National Institute for Health and Care Excellence

Lord Prior of Brampton Excerpts

Monday 13th July 2015 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government why the National Institute for Health and Care Excellence was asked to suspend its work on safe staffing guidelines regarding nurses.

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

The Government are committed to supporting NHS trusts to put in place sustained safe staffing by using their resources as effectively as possible for patients. The existing National Institute for Health and Care Excellence guidance on maternity settings and acute in-patient wards will continue to be used by NHS trusts. NHS England, working with NICE and other national organisations, will continue with this work in other areas of care and other healthcare professional groups.

[Lord Hunt of Kings Heath (Lab)]

I am grateful to the noble Lord, but that does not explain why NHS England put pressure on NICE to stop working on guidelines on safe staffing levels, despite the recommendation of Sir Robert Francis following the Mid Staffordshire inquiry. Was it because NHS England was no longer prepared to fund the implications of such work? Given that NICE has now decided to continue with work on A&E guidelines, will the Minister assure me that the Government will insist that the NHS implements those guidelines?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Lord is right that the responsibility for safe staffing is now with NHS England. It will take into account any advice given by NICE, whose guidelines for acute in-patient wards and maternity services still stand. The main reason why the responsibility has been transferred to NHS England has nothing to do with funding. It has to do with the fact that the new models of care, such as the new emergency care vanguards, are much broader than just A&E; therefore, we need to take into account other factors.

[Lord Willis of Knaresborough (LD)]

My Lords, this Answer does not empower any validation at all, unless we have criteria by which all trusts could be judged. We have the safer nursing care tool, which was produced in Sheffield and London and validated by Leeds University; it has been adopted by NICE and rolled out by the Shelford Group and other major trusts. This is a tool that would give all acute trusts the ability to judge safe staffing ratios based on acuity and patient need. Can the Minister give this House an assurance that that will be mandated to all acute trusts and then rolled out elsewhere?

[Lord Prior of Brampton]

I think it might be worth while for the House if I read out four lines from the NICE guidance on safe staffing:

“There is no single nursing staff-to-patient ratio that can be applied across the whole range of wards to safely meet patients’ nursing needs. Each ward has to determine its nursing staff requirements to ensure safe patient care. This guideline therefore makes recommendations about the factors that should be systematically assessed at ward level to determine the nursing staff establishment”.

I read out that paragraph because it is important to realise that every ward is different. Where there are tools to help assess the acuity of patients in wards, those tools will be used. I do not think we are planning to mandate any particular tool at this time.

[Baroness Gardner of Parkes (Con)]

Twice I have raised with the Minister the question of a different standard of training, particularly that of entrants to nurse training. We face this great shortage. He has replied to say that the Government have it in mind to introduce such a thing. Will he tell us more about what they are proposing and when?

[Lord Prior of Brampton]

I am sorry—I did not quite understand the question. I realise that I cannot ask my noble friend to repeat it, so I wonder whether I could pick it up with her outside the House.

[Baroness Walmsley (LD)]

Is the Minister aware that in Wales 12% of NHS staff have made complaints about staffing levels in the past few years? Will the Minister join me in welcoming the fact that the Labour Government of Wales will be held to account for that next year?

[Lord Prior of Brampton]

From what I understand, the problems in Wales mean that there is a lot more for the Government to be held to account for there.

[The Countess of Mar (CB)]

My Lords, from personal observation from being in hospital, nurses spend a awful lot of time behind a desk ticking boxes when it would be much more helpful and better for patients if they could deal with patients more. Is there any way of alleviating the need to fill in boxes so that they can look after patients? Can they cut the paperwork?

[Lord Prior of Brampton]

The noble Countess makes a very insightful point. Non-productive time—by which I mean the time when nurses are not dealing directly with patients—varies considerably, but the average seems to be about 20% to 25% of their time. The better-organised wards—which takes me back to an earlier point—where there is strong local leadership from the ward sister will be organised in such a way that staff will spend much more time with patients. I agree entirely with the noble Countess’s point.

[Lord Swinfen (Con)]

My Lords, is part of the problem due to the specialisation of nurses? Are far too many of them being trained only as specialists so that they are therefore unable to be moved from one part of a hospital to another? Would more general training be better?

[Lord Prior of Brampton]

I do not think that is a problem. In many ways, in acute hospitals we lack generalists. That is true of consultants as well of nurses. That is actually my noble friend’s point. Possibly there are too many specialists, but on a cardiac ward or a specialist acute ward you need specialist nurses who know how to operate the equipment as well as how to look after the patient. You need a good balance between the two but, if anything, I fear we have, as my noble friend said, become too specialist and insufficiently generalist.

[Lord Roberts of Llandudno (LD)]

My Lords, what is the Minister’s opinion of the Government’s decision to deport nurses from overseas who do not reach the £35,000 a year income level within five years?

[Lord Prior of Brampton]

The noble Lord raises a good point. We need to train as many of our own nurses as possible. There will be times when we get those calculations wrong and it will be necessary to bring in nurses from overseas. That is not a desirable outcome for many reasons, which there is not time to go into today. We need to train more ourselves.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister have another go at the Question? I still fail to understand why an independent body, NICE, was instructed by NHS England to discontinue work on safe staffing guidelines. What on earth caused NHS England to do that?

[Lord Prior of Brampton]

NICE has not been instructed to cease its work on safe staffing standards; on the contrary, it has been asked by NHS England to provide it with appropriate guidance.

[Baroness Meacher (CB)]

My Lords, the noble Countess rightly raised the amount of time that nurses spend filling in forms and ticking boxes. Is the Minister aware that much of this work comes from the rather microregulatory requirements of the regulatory bodies, and indeed NHS London? There are some very precise measurements, and if those were monitored carefully government Ministers and NHS England would know well whether services were being managed properly. Would the Minister consider revisiting the degree of microregulation of our health services?

[Lord Prior of Brampton]

I am not entirely convinced by the argument about regulation when it comes to managing wards. My own observation is that when you have strong leadership from strong ward sisters, ward managers or charge nurses, many of the problems that we identify seem to disappear and there is very high staff morale, low absenteeism and little use of agency staffing. So much comes down to local leadership, and sometimes regulation is used as a scapegoat.

[Baroness Brinton (LD)]

My Lords, given that everyone accepts that the new safer staffing guidelines will require more nurses, what will the Government and Health Education England do to reduce the number of nurses who do not qualify from their training, which is currently running at about 20%?

[Lord Prior of Brampton]

That is a very high figure. It is quite revealing that most of the people drop out in their first placement, and it behoves universities and Health Education England to ensure that they are recruiting new nurses who have done some work in a care home or hospital so that they know what the realities and practicalities of being a nurse are.

Health Funding

Lord Prior of Brampton Excerpts

Thursday 9th July 2015 Lords Chamber

[Baroness Walmsley]

To ask Her Majesty’s Government whether they carried out an equality impact assessment before deciding on the recent in-year budget cut to public health funding.

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

My Lords, we pay close attention to equalities considerations when deciding how to distribute the public health grant between local authorities. The Department of Health is about to consult on how to implement the savings and we will address our equalities duties in full when announcing our final decisions.

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for his reply, but given that these cuts will impact on teenage pregnancy programmes for the young, domestic violence programmes for women, HIV prevention programmes for gay men and some members of the BME community and TB prevention programmes for the poor and homeless, will he say where the equality is in that?

[Lord Prior of Brampton]

The noble Baroness will know that decisions on these matters are left to local authorities, and we wish to give them as much discretion as we can.

[Lord Hunt of Kings Heath (Lab)]

My Lords, there is not much discretion if the Treasury decides to take away £200 million in-year on public health programmes from local authorities. If the intention is to squeeze the public health budget, will the Government therefore take action at national level to compensate for this by legislating to reduce the amount of fat, salt and sugar in food and drinks that are aimed mainly at children and young people?

[Lord Prior of Brampton]

My Lords, prevention is very important to the Government and a very important part of the NHS Five Year Forward View. The reduction of £200 million in the grant to local authorities should be seen in the context of a total grant of £3.2 billion; it is a 6% reduction. Public Health England has a campaign to raise awareness of the damage that sugar and salt, as well as smoking and alcohol, can do to people’s lives.

