National Health Service: In-Patients with Learning Disabilities

Lord Crisp Excerpts

Monday 18th January 2016 Lords Chamber

[Lord Crisp (CB)]

My Lords, the new learning disability strategy, Building the Right Support, proposes that people with learning disabilities should get their mental health treatment from mainstream mental health services—which as noble Lords will know are already under considerable strain. Can the Minister let us know what assessment the Government have made of the likely impact that this will have on mental health services and how they envisage that the financial and other implications will be managed?

[Lord Prior of Brampton]

The noble Lord refers to the paper Building the Right Support, which I think he will be very supportive of. It is designed to treat and look after many more people with learning difficulties outside institutional settings—in their own homes or in special purpose, much smaller homes. Where necessary, they will of course need to receive mental health services. I am not aware that we have done a particular impact study on that, but I will investigate it and write to the noble Lord.

Health

Lord Crisp Excerpts

Thursday 26th November 2015 Lords Chamber

Moved by

[Lord Crisp]

To move that this House takes note of the case for building a health-creating society in the United Kingdom where all sectors contribute to creating a healthy and resilient population.

[Lord Crisp (CB)]

My Lords, first, I thank my noble friends on the Cross Benches for choosing this debate today, but I also thank all noble Lords who are taking part in it. I am very much looking forward to hearing everybody’s contributions. I recognise that this is last business on a Thursday, so I am particularly grateful to noble Lords taking part. I also welcome the three noble Lords making their maiden speeches. I know that we are very much looking forward to what they have to say now and in many future contributions in your Lordships House.

The health and care system is under great strain as needs grow, particularly from older people with long-term conditions, and as costs rise. This mirrors the position elsewhere, not only in Europe and America but in many fast-developing countries. Not surprisingly, and not just in the UK, there is widespread concern and considerable confusion about the future for health. This uncertainty and insecurity means that it is more important than ever to understand the complex nature of health problems and what can be done about them, and to set out a long-term vision and strategy for the future.

Health and well-being are affected by three big things: the availability and quality of health and care services; individual lifestyles and behaviours—individual responsibility for our own health is absolutely vital; and all the physical, economic and social factors such as education, employment, wealth, social structures and the physical environment. Those are the many determinants of health, and co-ordinated action is need across all three areas. However, my focus today is on the third of these—the wider determinants of health, which go way beyond the reach of the NHS and individuals.

There is a great World Health Organization quotation:

“Modern societies actively market unhealthy life styles”.

I want to talk about how we can set that on its head. What would it be like, instead, to build a health-creating society where everyone—citizens, families, communities and businesses alike—had a role to play? None of what I have said, however, should detract from the importance of the first two—the health and care system, and the choices and actions of individuals—and I am sure other noble Lords will address those.

Let me just give a few examples of what I am talking about. Barely half of our children achieve a good level of development by the time they start school, which affects their future physical and mental health and, of course, their ability to learn. Going to the other end of the age range, social isolation and loneliness in old age have the equivalent health impact of smoking 15 cigarettes a day and a slow recovery from illness. There is recent evidence that they also lead to earlier death. Having a social network and some meaning in life is hugely beneficial. Some groups in the population are affected more than others, including people with mental health problems. Men with severe mental health problems die up to 20 years earlier, and women 15 years earlier, than people without such problems. Importantly, there are also lower levels of subjective well-being and a higher burden of ill health in people from black and minority ethnic communities. Moreover, as Sir Michael Marmot has demonstrated, inequality damages health, with the most disadvantaged being most prone to ill health and living shorter lives.

Perhaps the most alarming statistic of all is that, on average, UK citizens have about seven years of ill health before we die; at the top of the scale, the Norwegians have only two years. What if we could reduce the UK figure by even one year? What a difference that would make for individuals and, at the same time, for the health and care system and therefore the economy. What is so different about Norway? This surely gives us a target to aim at.

These are complex problems, and they illustrate clearly that health cannot simply be left to individuals, the NHS, professionals or government. Everyone in every sector has a role to play. Moreover, improvements in health go hand in hand with improvements elsewhere. Education, the environment and the economy: all will benefit from a health-creating society. Better health and greater prosperity go together.

This is also very relevant to the future sustainability of the NHS, which is often discussed, like so much in health, in largely economic terms, as if it were really an economic problem and there could be purely economic solutions concerned with financing and/or restricting services and treatments. However, experience from the Netherlands to the USA shows that those solutions produce at best limited gains and may increase the economic cost to society as well as individuals. The long-term sustainability of the health and care system will come from changes in practice, finding health solutions to health problems and moving upstream into prevention, health promotion and, as I suggest here, building a health-creating society. Arguably, the NHS will not be sustainable without this.

