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11.52 am
Baroness Howells of St Davids: My Lords, I register my appreciation to the noble Lord, Lord Colwyn, for initiating this debate when so many are concerned not with the treatment that the service is offering, which is very good indeed, but with the direction in which the NHS appears to be moving. I feel very fortunate to speak so early in the debate, leaving me plenty of time to listen to other noble Lords and, as usual, to learn from them.
I will do some gathering up and express some concerns from the community from which I come. The population’s expectations of all public services are changing. They are more knowledgeable, and they expect to be treated as partners and equals and to have choices and options available to them. There is a strong perception, often backed by data, that services are not distributed equally and that inequalities continue to be a major challenge in the NHS; for the Government, for those who deliver the service and for the recipients. It is believed that to deliver on any of the realities, the contribution of the whole workforce and their ideas must be acknowledged, recognised and valued throughout the service.
The Government have defined healthy communities as being composed of individuals in good mental, physical and spiritual health who are able to contribute to wealth and harmony in their local communities. The Government’s aspirations for enabling healthy communities have their conceptual origins in the benefits gained from the synergy between economic regeneration, higher education, and healthcare. That means that workforce development and equality programming in the UK is vital. I trust that we agree that enabling healthy communities through service innovation is a must for professionals providing public services in the 21st century.
There is a need to integrate creativity, communication and cultural understanding as unshakeable pillars, where all human capital, knowledge, skills and expertise are paramount in meeting the demands and expectations of us all. Knowledge-sharing is a force for building capacity towards the establishment of new and innovative relationships, built strictly on collaboration, trust and consideration among all stakeholders with a common purpose.
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Yet, at this time, there is a major concern among professionals about the local improvement finance targets, known locally as LIFT. GPs complain about playing an unconscious role in the NHS and appear to be in conflict with government initiatives for data collection. They see their role as providing evidence-based medicine known in my local area as “medicine by numbers”—planned and priced medication with little regard to the health needs of the community.
Questions are being asked as to whether treatment centres, where the Government are heavily investing with the private sector, are good value for money and sustainable. These centres will not provide training for young professionals and their main purpose seems to be to cream off the least skilled jobs and do them quickly.
There are also concerns about the Government’s commitment to positive discrimination, which is illegal in this country, by employing European Community nationals before all else, despite language and other barriers. Experience has taught us that the most successful implementation programmes ultimately aim to ensure recognition and remedies of both specific and common issues among individuals and groups if they are to participate in the improvement of services for the benefit of the whole community.
I am sure that the Government’s intention, if they wish to achieve their objectives and outcomes for all their stakeholders, will be to continue to seek a structured means of communication, to influence actions and attitudes, to challenge views and to create new understanding, related to leadership, teamwork and service improvements in a more positive way than at present. Diversity of needs will then be a positive force for healthy communities at all levels. Patients, practitioners and all those engaged in delivering the service in whatever form will then continue to hold up our National Health Service as a beacon to all.
I should be grateful if my noble friend could answer some of the few concerns that I have raised.
11.58 am
Lord Rodgers of Quarry Bank: My Lords, I welcome the initiative of the noble Lord, Lord Colwyn, in raising today’s debate. Shortly before the last general election, I recall another debate in the House to which I listened but in which I did not participate. Almost all noble Lords who spoke had been professionally involved in the health service and were well disposed to the NHS, saying that so many things were getting better. After the bleak Thatcher era and Gordon Brown’s four lean years of public expenditure, there was now a perceptible improvement.
On the occasion of today’s debate, the mood may be a little different. Last year, I did not quarrel with the apparent consensus. My knowledge and experience arose entirely from me and my family, and we were glad that the NHS was recovering. However, I thought that the debate was rather too full of self-congratulation and provided too little recognition of the gap between the much-improved NHS and the so-called world class to which the Government had chosen to aspire. The glass of success was half full, but it was still half empty.
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As an example, I had applied at that time for my NHS hearing aids. In the House, Ministers proudly told us of the new digital appliances—the result of a successful deal between the public and private sectors. But I then discovered that fitting my hearing aids would take a full year, and elsewhere the delay was often very much longer. For those who had hearing problems, the glass was certainly still half empty.
I want to deal mainly with another current issue—the future of stroke care—and, again, I shall draw from personal experience. Today, I am not pursuing the subject of the highly controversial accident and emergency proposals spelt out by the Prime Minister this week, although I am not yet persuaded of their virtues. On 23 May, in a short debate, I had the opportunity to raise the National Audit Office report of November 2005, Reducing Brain Damage: Faster Access to Better Stroke Care. I explained that five years ago, I had been taken to the Royal Free Hospital, London, and then to the National Hospital for Neurology and Neurosurgery in Queen Square. A stroke had been diagnosed.
The National Audit Office report, the House of Commons Public Accounts Committee report which then followed, and the Government’s recent response—the 52nd report, Cm 6924—have this in common: they agree that stroke is the single biggest cause of death after heart disease and cancer and that three times as many women die of a stroke as die of breast cancer. Nor does the department dissent from the PAC’s conclusion that stroke costs the economy £7 billion a year, including £2.8 billion in direct care costs to the NHS.