[Baroness Howarth of Breckland (CB)]

My Lords, if the noble Lord takes into consideration not only the cuts to this budget but those to other local authority budgets, he will see that this will mean a reduction in youth services, the closure of young people’s centres and a range of preventive services for children being reduced. Will that not have a cumulative effect on the general health of the nation, and certainly on the protection of children?

[Lord Prior of Brampton]

My Lords, the NHS is facing a challenge over the next five years to achieve productivity savings of some £22 billion. If we wish to have a sustainable, tax-funded health service in the long term, we have to make these savings. I have no doubt that over this time this will cause difficulties, but, again, it has to be seen in the context that we have a national debt of more than £1 trillion and a public sector borrowing requirement that must come down.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, does the Minister not agree that, of all the places to cut the National Health Service budget, it is incredibly short-sighted to do so in areas to do with prevention because, although there may be short-term savings to be made there, in the long term it will build up problems which will cost a great deal more in the future?

[Lord Prior of Brampton]

I repeat my earlier response that prevention is extremely important. We are looking at a relatively small reduction of £200 million out of a total public health budget of more than £5 billion.

[Baroness Masham of Ilton (CB)]

My Lords, does this mean that campaigns on alcohol and drug abuse will be cut? Is the Minister aware that there is a great increase in liver disease and hepatitis C?

[Lord Prior of Brampton]

The decisions about which services to reduce must lie with local authorities.

[Baroness Janke (LD)]

My Lords, does the Minister realise that many of the contracts for public health are already let in the medium term? Is the proposed cut on uncommitted funding, or are the Government proposing to give some help to local authorities who have no way of ending those contracts?

[Lord Prior of Brampton]

The noble Baroness raises a good question. This will be a crucial part of our consultation, which will take place very soon.

[Lord Harrison (Lab)]

Does the Minister not recognise that, as was the case in our recent debate on diabetes, wise investment in public spending on health can save billions later, not only in terms of the tragedies in the lives of people who experience suffering from something such as diabetes but also in the weight placed on the public purse to fund the health service?

[Lord Prior of Brampton]

I agree fully with the noble Lord. Early prevention is crucial, not just for diabetes but for a whole range of mental health issues as well, and prevention will remain a critical part of the five-year forward view.

[Lord Mawhinney (Con)]

My Lords, will my noble friend make arrangements for someone to survey local supermarket shelves and record the number of items for sale that have either no added sugar or are sugar free? Will he then arrange for a similar survey to be conducted among the major supermarkets in the United States? After which, will he explain to us what government policy will be applied to try to get us even in the same vicinity as the sugar reductions that are available to American purchasers?

[Lord Prior of Brampton]

My noble friend raises a very interesting point. I will certainly bring it to the attention of Public Health England and, depending on its reaction, I will be happy to come back to the House and give the noble Lord the answer to his question.

[Lord Howarth of Newport (Lab)]

My Lords, the Government are placing new duties on local authorities in terms of the anti-drugs strategy, and Public Health England, very rightly and admirably, is seeking to develop its contribution to the strategy ambitiously and appropriately. Will the Minister ask his right honourable friend the Secretary of State for Health to give a very strong moral lead, at least to urge local authorities not to reduce spending in this area, which is so crucial to the health and safety of young people in particular?

[Lord Prior of Brampton]

I will certainly have a word with my friend the Secretary of State for Health. Clearly the Government have an important role in this area; I will have a discussion with him and come back to my noble friend.

[Lord Patel (CB)]

My Lords, this is my first opportunity to ask the noble Lord a question and I welcome him to his new brief. If he were looking at the evidence-based delivery of services, the evidence shows that 40% of illnesses are related to lifestyle. If that is the case, why do we not have a national plan for public health and prevention of disease, rather than leaving it to local authorities, where it will vary?

[Lord Prior of Brampton]

The noble Lord raises an interesting point, which we may come back to in the debate later. Public health spending is divided into two: £3.2 billion is decentralised to local authorities and the remaining amount, some £2 billion, is retained by Public Health England—which does have a national plan, but it may be that the plan could be better articulated.

National Health Service: Sustainability

Lord Prior of Brampton Excerpts

Thursday 9th July 2015 Lords Chamber

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

My Lords, I thank the noble Lord, Lord Patel, for introducing this fascinating debate, which has covered a very wide range of subjects. I hope noble Lords will forgive me if I do not address all their questions; I may not even be able to refer to all of them by name. That is not because I did not note what they were saying but because there is just not enough time to go into what they said in detail. I do have a speech here but I am putting that to one side because I do not think it does justice to the issues that were raised today. I have some notes here instead. I will come back at the end of my speech, if that is acceptable, to discuss whether or not there should be an inquiry and, if so, what kind of inquiry or investigation it should be.

I have a reputation at the Department of Health for being a bit of an Eeyore character because we often hear about great changes that are going to happen in the NHS but they never quite materialise. Perhaps we should stand back from the NHS for a minute. Every healthcare system in the developed world is facing almost exactly the same issues of sustainability that have been posed in the debate today. Most extreme is probably the United States of America, where healthcare accounts for over 16% of GNP. I worked in America for some time in the 1970s and I saw the cost of healthcare, which was largely loaded on to employers, literally destroy large parts of the steel and car industries. We may wish to explore alternative charging systems or different funding systems, but just moving the cost away from the state—from taxation—to insurance has not actually solved very many problems.

Ironically, perhaps, in the light of today’s debate, the NHS is probably one of the most affordable healthcare systems in the developed world. It consumes between 7% and 9% of GNP. In Germany and France, healthcare takes between 10% and 12%. We are about average across the OECD countries but among our peers we have a relatively cheap and successful healthcare system. I was talking to people from the Mayo Clinic recently and they rate the British system as the highest-value healthcare system in the world. So we should not get too depressed about the NHS. Noble Lords have referred to the Commonwealth Fund report, Mirror, Mirror on the Wall. In every category bar one the British system is first, and that is comparing it with all the other best healthcare systems in the world.

As my noble friend Lord Mawhinney pointed out, in 1947-48 we were spending 3.5% of GNP on healthcare—£400 million in the first year—and employing a few hundred thousand people. Clearly, since then the resources going into healthcare have expanded exponentially, and will continue to grow. The demographics, the cost of new drugs and procedures, and rising consumer expectations will drive that increase. We have heard a lot today about the importance of early prevention. That is an area we ought to explore further. As the noble Lord, Lord Crisp, mentioned, that kind of assessment should go well beyond traditional health topics.

These pressures are common to all developed systems. It matters not how you fund the system, the pressures will still be there. My noble friend Lord Fowler was not impressed by the mention of Derek Wanless. I will quote just one small part of his report. He concluded that:

“Private funding mechanisms tend to be inequitable, regressive … have weak incentives for cost control, high administration costs and can deter appropriate use”.

If the noble Lord does not like Wanless, I will quote him the recent OECD report, which is only months old. It says that,

“no broad type of healthcare system performs systematically better than another in improving the population’s health status in a cost-effective manner”.

There is at least no evidence to suggest that a tax-funded system is less effective or efficient than any other system. Indeed, tax funding allows the collective pooling of financial risk across the whole population for collective benefit. It is this pooling of risk that makes the NHS probably one of the lowest-cost systems in the world. I see that the noble Lord, Lord Lawson, has just arrived. That reminds me of his quote:

“The National Health Service is the closest thing the English have to a religion”.

Actually, you do not need just belief to think that the NHS is an efficient system—there is plenty of evidence as well.

The real question is: which healthcare systems are best equipped to beat this rising level of demand over the long term? In most industries, the forces of change that have driven productivity improvement—because in the long run everything depends on productivity improvement—have been driven by globalisation, by competition, as the noble Lord, Lord Warner, mentioned, and by consumer choice. But those drivers are weak in healthcare. The previous Labour Government tried to bring in more competition and a lot more private sector involvement. They would probably have to admit that they were disappointed by the impact. Actually, the market does not work as well for healthcare as perhaps they would have wished.

The market does not work so well in healthcare—in any country—because there is information asymmetry in the market: the patient will always be less well-informed than the professionals in the system. It is difficult to measure the quality of care. Even in a very transparent system, as we are moving to in this country, it is difficult for patients to determine which professional in which hospital is delivering the best care. It is very difficult to assess relative quality across providers when systems are so complicated. The market structure is difficult. Inherently, there will be natural monopolies, which limit choice and competition. You cannot have two or three A&E departments operating in close proximity. There are very significant barriers to both market entry and exit. Finally, of course, there is the nature of the good itself. It is very hard to rectify things—you cannot just “send it back” when you have experienced death or serious harm in a hospital. The market will always be limited in healthcare.