Those are the problems, but an enormous amount is already being done. We can look at what is going on in the community and voluntary sector, and I am sure we will hear a great deal about that from other noble Lords. We know, for example, that informal carers contribute services worth an estimated £119 billion a year at least. If the informal care sector fails, the burden falls on the formal sector. People do not want to be dependent and are keen to live independent lives.

Connecting Communities brings together many of the organisations that work on small, local health projects. There is a wonderful African saying: health is made at home, hospitals are for repairs. It matches the scientific evidence about creating the right environment in every sense. It is also for us a reminder of the work in the UK of the Early Intervention Foundation.

Let me turn to other sectors: to designers, architects and planners, who can design buildings which encourage walking and the use of stairs, communities where people meet each other and public buildings which bring together different services. I declare an interest as a member of the council of Reading University, and note as an example the work going on there on the built environment. Researchers are looking at topics as diverse as indoor air quality in schools and workplaces and its effect on health and the well-being and educational performance of children and workers, and the relationship between the design of homes and health and well-being.

Moving on to businesses, as well as developing healthy products, they can create healthy environments for their workforce, recognising how much time and productivity is lost every year through ill health. They can both promote health and tackle specific problems, as the firms working together in the City Mental Health Alliance are doing. It is good to see the work of Dame Carol Black as a government adviser raising standards in this area. Schools, colleges and universities can promote health literacy and competencies, integrate healthy activities into daily life and share facilities with health and other services.

I very much hope that my noble friend Lord Mawson will talk about the St Paul’s Way Transformation Project in the East End of London. It is perhaps the most complete example of all these things that I have ever come across. It is about the community coming together with the private sector, education, health and care services: joining up the dots, as I suspect he may say, and informed by an entrepreneurial spirit. It is very much a model for the future.

Of course, government has many roles here. I recognise the importance of the economy and that the aspiration for a higher skilled and higher paid workforce is fundamental to health and well-being. Government is also able to address regulation and legislation, be it on salt, sugar, alcohol or elsewhere. Government can run great public education campaigns, but it also needs to do more to support civil society. I question whether it is doing enough now to build the sort of enabling environment we want, with all the social and community activities I mentioned earlier. It can also support disabled people to live independent lives. I am sure that my noble friend Lady Campbell will have something to say on this, both in this debate and elsewhere.

So there is already an enormous amount going on. Let me note the work of NHS England, Public Health England and other such bodies, local government—I welcome the devolution of responsibilities in Manchester and elsewhere—voluntary bodies, professional associations, researchers and many more than I have listed here. My purpose in this debate is to point to all this and ask how much more we could achieve if we did it in an even more co-ordinated way. I am sure the Minister has a briefing folder bulging with excellent examples of policies, initiatives and activities, and I look forward to hearing about them. There are many out there. However, the Government could do much more in a joined-up way across government, bringing in all those bodies and sectors of society that shape the health of the population. In truth, only Government can really mobilise everyone who needs to be involved.

As the Minister knows, I wrote to the Prime Minister immediately after the election to propose that he and the Government take a big, bold initiative to mobilise all sectors around building a health-creating society. I received a broadly warm reply and understand that the time needs to be right for such an initiative. Now, with winter coming and industrial action planned, is certainly not it, but the time will come for a bold and imaginative commitment to engage all sectors in building a health-creating society. Does the Minister accept this analysis? Will the Government, at the right time, reach out and mobilise all those other sectors to help build a health-creating society—and not, as it so often appears in the newspapers, leave it all to the NHS, government and individuals?

There is also a challenge here for all political parties. I meet a lot of people working in the health and care system and I observe two things. One is frustration, depression and sometimes even despair about the future. However, when I listen to them I also hear a common vision of what that future might be like. In summary, and in very simplified form, this vision is of a transition from the current hospital-led, professional-dominated and fragmented system where things are done to and for patients, to a much more seamless people and community-based one where patients and communities play their roles alongside professionals. This is a vision of high-quality services, delivered in homes as well as local facilities, with a different infrastructure and far greater use of technology. My noble friend Lady Lane-Fox has talked about that, and I suspect she will do so again. With these changes comes the potential for both higher quality and lower costs.