I shall not set out further the large measure of agreement between the three reports on matters of fact. I concede that there have been significant improvements in the past five or six years and that stroke is now accepted as a medical sub-specialty, but I am unhappy about the tone of the 52nd report, which is bland, the lack of urgency on the part of the Department of Health and the apparent absence of additional resources sufficient to implement good intentions. In particular, I am greatly concerned about the arrangements necessary for scanning stroke victims.
The summary of the National Audit Office report said:
“There are barriers that prevent stroke patients from receiving rapid and responsive emergency care”.
Among the conclusions and recommendations in its report, the PAC said:
“All suspected stroke patients should be scanned as soon as possible after arrival at the acute hospital, ideally within three hours, and none should wait more than 24 hours”.
The Department of Health agrees with the recommendations, and that is fine, but there is too little evidence in the report that serious progress is being made.
In my speech on 23 May, I drew attention to my interest in the Royal Free Hospital—one of my local hospitals. So, a couple of months later, I asked the
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I am not making a target of the hospital. On the contrary, the chief executive gave a straightforward answer to my questions. But my guess is that the Royal Free is typical, plus or minus.
I am not asking the Minister to give an authoritative view this afternoon—that would be unreasonable—but I will table a Written Question to him to give me a complete picture, hospital by acute hospital, in answer to my two simple questions.
On access to stroke care, I am ready to concede that the glass is now half full, but I hope that in turn the Minister will concede that it is still half empty.
12.05 pm
The Lord Bishop of Worcester: My Lords, I am grateful to the noble Lord, Lord Colwyn, for initiating this debate. It is clear from the three speeches already made that it will be a very wide-ranging and searching one.
I have come to take part in it because I hope to have some answers to some puzzles. I am genuinely puzzled and I look forward to hearing some resolution to them from the Minister and others.
It is clear that an enormous amount of additional resource has been put into the National Health Service. To deny it would be churlish and would fly in the face of the facts. The results are, in part, there to see, and one has to be grateful for that. My puzzle is that, on the other side, there seems to be a financial regime so draconian that people are asked to cure deficits within quite unreasonable times with disastrous results on any sensible scale of planning that they might have had.
Here is another puzzle. We have a wonderful, new-looking hospital in Worcester that we are told was put up without any impact on the public sector borrowing requirement. But we notice that in the deficit that has to be dealt with, a large part is owed to the company that built the hospital. Therefore, for all intents and purposes it looks exactly like a debt. We used to buy things on hire purchase more than we do now, and we always thought that that was a debt. I am a bit puzzled that something that feels like a debt, looks like a debt, and walks like a debt is not a debt.
We are told that there is greater devolution of authority to local trusts. Indeed, the Minister who will be responding has told me on more than one occasion of the importance of this policy of local decision-making. But experience on the other side is different. When I go to the local trust, it says that it is required by the Government to do certain things that it wishes to question. As to the localness of decision-making, the trusts appear to be free to make
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I shall make some points about targets. Targets are another puzzle. I understand what the Minister said in response to the Question asked earlier by the noble Baroness, Lady Sharples. He said that targets have an effect on priorities and bring about the raising of certain standards. But where are the targets for quality, gentleness, attentiveness, waiting or listening? Where are the targets that relate to the heart of the service?
Noble Lords will understand that I do not wish to say very much today about the particular chaplaincy crisis facing Worcestershire because this is the very day on which the board of the trust is meeting, and it may yet be possible for there to be some acceptable compromise. I very much hope that there will be, and I do not wish to say anything that might make that more difficult. That crisis is an instance of the absence of any will to enforce targets for the heart of the service. I want the Government to give that some attention.
The priest responsible for National Health Service matters in a diocese in which I previously worked was taken around a hospital by the chaplain. They entered a ward that was clearly in crisis—such things happen. People were rushing about in great distress; it appeared that matters were out of control. My friend turned to the chaplain and said, “What on Earth could you possibly do in a situation like this?”. The chaplain replied, “Just walk slowly”.
There needs to be a target for walking slowly. In most situations, that will be the only way to allow the reality of a person’s illness, the reality of what staff are up against, to become clear. Chaplains, and their support across the faith communities, are part of that heart, as is nurse training, which we have heard is in some danger.
We have all been ill and we know that it is quite difficult to speak clearly about what is wrong with you unless somebody is spending time on it. I am not against targets, but I would like to see a target for spending “long enough” with a patient, not just ones that say how many patients you have to see.
The National Health Service is something of which we are not only proud, but for which we are hugely grateful. I am concerned about its heart, and some of my earlier puzzles are to do with that heart being in some danger. A National Health Service where nobody is asked to walk slowly is not one that will ultimately do us any good.
12.12 pm
Lord Layard: My Lords, I shall talk about the problems of those with depression and anxiety disorders. First, I praise the huge improvements in the NHS under the present Government. It was an extraordinary and momentous decision to raise our spending to the European level. No other Government would have done it, and the benefit to patients has been enormous.