How are we going to get these improvements? How are we going to drive the kind of productivity improvement we need in the health service in the absence of a market? This is the crucial question as to whether or not our system is sustainable. If we are not able to get the productivity improvements set out in the NHS Five Year Forward View, the sustainability of our system is very much in question. The answer that we are supporting in the five-year forward view is multifaceted. We want to see new models of care.

The noble Lord, Lord Turnberg, gave an interesting example of how in his own speciality of gastroenterology the tariff structure can lead to completely the opposite result to the one that was intended when the tariff was introduced. The only answer to the question that he posed is a much more integrated structure, where capitated payments are made and there are integrated models of care. The days of the stand-alone acute hospital are gone—if they were ever there. No man is an island; no acute hospital is an island. There may be a few hospitals—perhaps in London or Cambridge—which have tertiary and teaching income and can plough their own furrow, but I would argue that the vast majority of acute hospitals must integrate much more with their local healthcare and social care systems.

A number of noble Lords pointed out the deficits that are currently mounting up in acute trusts. It is interesting that it was a Labour Government who introduced foundation trusts. Perversely, although it was not the intention at the time, foundation trusts make it more difficult to integrate. Rightly, in many ways they are obsessed with their own profit and loss accounts and balance sheets and are unable to look more broadly across the system. We will see new models of care.

The noble Lord, Lord Reid, a former Health Secretary, made reference to purchasing. In his review, the noble Lord, Lord Carter, looked at purchasing, workforce, patient flow through hospitals, medicines management and estates. The review has looked at the whole spectrum of where cost savings could be achieved, and has come up with a figure of approximately £5 billion. That figure is small in relation to £22 billion, but the noble Lord went on to say in that interim report that he believes there are many more savings to be had from getting better patient flow through the system. He has drawn attention in various meetings to the fact that some 20% of patients who are medically fit to be discharged are still in hospital beds. That goes back to the issue of better integration. If we can crack patient flows through the system, I am sure that the productivity benefits will be substantial.

I am not as pessimistic as other noble Lords who think we cannot make those savings. The noble Lord, Lord Desai, talked about the demand side, which we have to address as well. Through a combination of supply-side and demand-side measures, we have a good chance of achieving the kind of savings set out in the Five Year Forward View. There is considerable consensus around that document. Although the Labour Party did not commit itself during the lead-up to the election to the extra funding required, there was certainly concern on the Liberal Democrat Benches and on our side—and I suspect on the Labour side as well. It would be a great pity if we were to ask for another review now, when we have considerable consensus around the Five Year Forward View.

The noble Lord, Lord Patel, raised the fundamental issue of the balance between the state taking responsibility for healthcare and individuals taking responsibility. We have often been long on rights and short on individual responsibilities. Other noble Lords have mentioned alcohol, smoking, diet, exercise and personal responsibility. That issue would benefit from more debate. There is a social contract between the state and the citizen—a contract which often seems to be very one-sided.

There is a strong moral argument for the NHS. In the latest opinion poll on the question whether people wish to have a tax-funded system, free at the point of use, providing comprehensive care to all citizens, about 90% of people were in favour of what we have. To some extent you can phrase the question to get the answer you want; however, it is remarkable that a state-run monopoly, after some 70 years, still has the degree of public support that the NHS has. To some extent, we tinker with the NHS at our peril. It is one of the only institutions we have that provides the same care—or service—to rich and poor, the lucky and the unlucky, to people born with a good genetic inheritance and those who are not. It is part of the glue that holds our society together, and I would not wish to be responsible for weakening those links. So, we have to be very careful in the messages that we give out as politicians.

However, I have listened to the debate and the strength of feeling about whether we should take a longer-term view that goes way beyond this Parliament. The sustainability of the health service is an issue that extends out 20 years, probably, but it is one that every developed country faces. I would like to meet the noble Lord, Lord Patel, and maybe two or three others, to discuss this in more detail to see whether we can frame some kind of independent inquiry—I do not think that it needs to be a royal commission. We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund. The issue is: what will the long-term demand for healthcare be in this country in 10 or 20 years’ time? Will we have the economic growth to fund it?

At heart, our ability to have a world-class health system will depend on our ability to create the wealth in this country to fund it. I am personally convinced, having looked at many other funding systems around the world, that a tax-funded system is the right one. However, if demand for healthcare outstrips growth in the economy for a prolonged period, of course that premise has to be questioned.

In conclusion, perhaps I might address issues such as whether there should be an independent inquiry with the noble Lord, Lord Patel, after today’s debate. I thank all noble Lords who have contributed to the debate for raising some very important issues.

Health: Children and Young People

Lord Prior of Brampton Excerpts

Tuesday 7th July 2015 Lords Chamber

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

My Lords, first, I congratulate the noble Baroness, Lady Hollins, on securing this debate. One advantage of the debate having quite a broad title is that one does not quite know where noble Lords will be coming from.

I shall start with schools, and I declare an interest. I was a founder of two free schools and, until recently, I was chairman of a free school and an academy group of schools in Norwich. It is good that they have freedom to decide on things such as school meals; it is right that academies should have that freedom. I spent last week talking about a sports strategy for our schools. Competitive sports and physical exercise are extremely important, and I do not agree with the noble Lord, Lord Hunt, that the curriculum crowds out those activities. One can make room for them. I agree very much with the noble Lord, Lord Northbourne, that not just in secondary schools but in primary schools such activities are essential in building up young people’s self-esteem, self-worth and a sense of purpose, whether they are doing competitive sports, the Duke of Edinburgh’s gold award or any schemes of that kind. They are hugely important.

The thing that ran through the speech of the noble Baroness, Lady Hollins, and many other speeches, was early prevention. We have had four debates on this subject in the last few weeks. What I have learnt most is the importance of early prevention, right through to early pregnancy—and indeed before.

I also draw attention to the comments of the noble Baroness, Lady Stedman-Scott, on the importance of the family. Other noble Lords have also stressed that. There is no substitute for family; the state can never be a substitute for the family. The noble Baroness put a figure of £48 billion on the cost of family breakdown but that does not do justice to, or begin to reflect, the family misery that that encompasses. The noble Earl, Lord Listowel, drew our attention to the number of families growing up without a father. He mentioned that the figure will be 35% by 2030, according to an OECD report, which is truly frightening.

I hope that I can pick up a number of other points made by noble Lords. I was shocked by the comparison between our performance and that of Sweden. I have not seen that figure before. Infant child and adolescent death rates in the UK have declined substantially, but the overall UK child mortality rate is higher than that of some other European countries. I had not realised that as many as five more people under the age of 14 die each day in our country compared with Sweden. I think that that is what the noble Baroness, Lady Hollins, said. Sometimes numbers can detract from an argument; that number certainly adds to this one. The Why Children Die report by the Royal College of Paediatrics and Child Health stated that there is no single cause for the disparity between countries and, equally, there are no simple solutions. I have no doubt that inequalities of health and of life contribute more than most to that rather startling statistic.

If I have time, I shall talk about three broad areas: ensuring that children are properly supported by health services; steps to ensure that children can live healthier lives; and those services that ensure that we can protect our children. I will leave the issue of child slavery, raised by the noble Baroness, Lady Hollins, for another day. Perhaps I may write to her on that?

Starting with maternity, what happens in pregnancy and in the early years of life has a long-term impact. There can be no doubt about that. We have made some achievements over recent years. Again, I am not sure that the numbers add much to the argument, but I have a list of the additional midwives and midwifery-led units, and of the extra money that we have spent in this area. I do not think that that adds much to the argument because we know that much more can be achieved.

Noble Lords are probably aware that my noble friend Lady Cumberlege is leading a major review of maternity services and that the Government will provide an additional £75 million over the next five years for services to support women with mental health issues in the perinatal period. We heard in an earlier debate from, I think, the noble Baroness, Lady Walmsley, who said that one in five children whose mother suffers from mental illness—postnatal depression—will, in turn, suffer from mental health problems. That was another point that the noble Earl, Lord Listowel, made: there is a cycle to these things. If a child is brought up in a family that has suffered a breakdown, there is more chance that, in turn, that child’s family will also suffer. I know from personal experience how mental health, whether for genetic or other environmental reasons, can dog families through the generations.