This vision will require major change. I have no doubt that it will require the closure of some hospitals and changing roles for staff. This will be difficult, both practically and politically, and will need political support. The challenge to the political parties seems to be that we need a shared vision for the future and some cross-party political will to make this happen. There will be plenty of political differences about the means of getting there but it seems that this end, this sort of vision, is common ground.

We already have some elements of such a vision in current policy: the Five Year Forward View is very good and has a lot of support, but is ultimately a technocratic and managerial document—I know because I have written such documents in the past. There is a need for a broad-based, cross-party coalition of agreement about what the future looks like. I do not know how that should be achieved, whether through some appointed commission or otherwise. What I do know is that people in the NHS and the country more widely would benefit from clarity of vision and strategy.

Your Lordships’ House also has a role here. It has very often led the way in discussing new and coming ideas and influencing the future. I think of debates I have heard here, for example, on genetics and, most recently, on securing parity between mental and physical health. Noble Lords from all sides of this House argued that case cogently and ultimately very successfully. I hope we might be able to do the same sort of thing here. I note that we are presently asked if we want to put forward proposals for ad hoc committees. I wonder if we should put forward one on building a health-creating society, so that these important ideas can be deliberated on in much more detail than the five minutes noble Lords have today allows. I would be interested to know if noble Lords thought that a good idea and would like to join me in making such a proposal.

Let me finish in optimistic and mildly jingoistic style. The UK is a great world leader in health. We have astonishing strengths in academia, the NHS, the role of DfID globally, the voluntary sector and our commercial organisations. The UK was a pioneer in providing a National Health Service that covered everyone in the population. It would be wonderful if we could lead the way again in moving beyond the professionally dominated and rather industrialised system of service to build a health-creating society served by a modern, fit for purpose health and care system. That would benefit us all as individuals, and bring with it wide-ranging benefits to the country in both prosperity and health. I beg to move.

--- Later in debate ---

[Lord Crisp]

My Lords, as I said at the beginning of the debate, I am very conscious that this is the last business of the day, so I will not detain the House for any length of time. I just want to thank noble Lords for the outstanding contributions from all parts of the House and for the wisdom, experience, imagination, practicality and practical experience that they have brought to bear to the debate. I have learnt a lot, not least about the Isle of Axholme and Bath, and indeed I intend to visit the Hindhead Tunnel—when I say it like that, I make it sound a bit like a pub, which is perhaps appropriate.

We have heard three impressive maiden speeches covering the health and well-being hubs in north Lincolnshire, personal responsibility and the role that government should play, and the importance—this was also drawn out by other noble Lords—of sociability and social networks.

There are four big themes, which I shall set out briefly. The first is the role of the Government. At the beginning of the debate, the noble Baroness, Lady Jay, spoke about needing a Cabinet-level Minister to provide some real drive and traction. The second theme, which I was slightly surprised to hear so much about, concerns relationships, sociability and loneliness. Many noble Lords raised that issue, which is of fundamental importance. The third theme is concern about vulnerable people and inequality, with the recognition that we understand that social structures affect health. The final theme is innovation and imagination, and the fact that there are new things which we can do and which we need to deploy.

Noble Lords will not be surprised to hear that I do not want to leave this subject here. A lot is happening but, as I said at the beginning, it is not being done with enough scale and co-ordination—or perhaps “oomph”, to use a technical expression. Therefore, I will be pressing for an ad hoc committee to dive deeper into these issues and to find practical ways of moving this issue forward.

Motion agreed.

Health: Global Health

Lord Crisp Excerpts

Monday 26th October 2015 Lords Chamber

Asked by

[Lord Crisp]

To ask Her Majesty’s Government what is their assessment of the report The UK’s Contribution to Health Globally, published by the All-Party Parliamentary Group on Global Health in June.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I congratulate the all-party parliamentary group on producing its report. The Government are determined to maintain Britain’s strong global role and welcome the report’s suggestions as to where we can continue to play a leading role in health globally. The United Nation’s sustainable development goals provide added incentive to look critically at where we can add maximum value in improving health systems overseas.

--- Later in debate ---

[Lord Crisp (CB)]

I thank the Minister for that very encouraging reply. The UK is a world leader in health. This report, produced by researchers from the London School of Hygiene & Tropical Medicine, shows that we have extraordinary strength in research, education, commerce, development, the NHS and the NGO sector. Given that, does the Minister agree that it is time for the UK to develop a new global health strategy to use that all-round strength to help to improve health globally—but, at the same time, to strengthen the UK’s health, science and technology base? More specifically, does the Minister agree that the UK’s medical, nursing and healthcare schools could be supported to play an even larger role in training health workers in low and middle-income countries?