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That is true of mentally ill people in the secondary sector as well as the physically ill. Compared to 1997, the secondary mental health services employ 50 per cent more psychiatrists and 75 per cent more clinical psychologists. Of course, the premises have often been transformed beyond recognition. However, the secondary mental health service provides for only about 1 per cent of the population—chiefly those who suffer from the serious conditions of schizophrenia and bipolar disorder. Another 16 per cent of the population suffer from clinical depression and chronic anxiety disorders, which can cripple their lives—one need only think of the hundreds of thousands who cannot even leave their homes.
That 16 per cent have always had a raw deal from Governments of all persuasions. For most of them, all that has been available has been either medication or, possibly, a little counselling. This provision is completely contradictory to the NICE guidelines—an extraordinary situation of which people may not be aware. The NICE guidelines recommend that, except where the condition is very mild, all those with these conditions should be offered modern, evidence-based psychological therapies. That guideline is based on hundreds of random assignment control trials which show that after less than 16 sessions of cognitive behavioural therapy, for example, half of all who suffer from these conditions will be cured. In addition, surveys show that patients want psychological therapy more than anything else. It is not expensive: the average cost is about £750. Is it not dreadful to think that millions of people in misery could be relieved by so little expenditure? It is even more shocking when we realise that the net cost of doing so is nothing because 1 million of those people are on incapacity benefit and being on that a month rather than working and paying tax costs £750, which is the same as the cost of a course of therapy. Huge savings could be achieved through more widespread provision of psychological therapy according to the NICE guidelines. I am not saying that we should treat people simply to save money—far from it—but if we can relieve misery and at the same time save money, it is a powerful argument for quick government action. On any reasonable calculation, it would cost the Government nothing net to implement the NICE guidelines in this area.
Implementing the guidelines on depression and anxiety disorders must be a top priority for the Government’s forthcoming Comprehensive Spending Review. The aim must be to create an evidence-based psychological therapy service within every PCT to which GPs and jobcentres can refer their clients. That is what GPs want. They complain all the time about the absence of such a service, and the proposals put forward in The Depression Report, published by the London School of Economics, were backed by the Royal College of General Practitioners and the GP representatives of the BMA. The main danger is a dumbed-down response providing therapy on the cheap by inadequately trained people offering too few sessions aimed at improvement rather than cure. That would be false economy and is not based on the evidence. People who have these conditions should be treated as we would like to be treated if we had them. That should be the fundamental principle in the
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We need an adequately trained workforce. One estimate is that we need approximately 8,000 more therapists than are now in the service. It is obvious that this problem cannot be dealt with overnight, and nobody is saying that it should be dealt with in the middle of this financial crisis. It should be dealt with by a phased seven-year plan. We have to have a clear concept of where we want to get to at the end, so it is necessary to start at the end, not the beginning. First, we have to decide what is an acceptable service; secondly, there needs to be a commitment to getting there by, I suggest, 2013; and, thirdly, there needs to be a national training plan for making that possible. All that needs to be spelled out in the settlement before the Comprehensive Spending Review.
This is a long-standing problem that has been ignored by Governments of all persuasions and, in fairness, I should add that the NICE guidelines in this area are only three or four years old. However, they are breached to a degree quite unknown with any other form of illness. To get a change of approach, we have to have a different perspective on mental illness. We need to recognise that mental illness is one of the main forms of deprivation in our society. Research shows that it causes more misery than poverty or physical illness. If we can recognise that mental illness is a major form of deprivation, I am sure that it will become a central policy issue in the years to come. Now is the time not only to plan for action but to begin it.
Mental illness has been with us since the Stone Age. What is new is that we now have the techniques for tackling it. It would be hard to forgive a Government if they did not rapidly make those techniques available to people who so desperately need them, especially when it would cost nothing.
12.20 pm
Lord McColl of Dulwich: My Lords, I, too, welcome the initiative of my noble friend Lord Colwyn in securing this debate. I should like to draw attention to the trafficking in human beings, which has such a serious effect on the health of its victims. The United Nations has defined trafficking in human beings as,
- “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat of use of force or other forms of coercion, of abduction, of fraud, of deception ... for the purpose of exploitation. Exploitation shall include .... prostitution ... forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs”.
People trafficking is a global issue that affects virtually every country worldwide. An article in the Herald Tribune this week reports that the Council of Europe estimates that people-trafficking revenues have reached a staggering $42 billion. Nearer home, it is rather worryingly reported that an average of 100 unaccompanied minors come through UK
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It is common practice for traffickers to make trafficked people memorise a phone number before they leave their country of origin, even though they do not know why. These people are often abandoned at the departing airports with their only option being to carry on with their journey. On reaching the UK, they expect—this is the deception—a helpful person to meet them and to provide them with the job that they were promised. When they arrive alone, the Immigration Service has to refer them to the police or social services and they are temporarily housed until, usually, they are flown back to their port of embarkation, where the traffickers are often waiting to retraffick them. This can happen 20 times in their lives. Often, before these people are sent back, they call the memorised phone number and are picked up by the traffickers in the UK. The police and social services have no idea of their whereabouts.
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