Support in the community in early years is provided through the Healthy Child Programme, led by health visitors and their teams. Over the last four years, a major programme to revitalise the health visiting workforce has taken place, with 4,000 new health visitors now in post and a further 9,000 completing training. I ought to mention, although it is not an easy question, the £200 million that has come off the public health budget, as raised by the noble Lord, Lord Hunt. I hope that the noble Lord will allow me to defer an answer to that until the Question that will be asked on it early next week. From September 2015, health visitors and early education practitioners will deliver integrated reviews with the aim of giving families and health and education professionals a more complete picture of child development.

A number of noble Lords raised obesity. Childhood obesity is clearly a huge issue. The latest estimate of the cost to the NHS of overweight or obesity-related conditions is £5.1 billion, but of course obese children are more likely to become obese adults, with all the health conditions that go with that. The noble Lord, Lord Hunt, said that he detected signs of passion in NHS England, reflected in the NHS Five Year Forward View, about this subject and about prevention more generally.

There is a wider debate to be had about the role of government, how much legislation we want in this area and how much we rely upon personal responsibility. If we bring tax into these areas, for example, does that fall disproportionately on the very people who can least afford it? These are big issues and I do not think there is a right or a wrong answer.

It is not acceptable that one in five children leaves primary school clinically obese—that is, obese children aged 10 and 11. Obese children are more likely to be ill, absent from school, and suffer psychological problems than children with normal weight. While some progress has been made, we know that we must go much further. We have invested £222 million in programmes such as the PE and sport premium for primary schools, School Games, and Change4Life Sports Clubs. Last week we launched this year’s Change4Life 10-minute shake-up campaign with Disney, which encourages children to do 10-minute bursts of moderate to vigorous activity, inspired by Disney characters. I guess it is a fact that we cannot do enough in this area and there is a lot more that we, schools, families, parents and society could do. Clearly, there is a role for government but it is easy to say always that government should do more.

I should touch on preventing domestic abuse and child sexual abuse. As part of our strategy to prevent violence and abuse towards women and girls, we are providing tools and guidance for health and care professionals to enable them to better identify cases of violence and enable the young people affected to access the right therapeutic support. Routine inquiry into domestic abuse is expected to be undertaken in maternity and adult mental health services. Following publication on 3 March of the Government’s report, Tackling Child Sexual Exploitation, this will be expanded to settings used by children at risk of sexual abuse, including mental health services for people over 16 years old.

Last week, the Care Quality Commission published the results of its children’s in-patient and day case survey. I was going to talk about this but as no noble Lord raised it I will leave that for another day and move on to children’s mental health. It is an issue that we have discussed before but it is important to say that the Government are committed to spending an additional £1.25 billion over the next five years. That is a huge increase in the budget. This is on top of the £150 million for children and young people with eating disorders. That has to be one of the most shocking and ghastly illnesses that any child or family has to cope with.

This Government have also introduced the first ever waiting time standards for mental health. I think it is too early for me to report back to the noble Lord, Lord Hunt, on how that is going. Parts of these standards will apply to children and young people, including the target of treatment within two weeks for more than 50% of people of all ages.

I am afraid that my time is up. This has been a very quick whistlestop tour of some very important issues. I thank the noble Baroness, Lady Hollins, for bringing this debate to the House.

House adjourned at 7.38 pm.

Health: Diabetes

Lord Prior of Brampton Excerpts

Thursday 2nd July 2015 Lords Chamber

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

My Lords, I thank the noble Lord, Lord Harrison, for introducing this very interesting debate—I have certainly learned a great deal. I will reflect on a number of themes that came out of the debate before turning to my prepared speech, and obviously I will come back to education and prevention.

First, I was struck by the contributions from noble Lords who have suffered directly from type 1 or type 2 diabetes—the concept of the expert patient is clearly very strong and important here. The noble Lord, Lord Harrison, looks very well on it: he has obviously looked after himself extremely well. Self-care will be a very important part of going forward. Secondly, we have to do better on education. The noble Baroness, Lady Young, made some interesting suggestions about how we can increase the uptake of education. The work that Diabetes UK does is terrific. It must be one of the most active charities in dealing with these terrible long-term conditions. Thirdly, on the relationship between diabetes and other long-term conditions—be it stroke, cardiovascular disease or other things—the number of people now living with multiple, very complex long-term conditions is a huge challenge for the National Health Service. That challenge was simply not there in 1948 when the NHS was set up. We have to change the way in which we deliver care very radically to address these issues.

The noble Baroness, Lady Masham, talked about the importance of diabetic specialist nurses who provide a tremendous resource to people suffering from diabetes. The noble Viscount, Lord Falkland, talked about the growing use of technology and referred to the artificial pancreas, which was also mentioned by the noble Baroness. That illustrates another huge challenge to the health service, as many of these developments will be hugely expensive. Whether a tax-funded healthcare system can afford these very expensive treatments will be a big challenge for the National Health Service as we go forward.

Over the past year I have heard many things said about the five-year forward view but never before have I heard it said that it made someone feel frisky. However, I am pleased that it made the noble Baroness, Lady Young, feel that way. The five-year forward view recognises the challenge of long-term, difficult conditions such as diabetes, and it offers a way of dealing with them. The noble and learned Lord, Lord Morris, referred to medical research, particularly into type 1 diabetes. His concern was that type 1 diabetes was getting less attention than type 2 diabetes, a point that was very made well.

Diabetes is a priority for the Government. Frankly, it would be a priority for any Government, because more than 3 million people—probably nearer 4 million people—have been diagnosed with diabetes and maybe a further 500,000 are undiagnosed. The noble Viscount, Lord Falkland, was one of those undiagnosed people. With a blood sugar of more than 29, I think he said, it is remarkable that he is still here with us. I am very pleased that he is, but that just illustrates the fact that many other people have it less catastrophically badly than the noble Viscount and are undiagnosed.

Diabetes is directly responsible for some 5,000 deaths per year and is a major contributor to causes of premature mortality, such as heart disease and stroke. The noble Baroness, Lady Masham, described her husband’s conditions as both diabetes and strokes. There are, I believe, 22,000 avoidable deaths attributable to diabetes each year. This is a very serious illness. It not only has huge and tragic consequences for many individuals, but, as we have been told by other noble Lords, is a cost to the NHS of some £10 billion a year and a much wider cost to the economy as a whole.

On prevention, the noble Lord, Lord Harrison—I thank him for giving me sight of his speech before the debate—spoke of his personal experience of living with type 1 diabetes. Although we know that type 1 diabetes is not preventable, it is estimated that some 80% of type 2 diabetes is indeed preventable.

I thank the noble Baroness, Lady Manzoor, for her contribution. I apologise to the noble Baroness, but I was not going to address the international implications of diabetes. The statistic that she gave—that some 387 million people suffer from diabetes worldwide—is indeed sobering. I know from experience that in some parts of the world, for example in the Middle East, prevalence of diabetes is particularly strong. Her points about co-infection with TB were well made. I am very happy to put the noble Baroness in touch with my opposite number in DfID if that would be helpful.

The NHS diabetes prevention programme is a joint commitment from NHS England, Public Health England and Diabetes UK to help people identified as being at high risk of developing type 2 diabetes to take personal responsibility for lowering their weight, increasing their physical activity and improving their diet. It will be the world’s first national at-scale prevention programme. It will link into the NHS health check programme—commissioned by all upper-tier local authorities—which invites adults between the ages of 40 and 74 to a check for risk awareness, assessment and management of the key risk factors leading to premature death and disability in England. These checks take place every five years and include a diabetes risk assessment and blood test for those at risk, which could enable early detection of 4,000 cases of diabetes each year. Since the programme began, more than 10.5 million NHS health checks have been offered and more than 5.2 million checks have been undertaken. The fact that that is only 50% take-up reinforces the point made by the noble Baroness, Lady Young, that we should be able to do more about marketing these schemes to ensure a higher take-up.

On patient education, the noble Lord, Lord Harrison, and other noble Lords stated that once a patient is diagnosed with diabetes, education is vital in ensuring that they can manage their condition as effectively as possible. We have heard that GPs in some cases perhaps do not give sufficient encouragement for sufferers of diabetes to do this. There has been an interesting observation that companies, through their corporate and social responsibilities, should do more to ensure that their staff and employees take up the opportunities for better education.