[Lord Prior of Brampton]

My Lords, I agree with all the sentiments that the noble Lord mentioned—and, perhaps, one other, which is that in a number of other pioneering areas, such as genomics, dementia and antimicrobial resistance, the UK is very much at the forefront. The Government are following up the “Health is global” strategy that was initiated back in 2008 and will be reporting back in detail in 2016. I assure the noble Lord that we will take fully into account the findings of the all-party parliamentary group.

Access to Palliative Care Bill [HL]

Lord Crisp Excerpts

Friday 23rd October 2015 Lords Chamber

[Lord Crisp (CB)]

My Lords, I, too, congratulate the noble Baroness on introducing this Bill and on her very eloquent speech, in which she drew out all the essential points.

The provisions of the Bill are important in themselves but the Bill is also important in raising issues of dying with dignity and good care at the end of life, not all of which, of course, can be legislated for. However, it is significant in another way in that it is about some of the wider changes in priorities in health that are beginning to take place. We are beginning to see both globally and nationally much more focus on disability and on mental health, which I am pleased to see is keeping the Minister busy in this House. There is much more focus on social care, on care more generally and on what are called non-communicable diseases or long-term conditions, where the task is not to produce curative effects but to help people to live with disability and limitations. As the noble Baroness, Lady Finlay, said, it is also about quality, care and costs.

There are things that all those emerging or renewed priorities for health have in common, and I want to mention three of them. The first is the very strong individual, and indeed family, focus. The point has already been made that palliative and end-of-life care needs to be about what individuals want. It is not just about offering a menu of choice; as the noble Lord, Lord Davies, said, it is about control. I am reminded of my father, who, in the last year of his life in his 90s, discharged himself from hospital against the advice of the medical staff. I was quite sure, as I believe were the medical staff, that that act of rebellion—or, if you like, bloody-mindedness—was very good for his morale and probably affected the length of time that he subsequently survived. Therefore, this is about control as well as about a menu of choices, but it is also about families.

Although I agree with the provisions of the Bill, it is a question not just of having a professionalised death but of people being a bit more willing to talk about death, having those sorts of conversations and thinking about death in a much wider way. I am aware of the important point made by the noble Baroness, Lady Hollins: that the person who is dying dies but there is often a serious aftermath, which I guess all of us know something about.

The second important point is variation, and it keeps coming up. We have some absolutely excellent practice—I am sure we all wish to congratulate the UK on coming top of the palliative care table in a recent Economist Intelligence Unit survey—but we also have some awful care. Therefore, it is important to manage variation. The other point that needs to be brought out here is that we need to understand who misses out. We often talk about averages and so on in healthcare but we need to know who is likely to miss out by disaggregating the data and gaining an understanding of whether it is men or women, poorer people or less educated people. Interestingly, in palliative care there is some evidence that one of the groups that seems to miss out is the very elderly—the over-85s. Again, this is a global issue. In the recently agreed sustainable development goals, the great phrase was “Leave nobody behind”, and that must be true of where the noble Baroness, Lady Finlay, is taking us with palliative care.

My final point, which joins up all these emerging priorities, concerns technology—not just assistive technology, pharmaceuticals and so on, which are all extremely valuable, but IT and communications technology. My noble friend Lady Lane-Fox, who is not able to be in her place today, is happy for me to say that her new organisation, Doteveryone, believes that digital health and new technologies can radically transform services. Importantly, Doteveryone will be working on a project focused on older people at the end of life, reaching those traditionally seen as the most excluded—the over-85s. It will be very interesting to see where that project takes us.

I want to make a couple of specific points. First, I know that we have all been lobbied about children’s palliative care. We have not really mentioned it so far in the debate, although I do not know whether others will raise it. It seems important that there is some reference to the particular and specific needs of children when we talk about palliative care.

Secondly, I agree very strongly that this is about all health and social care workers; it is not just about the specialist few. It is about everyone understanding this holistic approach to care.

Finally, in her opening remarks the noble Baroness, Lady Finlay, said that it is time to act and that the Bill is about saying, “These are some mechanisms to make something happen”. That is very important in the context that she and others have articulated—that improving quality is very often about eliminating waste and wasteful procedures. Getting it right and therefore improving quality in many cases also has a beneficial effect on costs. For all those reasons, I very much support the introduction of the Bill to this House.

