs running into the tens of thousands. There is a shortage of hospital consultants and shortages everywhere.

So what do we do? It is not easy, because more nurses are leaving than entering the profession. We cannot do anything about the training, as that will take a number of years, but we can do something about retaining people in post, by persuading GPs to carry on a bit longer and persuading nurses to stay in post as it is worth while doing what they do. That is what we should be doing. It would be a great help if the 1% cap on wages could be lifted, because that has meant that the average nurse is probably 12% worse off than they were a few years ago. That would be one way of making it easier to retain people.

Then there is the other point that was made by my noble friend who introduced the debate, whom I thank, about the number of nurses and doctors who have worked in the health service who are from the European Union. Can we offer them something to persuade them that we want them to stay in our country? For example, as the Minister knows, anyone from the European Union who has spent five years working in this country, which includes people in the health service, can apply for the right of permanent residency. But we cannot get the Government to say what that means. Does permanent residency mean that they can stay here, or will they be sent back to Europe? That increases the uncertainty and anxiety. I urge the Minister to go back to his colleagues and say, “All right, if we can’t or won’t make a commitment to the European Union citizens to stay in the health service, let us say that at least those who have gained permanent residency can stay”. That would help the issue.

I return to my basic point. This now requires political will. I do not doubt the Minister’s commitment. I know where the Minister stands and how much he believes in the health service. He has made that quite plain in a number of debates that we have taken part in. But we need political will and we are looking to the Minister to try to argue his corner and punch above his weight and give every support that he can to try to make health staff in the health service more satisfied so that they stay in their jobs and help us to reduce waiting times.