The NHS Five Year Forward View sets out a clear ambition to do more to support people with long-term conditions to manage their own health and care. To achieve this, NHS England has set up the Realising the Value programme, which will help strengthen the case for change, identify a set of evidence-based approaches and develop tools to support their wider implementation across the NHS and local communities.

The NICE quality standard for diabetes sets out that people with diabetes should receive a structured educational programme as this is key to ensuring that they are able to manage their condition as successfully as possible. Sixteen per cent of people newly diagnosed with diabetes were offered structured education in 2012-13, compared with 8.4% of those diagnosed in 2009, so there is improvement but from a very low base. In the same period, the number of people newly diagnosed with diabetes offered or attending structured education rose from 11% to 18.4%. I can only agree with noble Lords and the noble Baroness, Lady Young, that that is still far too low and that we must do more to increase that take-up. I agree with the noble Lord, Lord Harrison, that sharing best practice across areas is vital in increasing patient education.

To support this, we have increased transparency through the creation of Healthier Lives: Diabetes, Hypertension and NHS Health Check. This is a major online tool from Public Health England which has revealed large variation in the prevalence and treatment of diabetes. I am afraid that variation exists between hospitals as well.

The clinical commissioning group outcomes indicator set also provides clear, comparative information for CCGs, health and well-being boards and local authorities. I think that eliminating variation is the only way of addressing the postcode lottery to which the noble and learned Lord, Lord Morris, referred. I could refer him to PHE’s atlas of variation, but the more we can publish about the performance of individual CCGs and, indeed, GP practices, the more we can eliminate variation.

I turn to children’s education. The most recent national diabetes audit report noted that the take-up of patient education was particularly low among younger people who develop type 1 diabetes in childhood. To incentivise improvements, the best practice tariff for paediatric diabetes provides an annual payment for the treatment of every child and young person under the age of 19 with diabetes, providing that 13 standards of care are met. One of these standards is to ensure that each young person has received a structured education programme tailored to meet their and their family’s needs, including their carer’s needs—a number of noble Lords referred to that—both at the time of initial diagnosis and ongoing updates throughout their attendance at the paediatric diabetes clinic. The noble Lord, Lord Harrison, referred to the important role of pharmacies in this regard. Increasingly, we will see a primary care system which is not just a traditional GP practice but encompasses pharmacy and other activities, and perhaps hospital outpatient clinics.

Once again, I thank the noble Lord for highlighting this vital issue. The Government are fully committed to combating and preventing diabetes. I hope I have demonstrated that we are working hard—although we are by no means fully satisfied yet with our results—not only to ensure that those who have diabetes are empowered to manage their condition as effectively as possible, but that those who are at risk of diabetes are given the tools, knowledge and support they need to reduce their chances of developing it.

House adjourned at 6.24 pm.

NHS: Whistleblowing

Lord Prior of Brampton Excerpts

Tuesday 30th June 2015 Lords Chamber

[Lord Desai]

To ask Her Majesty’s Government what is their policy on whistleblowing in the National Health Service.

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

My Lords, the Government are committed to improving openness in the NHS and ensuring that whistleblowers are considered an asset and receive proper support. The Freedom to Speak Up report sets out principles and actions to help create a culture change in the NHS. It calls for local accountability, with system regulators providing national oversight and guidance. We will publish our consultation response on a package of measures arising from the review and next steps shortly.

[Lord Desai (Lab)]

I thank the noble Lord for that Answer, but is he aware that there is considerable anxiety among junior doctors, especially among those from a black or ethnic-minority background, that their career prospects may be harmed or they may even find their contract terminated if they are whistleblowers? Will he promise to take a look into that problem?

[Lord Prior of Brampton]

The noble Lord makes a very important point. There are many junior doctors from BME backgrounds who do indeed feel that it is difficult to raise concerns. One recommendation in Sir Robert Francis’s report is that every NHS organisation should have a local freedom to speak up guardian, which I hope will help. But whatever we do to change the law or codes from the GMC and others, it will not replace the need to have an open, transparent and learning culture in all NHS organisations.

[Baroness Walmsley (LD)]

My Lords, would it not be more likely that such discrimination as mentioned by the noble Lord, Lord Desai, would be stamped out if there were more black and ethnic minority members of staff at senior levels in the NHS? Is he aware that the proportion in London NHS trusts of those from a BME background is only 8%, compared to 45% in the general population and 41% among NHS staff?

[Lord Prior of Brampton]

The noble Baroness has probably read The “Snowy White Peaks” of the NHS, which sets out very clearly for all to see the really shocking lack of representation of people from BME backgrounds at senior levels of the NHS. This is an absolute priority. NHS England has appointed Yvonne Coghill to look at all the racial inequality issues, and she and NHS England have my full support in their endeavours.

[Lord Harris of Haringey (Lab)]

My Lords, I declare an interest as having two family members who work in the NHS. Further to the answer that he has given, will the Minister reflect on the fact that many trusts have contracts in which staff are warned that if they bring the trust into disrepute, they are likely to face disciplinary action? This has a stifling effect on whistleblowing and people raising issues of legitimate public concern with the media. Will he comment on that practice and what is going to be done about it?

[Lord Prior of Brampton]

In Robert Francis’s report, Freedom to Speak Up, he specifically mentions—I think it is in principle 13, from recollection—that there should be no such clauses in NHS contracts unless it can be demonstrated that there is indeed a true public interest. In any severance package in which there is a gagging clause of any kind, CQC is entitled to inspect those agreements during its inspections.

[Baroness Wall of New Barnet (Lab)]

My Lords, the duty of candour has made a big difference in hospitals to staff owning up if there is a difficulty or they have made a mistake in any part of their service. Does the Minister accept that there is a relationship between that and whistleblowing and with the guardians that are in existence in hospitals, such as in my own in Milton Keynes, where they are designated by the people in the department and so are trustworthy in the sense of how they are elected or selected? Does the Minister not agree that the duty of candour is making a difference to the whole culture of the health service being open and honest?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. The duty of candour, which puts an obligation on organisations to show candour, is making a difference. I congratulate the GMC and the NMC, which have spelled out clearly in their codes that the professional duty of candour is equally important.

[Baroness Masham of Ilton (CB)]

My Lords, if one was going to whistleblow, who would one contact?

[Lord Prior of Brampton]

There are a number of organisations that the noble Baroness might wish to contact, but most important is to raise the matter first in the local organisation. All organisations should have their own whistleblowing procedures, and that is the right way to raise concerns. If any individual finds that not to be satisfactory, the right way to proceed is through the Care Quality Commission, which has a dedicated hotline in its service centre in Newcastle.

[Baroness Brinton (LD)]

My Lords, which takes priority: duty of candour or an employee’s contract with their NHS trust where they are gagged?

[Lord Prior of Brampton]

The duty of candour should clearly take precedence. It should be seen in the context of an agenda to improve patient safety in hospitals; if we are not open about our mistakes, we will not learn from them.

[Lord McFall of Alcluith (Lab)]

My Lords, the experience of whistleblowers in the NHS is not for the faint-hearted, with lip service paid to internal hotlines. To ensure the maximum protection for genuine whistleblowers with no retribution whatever, is it not time that a legal duty of care towards them is imposed on NHS trusts?

[Lord Prior of Brampton]

The Government have taken a lot of action to help protect whistleblowers. I think that there is a limit to the law in this regard and the changing culture is more important. The Small Business, Enterprise and Employment Act 2015 places an obligation on NHS employers not to discriminate against people who have blown the whistle or raised concerns. I believe strongly that the law has a role to play in this but that we need a fundamental change of culture in the NHS.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord rightly expects a fundamental change of culture among NHS bodies, but does he agree that one way in which that could be helped would be if Ministers welcomed criticism from chief executives and leaders of those bodies of unrealistic expectation on the part of Ministers and of there being too few resources? Does he agree that such leaders are stamped on for making their views known, which is simply not conducive to encouraging openness in their own organisations?

[Lord Prior of Brampton]

The noble Lord makes a good point. If one looks back at the history of Mid-Staffordshire, one sees clear evidence that the priorities of that organisation were too skewed towards hitting financial targets and meeting other extraneous objectives such as becoming a foundation trust. The message to all NHS organisations should be that patient safety and quality of care come first.