National Health Service: Sustainability

Lord Crisp Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Crisp (CB)]

My Lords, like others, I agree that the noble Lord, Lord Patel, is right about the need for a fresh look, going beyond politics and all the experts. We need to reframe the arguments and get others into the debate, and to take a long-term view.

I agree with the many people who have spoken, starting with the noble Lord, Lord Fowler, about the importance of understanding and reviewing how the NHS is financed. However, I want to take these arguments a bit further and think about sustainability in the round. Sustainability is not just a financial issue. I shall give two examples. Barely 50% of children have met all their development milestones by the time they start school. This influences children’s future physical and mental health and their ability to learn. The second example is that social isolation and loneliness in old age have the equivalent health impact of smoking 15 cigarettes a day. Moreover, loneliness very much slows the rate of recovery. Your Lordships can see where I am going with this argument. I have deliberately chosen two issues that are not directly about healthcare yet the NHS has to pick up the pieces; in most cases it cannot have a direct impact on these issues, although others can.

Sustainability is wider than that, too. If the NHS and social care are the formal healthcare system—and we have heard the figures for what that costs—the latest figures from carers’ associations is that if we were to monetise what carers provide, we would see that they provide about £120 billion worth of care. If you add into that what civil society, volunteers and all the NGOs and so on do, you see that there is a vast informal care system. My point in raising that is that what happens in the informal care system impacts on the formal care system, and vice versa. If the informal care system gets weaker, it puts more pressure on the NHS, and if the informal care system gets stronger, it takes some pressure off it. These are important points about sustainability, and any future commission needs to be thinking about these as well as how to finance the NHS.

A lot has been said about prevention, but we also need to think about this in a different way as being a positive term, sometimes called “health promotion”. It is about the creation of a resilient, healthy population and society. The Minister knows that I have a debate—later in the autumn, I hope—on what I call “health creation”, which is precisely what we are talking about here. There are two simple points here, and I will not go any further: we need to think about sustainability in the round, and the NHS itself cannot make itself sustainable—others have to play a major role in that.

My second point is that looking at financing is right, and clearly we need to chase improved efficiency at every level. However, we should not hope for too much from a review of a new financial model. I will give just two examples from around the world—again, I do not have time for more. Holland changed its system with great fanfare about five years ago so that it consisted of private insurers which then purchased from anybody. The net result of that, which was probably predictable, was that unit costs have gone down and volumes have gone up, and Holland, which now spends 25% more than we do, is spending more than it did. That was an experiment in changing the financial arrangements.

I will not talk about co-payments—that is, getting people to pay as well—other than to say that all the studies show that if they are to be big enough, they will affect both the poor and the rich: they affect the behaviour of the rich, who then go elsewhere, while the poor cannot afford to pay for services. You can have small co-payments, but large ones have those impacts. My point is that we must look at how the NHS is financed—I understand and agree with that point—but we should not hope for too much from what others around the world have done.

My third and final point is that in the short term you cannot take politics out of the NHS. To go back to Holland, the Dutch Government do not directly run hospitals, but the Dutch Health Minister gets all the questions about hospitals in his Parliament anyway. However, we can have a cross-party consensus about the longer term.

I will quote from a Portuguese report—if noble Lords allow me, I will say it in English; indeed, your Lordships may prefer me to do so. Portugal is trying to transition from today’s hospital-centred and illness-based service system where things are done to or for a patient to a person-centred and health-based one where citizens are partners in health promotion and healthcare. It will use the latest knowledge and technology and will offer access to advice and high-quality services in homes and communities as well as clinics and specialist centres. It will provide a better service with lower infrastructure costs. That is Portugal’s aim over 25 years. It will not be difficult for us to construct that sort of consensus and vision about where we are trying to go, but we need to understand that that is a radical change. If we are to have a radical change and we are pointing in that direction, we need a clearer longer-term plan than the five-year plan we have, and we need the sort of transition fund that some people are arguing about.

My final point is that I absolutely agree with the proposal of the noble Lord, Lord Patel, that there should be an independent reframing of the arguments, which will bring other people into the argument so that the same people are not having the same arguments, which has often been the case in the past. To do that, the starting point is to create that shared vision of where we are going, so at least we have something to steer towards, and we need to understand that sustainability is about these wider social impacts, not just about the efficient management of money within the NHS, important as that is.