Mental Health: Young People

Lord Prior of Brampton Excerpts

Tuesday 30th June 2015 Lords Chamber

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

My Lords, I congratulate the noble Baroness, Lady Tyler, on securing this important debate. Mental health is a key plank of this Government’s health policy and will certainly be highlighted in the mandate given to NHS England. Whether or not there will be an annual report, I can assure the noble Baroness that there will be clear progress reports on implementation.

A number of noble Lords said in relation to parity of esteem that words are cheap. The noble Lord, Lord Patten, said that we have parroted those words for far too long without putting resources behind them. Even after this new investment, if one today compares the kind of treatment that young children receive if they have cancer with the kind of treatment they get for severe psychosis or eating disorders, even though it may no longer be a Cinderella service I am afraid that the tag “Cinderella” would still be there until we have proven otherwise.

I am happy to confirm this Government’s commitment to transforming children and young people’s mental health and well-being. The Future in Mind report, published on 17 March, sets out a clear consensus and vision for improving services. In the foreword to that report, the NHS England chief executive, Simon Stevens, said:

“However in taking action there are twin dangers to avoid. One will be to focus too narrowly on targeted clinical care, ignoring the wider influences and causes of rising demand, overmedicalising our children along the way. The opposite risk would be to defuse effort by aiming so broadly, lacking focus and ducking the hard task of setting clear priorities”.

There is a real danger that one could fall between those two stools if one were not careful.

I can confirm that there will be an additional £1.25 billion allocated for improving children’s and young people’s mental health over the lifetime of this Parliament. This is in addition to the £150 million announced in the autumn Budget. The noble Lord, Lord Patten, and others made the important point that we are talking with mental health not only about a human tragedy but about a huge economic waste as well. On both counts this should be a major priority for this Government.

The first step in delivering the vision set out in Future in Mind will be the development of local transformation plans which will be produced collaboratively by local areas. The right reverend Prelate the Bishop of St Albans and the noble Baroness, Lady Walmsley, both mentioned the importance of local charities and voluntary groups in this area. We will not in any way ignore the vital role that they play. I am not familiar with the work of HeadStart, to which the noble Baroness and the noble Lord opposite referred, but I would like to find out about it after this debate. These plans will have an emphasis on local partnering and joint commissioning. I take on board the noble Lord’s comments about the number of different CCGs. When one spreads the money around CCGs it does not look all that much. I am not sure whether the noble Lord is suggesting that we should reduce the number of CCGs or increase the money.

NHS England and the De[apartment of Health are working with partners to jointly produce national guidance to support local areas to develop these plans. NHS England aims to publish its guidance in July.

I was struck by two comments in Future in Mind by two young people. One was:

“You have to fit into their paths and none of their paths fit you”.

The other was:

“Mental health isn’t a one size fits all treatment, it really depends on the person”.

The right reverend Prelate the Bishop of St Albans laid particular stress on the importance of co-ordinated care.

The Care Quality Commission report, From the Pond into the Sea, highlights the complexity and cliff edge that many children experience as they transition from children’s to adult services. We should be particularly focused on this area.

As well as the development of the local transformation plans, I am pleased to say that progress is also being made against many more of the Future in Mind proposals. We are expanding the highly regarded Children and Young People’s Improving Access to Psychological Therapies programme. This is due to increase access and coverage across England from 68% to 100% by 2018.

We are introducing waiting times. In particular, this will include a target of treatment within two weeks for more than 50% of people of all ages experiencing a first episode of psychosis. It was here that I thought that if you substituted “psychosis” for the word “cancer”, we would not be standing here feeling all that good about ourselves. It is not enough, but it is a start. It will go some way to help reduce the number of young people having to wait an unacceptable length of time to access services.

The noble Earl, Lord Listowel, and a number of noble Lords mentioned the prevalence study produced in 2004. We are doing a new prevalence study, as the noble Earl will know. One of the differences with the new study is that it will pick up the impact of social media on young people, which was not there in 2004—a point made by my noble friend Lord Patten. It will include 16 to 17 year-olds and older children as well.

We know that schools have a hugely important role to play in supporting and promoting good mental health. The noble Baroness, Lady Walmsley, raised the question of whether Ofsted in its inspections could look at the liaison with mental health services. The noble Baroness, Lady Tyler, pointed out the good work that is being done by Kingston Council. I will raise the issue of Ofsted with the Department for Education.

The noble Lord opposite raised the issue of the use of prison cells and Section 136. We covered that in a previous debate, so I will leave it today if I can.

We are working with the Department for Culture, Media and Sport to explore how we can better support and protect young people online to prevent damaging experiences and better support distressed users. We are also looking at how we can better use the internet and digital devices to provide clear information and advice to young people in an accessible and familiar environment.

A number of noble Lords raised the issue of vulnerable groups. We must ensure that the benefits of this transformation are felt by all children and young people. I was interested in the particular example mentioned by the noble Baroness, Lady Tyler, of a young man called Jay and the beneficial impact that a youth worker can have on a young person with complex and difficult issues. That gelled with a comment made by another noble Lord who said that we must not always be looking for evidence—rather, we must allow professional judgment to have full sway. Vulnerable groups include people from black and minority ethnic backgrounds who, as outlined in the 2014 report of the Institute for Health and Human Development, face additional barriers to mental well-being.

Perhaps I may briefly address the other two points made by the noble Earl, Lord Listowel. Of course I will be very happy to meet the noble Earl outside the Chamber to talk about looked-after children, particularly in the light of the NSPCC report to which he referred in his remarks. I have not seen it yet—I think that it comes out in a few days’ time. I will write to him about the other issue that he raised.

I turn back to prevention. The social and economic case for prevention and well-being promotion is set out clearly in Future in Mind and will form an important part of the Government’s work. There is no doubt that early intervention is crucial. I was struck by the remark made by the noble Baroness, Lady Tyler, that it is five times more likely that a child will suffer from depression later on if their mother suffered from perinatal depression. That is a new statistic for me and more evidence that you cannot do enough for people when they are very young. I shall quote from Future in Mind:

“We can all look out for those children and young people who might be struggling right now. We can confront bullying and we can make it OK to admit that you are struggling with your mental health. We can end stigma. And we can support our friends in their treatment and recovery”.

My noble friend Lord Patten raised the issue of stigma. It is a lot better than it used to be, but, again, there is much more that we can do.

The Department of Health is currently working with other delivery partners to develop the collaborative partnering required to co-ordinate delivery of this important work. We will continue to drive forward transformation across children and young people’s mental health and well-being, delivering system-wide and sustainable transformation for all children and young people across England. I can assure all noble Lords that the issue of young people’s mental health is very important—it is hard to think of a more important issue facing the Department of Health, or indeed a more difficult challenge because these are not easy issues. The right offer, available in the right place and at the right time, delivered by a workforce with the right skills and knowledge, are all essential if we are to deliver this important report into reality.

Again, I thank the noble Baroness, Lady Tyler, for securing this important debate. If I have not done justice to all the questions that have been raised, I am happy to meet noble Lords outside this Chamber or to write to them.

NHS: GP Clinics

Lord Prior of Brampton Excerpts

Thursday 25th June 2015 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government whether they will provide an annual report to Parliament regarding the operation of seven-day opening of general practitioner clinics.

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

My Lords, we are committed to seven-day GP access. We have already invested £175 million in 57 schemes covering 2,500 practices, offering improved access including evening and weekend appointments. The 2016-17 mandate to NHS England, to be published later this year, is expected to reflect Government commitments, including on access. The Government hold NHS England to account for progress against these objectives and publish an annual assessment of NHS England, including progress in delivering the mandate.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful to the Minister for the information he has just given. Will he recall that earlier in the week, in reply to a Question about the number of GPs in practices, he said that the general practice model “is largely broken”? His second statement was that it “is probably broken”. In the light of that expression of his concerns about what was happening in GP practices, I presume that he was associating himself with those millions of NHS patients who increasingly find it difficult to see a GP within the time they want, or to see a GP of their choice. If so, can he say whether moving from what is broadly a five and a half-day weekly GP practice to seven days for all will improve matters for those patients or make matters worse, especially as it is being done on a broken model, to use his own words? In those circumstances—

[Lord Brooke of Alverthorpe]

In those circumstances will he say what the new model will be, spell it out to the public and say how many GP practices will have to close?

[Lord Prior of Brampton]

The noble Lord makes a number of interesting points. One of the leaders of the BMA talked yesterday about the need for a renaissance in general practice, which was about the only thing in that speech that I agreed with. We need a renaissance and a complete transformation in general practice because the structure of primary care is largely unchanged since being set up in 1947, and the population’s requirements have changed fundamentally. So over the next five years, I expect primary care to go through a renaissance and be transformed from the bottom up.

[Baroness Meacher (CB)]

My Lords, the Minister referred to a renaissance of general practice. Given that about 30% of GPs are expected to retire in the next five years and even the most popular training schemes cannot find anyone to come and train—I should not say “anyone”; however, Winchester has six people but places for 16—what sort of renaissance will it be? We actually need GPs, so perhaps the Minister can explain.

[Lord Prior of Brampton]

The noble Baroness is quite right. We do need GPs, and they will be at the heart of the renaissance in general practice. The Government are committed to recruiting an extra 5,000 GPs into general practice over the next five years—that figure is net of people retiring. We accept entirely the noble Baroness’s proposition that we must persuade more newly qualified junior doctors to opt for general practice rather than for working in hospitals.

[Baroness Walmsley (LD)]

My Lords, what discussions have the Government had with the Royal College of Emergency Medicine about the idea of collocating GP clinics in A&E departments? Surely such a strategy has the potential for killing two birds with one stone.

[Noble Lords]

Oh!

[Lord Prior of Brampton]

I agree with the sentiments of the noble Baroness. There are indeed many GP practices that are collocating outside or very close to A&E departments. For example, I saw one at the Royal Free only last week. It is one of a number of new models of care that we should be exploring.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, may I press the Minister a little more on recruitment? In an answer to me earlier in the week, he made the same reply—that the Government were committed to recruiting more GPs—but he has not yet told us what incentives would make a newly qualified doctor wish to go into general practice, and whether those incentives are financial or otherwise. In particular, the idea that part of your commitment would be to a seven-day week is possibly not quite as alluring as he would like it to appear.

[Lord Prior of Brampton]

The right answer to the noble Baroness is twofold. First, we have to paint a picture that inspires young doctors to go into general practice. There is no doubt in my mind that the solution to the health needs of today’s population depends on a different model of general practice. We can paint that picture, and I hope that leaders of the BMA might wish to help paint it as well. Secondly, on the seven-day week issue, we are living in 2015 and people expect to be able to see GPs at the weekend. People get ill at weekends, and if we want good quality of care, we have to provide that care seven days a week. If we wish people to be treated outside hospitals, we have to provide good access seven days a week in primary care.

[Lord Colwyn (Con)]

Will my noble friend make it easier for GPs who have retired to come back to work in part-time practice? I am told this is extremely difficult at the moment.

--- Later in debate ---

[Lord Prior of Brampton]

My noble friend makes a very good point. Health Education England and NHS England have a return-to-practice scheme precisely to do as he suggests, making it easier for those who have temporarily left practice by going overseas, or taken time out, to come back to practice.

[Baroness Wheeler (Lab)]

How does the Minister see the plans for seven-day working going forward in the light of recent data showing that there is growing pressure on surgeries and that practice closures have resulted in one in four GPs now working as locums, who are increasingly forming an integral part of practice teams? Does the Minister see the new models of care and the transformation he refers to embracing these new forms of working, together with partnered and salaried GPs? We often hear the view that local and part-time working, particularly for women GPs, is one of the major causes of GP shortages.

[Lord Prior of Brampton]

The noble Baroness makes a good point. The old model, based largely around partners, often in small practices, is the one that I think will evolve over the next five years. We will certainly see many more salaried GPs coming into the workforce. The fact that there are now many more women doctors, who will wish to take time out to look after their children or for maternity leave and the like, means that the structure of general practice will change fundamentally. It may also mean more locums. I do not have a view on that particular aspect of the noble Baroness’s question.

[Baroness Howarth of Breckland (CB)]

My Lords, if the Minister believes that we have had the same model since 1948, what was the House doing taking through during the last Session the health legislation that changed the structure so that the business model was around GP practices? Many GPs find that extremely onerous. They want to be doctors, not business managers. There has been significant change and not necessarily for the better. Would the Minister not agree?

[Lord Prior of Brampton]

The noble Baroness—

[Lord Foulkes of Cumnock (Lab)]

Has a very good point.

[Lord Prior of Brampton]

The main thrust of the legislation was to put GPs more in control of the delivery and structuring of local healthcare.

Mental Health Services

Lord Prior of Brampton Excerpts

Thursday 25th June 2015 Lords Chamber

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

My Lords, I congratulate the noble Baroness, Lady Thornton, on bringing this really important debate to the House. I also pay tribute to the noble Lord, Lord Graham, for his very perceptive and important contribution. He put his finger on it when he said that co-ordination of services for patients who often have huge and very complex difficulties lies at the heart of all we must do. He also said that although little is new in life, the environment in which young people grow up today is very different from that in which he grew up. Although in many ways the environment has improved, the pressures on young people growing up today are probably greater now than when the noble Lord was a boy. The noble Baroness, Lady Massey, referred to this and I will bring it up again later in my speech.

On 18 May, the Prime Minister underlined in his first major speech following the election that mental health, including the mental health and well-being of young people, is a key priority for this Government. The noble Lord, Lord Hunt, can be assured that the Government will hold CCGs and NHS England strongly to account for delivering the substance of parity of esteem. For too long, parity of esteem has fallen into motherhood and apple pie territory. We need serious resource behind it to ensure that we deliver it on the ground.

Last year, the Department of Health asked the Care Quality Commission to review the experiences of people receiving crisis care. The resulting report, Right Here, Right Now, shows that although there is some excellent practice in areas such as Lambeth there is far too much variation across the country in the quality of crisis care—and, as the noble Baroness, Lady Thornton, noted, between services as well as geography.

The report provided powerful insights into the stigma that too many service users face. One patient from the report said:

“A&E was horrible. I felt like I was being judged for inflicting injuries on myself and that certain staff actively didn’t want to treat me”.

As Dr Paul Lelliott, Deputy Chief Inspector of Hospitals at CQC, who led the review, stated, there is a,

“real weakness in mainstream mental health provision as regards 24 hour crisis care. In some cases, the only recourse for people trying to access crisis services is to a phone line telling them to go to their local emergency department”.

As other noble Lords said, going to an A&E department is, for someone suffering a mental health crisis, no solution of any kind.

Another patient said:

“I have a clinical illness. It’s not my fault my brain chemistry fluctuated … To be treated as a drunk, an inconvenience and with visible contempt only makes it worse”.

That points to a need for greater training in some A&E departments and the importance of having a psychiatric liaison nurse in A&E departments. The report also found that in some areas there are still problems with under-18s being detained in police cells under Section 136 of the Mental Health Act. I agree wholeheartedly with the noble Baroness, Lady Thornton, and others that this practice is wholly unacceptable. I will say more on that a little later.

Dr Lelliott stated that there are reasons to be confident for the future as well. We are beginning to see a shift in public attitudes to mental health, away from the stigma of the past. As the report states, there has been huge progress in improving crisis care, thanks to the crisis care concordat and successful approaches such as street triage.

The crisis care concordat was launched in February 2014 and signed by more than 20 national organisations. It seeks to improve the experience of those in crisis and in particular to prevent those detained under Section 136 of the Mental Health Act being held in police cells. I spoke not all that long ago to a young woman of no more than 17 who had had a mental health crisis and tried to take her own life. She spent two nights in a police cell. It is hard to imagine a worse place for a young woman to spend time. That was two years ago.

All localities signed up to the principles of the concordat before the end of 2014. Detailed action plans are now in place across England and set out how local partners will work together to improve service responses for people in crisis. I have taken on board the words of the noble Lord, Lord Hunt, that we must be able to assure ourselves that effective action is taken on the ground and that there is clear accountability.

Since the launch of the concordat in February 2014, the number of times that people of all ages were detained in police cells under Section 136 has fallen by 55% compared to 2011-12. This marks a considerable achievement in meeting the concordat’s ambition. There was also a very big reduction in the number of under-18s detained in police cells under Section 136 for the first time since figures began to be collected in 2011-12, with 145 cases, an almost 40% fall within the year. But I agree wholeheartedly with the noble Baroness, Lady Thornton, that one case is one too many. There is good progress but more work to be done.

In May, my right honourable friend the Home Secretary announced that the Government will reform the law on use of police cells to end this practice altogether for under-18s. I am pleased that the noble Baroness, Lady Tyler, supports that move. The Government will also clarify the legislation so that, for people of all ages, police cells are used only in very exceptional circumstances. A number of noble Lords and noble Baronesses have made the point that there is no point in stopping people going into police cells if alternative provision is not made elsewhere. The Government have committed £15 million to improve the provision of health-based places of safety, so that there is better availability of alternatives to police cells.

The insights from the Right Here, Right Now report will also directly improve crisis care, influencing the Care Quality Commission’s regime for future inspections. In addition, the Department of Health, NHS England and Mind are supporting all localities to develop and improve their local concordat action plans in light of the CQC’s review.

The noble Baroness, Lady Walmsley, gave an example of police being accompanied by a therapist. The CQC report makes reference to street triage. These are schemes whereby a police officer might be accompanied by a nurse, therapist or someone else, when they meet people going through a crisis. Paul Lelliott particularly marked that in his report as being a very good development. The Department of Health has funded pilots using street triage with nine police forces, and I believe that 25 police authorities are now using that triage as a way in which to make a bad situation at least no worse. There have been some very encouraging results, with the use of Section 136 to take people of all ages into police custody almost eradicated in many of the pilot areas.

Liaison and diversion services are also being used to help children, young people and adults in crisis. They identify, assess and refer people with a wide range of mental health, learning disability and substance misuse vulnerabilities when they first come into contact with the youth and adult criminal justice systems. NHS England has now rolled out a national liaison and diversion standard service specification and operating model serving 50% of the English population, and it is anticipated that that will cover the whole population by 2017-18.

It is clear that we need to do more to ensure that, for those in need, help can be found in the right places at the right time. The noble Baroness, Lady Tyler, made the very strong point that it must be unacceptable that some young people have to travel more than 200 miles to find an appropriate bed. The previous Government supported NHS England with £7 million to provide additional mental health beds for children and young people. This increased the number of beds to more than 1,400, the highest this has ever been. But I agree completely with the noble Baroness, Lady Massey, that, while we must ensure that help can be found for those in crisis when it is needed, it is not enough simply to provide more and more beds. Home treatment is also very important.

Three-quarters of mental health problems in adult life begin in childhood. It is therefore essential that we focus on improving the whole care pathway for children and young people’s mental health, preventing issues arising, and taking action before hospital treatment is required. I can confirm there will be an additional £1.25 billion over the next five years to enable transformation across health, social care and education for children’s mental health and well-being. In addition, we are investing £150 million over the next five years in services for young people with eating disorders and those who self-harm. Although this Government can take credit for that, I pay tribute to the Liberal Democrats, and particularly Norman Lamb, for ensuring that mental health was so high up the agenda.

I take the strictures of the noble Lord, Lord Hunt, when he says that we must have clear accountability for spending that money. I place considerable hope in the report that has been commissioned by NHS England from Paul Farmer, the chief executive of Mind.

I have been told that I have only one minute left. That is the difficulty with debates in the House of Lords: all the comments are so helpful that it is hard to do them all justice. I conclude by saying that we have all talked about parity of esteem, in this and the other House, for too long. Until now it has been just motherhood and apple pie. I hope that the resources that we are putting into mental health and the accountability that needs to back them up will make a reality of that expression. I pay tribute to Paul Lelliott of the CQC for his very valuable report and thank the noble Baroness once again for bringing the debate to the House.

Prisons: Mental Health

Lord Prior of Brampton Excerpts

Wednesday 24th June 2015 Lords Chamber

[Lord Patel of Bradford]

To ask Her Majesty’s Government what steps they are taking to achieve parity of esteem between mental health and physical health in prisons.

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

My Lords, achieving parity of esteem between mental health and physical health in prisons is a government priority. Following the 2009 review by the noble Lord, Lord Bradley, we ensured that prisoners can access equivalent health services to people in the community. The Government’s mandate to NHS England has objectives to achieve parity of esteem, including in health and justice settings, and to develop better offender healthcare that is integrated between custody and community, including developing liaison and diversion services.

[Lord Patel of Bradford (Lab)]

I thank the Minister for that Answer. I am sure he will be aware that a great deal of effort has been made to improve data accuracy and the quality of recording of mental health diagnosis in NHS trusts, including new coding standards, all as part of preparation for a national payment tariff for mental health, similar to those for people in hospitals with physical health conditions. Can the Minister describe, first, how this will be implemented in the prison setting? Secondly, what support will his department be giving to implement the standards for prison mental health services, which the Royal College of Psychiatrists published recently due to, as it said, the lack of a national blueprint for mental health services for people in the criminal justice system?

[Lord Prior of Brampton]

I thank the noble Lord for his two questions. On the first, about coding, it is very important that we get the tariff right and that it does not become just another measure of activity but that outcome is built into that tariff. Paul Farmer, the chief executive of Mind, is preparing a report for NHS England, which will include proposals for the tariff and payment systems. That will include health in prisons as well as outside prisons.

The second question was about the standards issued recently by the Royal College of Psychiatrists. The noble Lord, Lord Bradley, in his foreword to The Bradley Report Five Years On, referred to the importance of having a national blueprint, which of course is now possible given that NHS England is the commissioner of specialist services throughout the country. I will also draw those standards to the attention of Paul Lelliott, the chief inspector of mental health within the CQC. I am sure that the CQC will wish to incorporate those standards into its inspection regime

[Lord Walton of Detchant (CB)]

Can the Minister say what qualifications are now required of doctors who are recruited to work in prisons? Can he further say what proportion of those who are now employed to work in prisons have had formal psychiatric training?

[Lord Prior of Brampton]

I thank the noble Lord for that question. I hope he will think it acceptable if I reply to him in writing after this session.

[Lord Dholakia (LD)]

My Lords, could the Minister explain why we lock up so many mentally ill offenders in prison institutions that are not fit for the purpose? Has he read yesterday’s report by the prisons inspector, which describes one prison as containing “shocking” squalor, high levels of violence and drug abuse, and high levels of staff sickness? Would the Minister explain how many mentally ill offenders are in our prison institutions and what efforts are being made to place them where proper mental health care and social care are available?

[Lord Prior of Brampton]

There are, as the noble Lord knows, some 85,000 people in prison, of whom more than 70% have two or more mental health conditions. Many of them suffer from drug or alcohol abuse, and I think it is generally accepted that a number of those people could be better treated outside a prison environment. He will also know that the liaison and diversion services that were so highly recommended by the noble Lord, Lord Bradley, now cover 40% of the prison population. There is a proposal that that should cover the whole population by the end of the year, subject to evaluation of those pilot schemes.

[Lord Bradley (Lab)]

My Lords, it is vital that a prison has all relevant information about an offender’s health needs when they arrive at prison reception. Does the Minister agree that an evaluation of the current health screen should be undertaken to improve the identification of mental health problems at prison reception and that the identification of learning disabilities should be part of that screen?

[Lord Prior of Brampton]

The noble Lord raised this in his report five years ago and in the follow-up report that was published more recently. A very early assessment of a prisoner when he arrives in prison is of course extremely important.

[The Lord Bishop of Bristol]

My Lords, given the complex needs of so many prisoners and the fact that those needs have to be addressed consistently, does the Minister agree with me that the risks associated with such prisoners could be greatly reduced were all operational staff in prisons given training on mental health awareness?

[Lord Prior of Brampton]

The right reverend Prelate’s comments are true throughout the whole healthcare system and would also apply to nurses in physical health surroundings. Training in how to recognise and deal with people suffering from mental health problems would be a huge benefit.

[Lord Ramsbotham (CB)]

My Lords, the figures that the Minister cited come from the last survey of psychiatric morbidity in prisons, published in October 1998. Since then, the morbidity profile has changed. Is there any intention to conduct another survey so that the figures are up to date and people know the size and shape of the problem with which they must deal?

[Lord Prior of Brampton]

I am not aware of any current plans to conduct a survey similar to the one to which the noble Lord referred from 1998.

[Lord Roberts of Llandudno (LD)]

My Lords, what action will the Government take in Wales, where health is devolved to the Welsh Assembly but prisons are part of the Home Office remit? How will those two different aspects of government work together?

[Lord Prior of Brampton]

The noble Lord raises an issue to which, I confess, I have not given sufficient consideration to give a proper reply today. Perhaps I may take that away and come back to him. The simple answer to that question is: dialogue.