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Here we are at crisis point again, but on an unprecedented scale. As has been mentioned, the budget rose this year by 5.5 per cent and is set to do the same next year. Experts are suggesting that it may rise by only 1 per cent in 2010, which may well result in a fall in funding once inflation is taken into account. As mentioned earlier, the most humane way—in, I stress, my personal opinion—to cope with this crisis is to
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In past financial crises, hospitals have saved money by curtailing regular maintenance of their buildings. That is a tempting short-term expedient, but in the long term the total amount that has to be spent to catch up on sorting out the maintenance is greatly in excess of what it would have been if regular maintenance had been carried out every year. I hope that the Government will strongly discourage this expensive short-term measure.
So much for the future. What about the present? I can best illustrate that with a case history. I am not in the business of exaggerated scare stories. I think it was a former Minister of Health who said that a bed pan cannot fall off a shelf in an NHS hospital without the whole country hearing about it. The following case history, however, illustrates a real longstanding problem that has now got completely out of hand and must be solved once and for all.
The patient, Mrs B, was involved in a road traffic accident on a Wednesday several weeks ago. This resulted in a severe laceration to her calf, requiring admission to the accident and emergency department of a large teaching hospital. The nursing, as usual, was superb, but the management was a scandalous disgrace. As she needed surgery for her laceration, she was starved all day in preparation for a general anaesthetic and surgery. She waited all day, and in the evening was told that the operation had been cancelled. Having been starved all day, she was very hungry and dehydrated, so she asked for some food. She was told it had all been cleared away but eventually got a box of sandwiches. The following day was Thursday and exactly the same thing happened. The following day was Friday, and the same thing happened again—she was starved all day, dehydrated, frustrated, angry and kept in bed with all the attendant risks, including thrombosis.
Saturday was the fourth day. She went to theatre but the wound was found to need a skin graft and so the operation had to be postponed for another two days. On the sixth day, the operation was completed. As this ordeal unfolded, she began to wonder why she had been treated like this: what had she done to deserve it? As so often happens, she concluded that it was her fault because she was 81—a very active 81. I must emphasise that these repeated cancellations were not for clinical reasons to do with the patient; there was no effective attempt to assess clinical priority.
Prime Minister Thatcher used to say, “Don’t bring me problems, bring me solutions”. The solution to this problem is to have the most experienced person there make a management decision to interrupt any suitable theatre used in the five or six operating lists and say, “Excuse me, but at the end of this operation will you please go and have tea because we need to do a
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A few weeks after this episode, a doctor fell downstairs at home and lacerated her scalp. Her husband is a surgeon and they discussed what to do. If they went to the nearby hospital, she would probably be starved all day and who knows when the operation would be carried out. So they decided on a DIY job. The surgeon excluded any other injuries, cleaned the wound and, because he had no anaesthetic or sutures to stitch the wound, he twisted a tuft of hair on one side of the wound, twisted a tuft of hair on the other side of the wound and then tied them in a neat surgical reef knot, bringing the wound together satisfactorily. This took five minutes, which they thought was preferable to the five days suffered by their friend Mrs B.
Will the Minister take steps to ensure that it is clearly understood that in every appropriate hospital there must be one person whose duty it is to ensure that repeated cancellations such as those suffered by Mrs B never ever occur again?
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Baroness Thornton: I am grateful to the noble Baroness for the opportunity to debate these important matters.
As noble Lords have mentioned, the current economic crisis is a source of hardship and anxiety for many families and businesses. For many people of working age, work and security are central to their health and well-being. Income shocks, lack of job security, unemployment and problem debt can contribute to an increased likelihood of depression and other health problems. Indeed, data from the health service for England show that being unemployed is associated with a reduction in health status roughly equivalent to that associated with being a smoker and, as was so eloquently described by the noble Baroness, Lady Barker, we know that this will increase the demand for some health services during the forthcoming period.
For several reasons, the NHS is in a good position to support people through the present times. First, NHS finances are now in a stable, sustained position thanks to significant investment and careful management. Annual expenditure on the NHS will soon exceed £100 billion per year, compared with £35 billion when we came to office in 1997. We have turned round some of our historic deficits, which will allow us to be flexible in responding to some of the fluctuations in demand for healthcare while maintaining sufficient funds to invest in new services.
We are very much aware that every pound spent on the NHS is from taxpayers, so value for money is critically important at this time, as the noble Lord, Lord McColl, mentioned. Nationally and locally, we need to be vigilant against waste and endeavour to ensure that all funding is used effectively.
We have secured costs in two of the areas of heaviest NHS expenditure—in drugs and pay. The 2009 Pharmaceutical Price Regulation Scheme provides stability in the price of branded drugs for the next five years. The deal allows a price cut of 3.9 per cent in the first year, followed by a further cut of 1.9 per cent and the
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On NHS pay, as noble Lords will be aware, we agreed a three-year pay deal for the 1.1 million staff covered by the agenda for change pay system. It runs until 31 March 2011 and will give certainty to staff and employers.
Through our reforms, we have tackled waiting lists, improved access and raised standards of care. As my noble friend Lord Darzi set out in his report, High Quality Care for All, we are now in a position to emphasise local innovation and action to meet local needs and raise quality. Clinicians and managers are free to respond to fluctuations in local demand for services without having to respond to any new national targets.
It is the responsibility of primary care trusts to understand and plan for change as demands change locally. World Class Commissioning is supporting PCTs to develop their capabilities to assess need, identify strategic priorities and prioritise investment to respond to the healthcare needs of their local populations.
We are very much aware of concern about the effects of the downturn on social care, particularly pressures on care home costs. We are continuing to work closely with local authorities and private providers to ensure that they are able to meet their statutory responsibilities and protect the welfare of care home residents. As noble Lords, and particularly the noble Baroness, are aware, we have been consulting extensively on a Green Paper, which will put forward proposals on how care and support can be funded and delivered in the future.
The noble Baroness will be aware that the department issued guidance to local authorities, circular LADH 2093, which includes guidance on deferred payments. We expect councils to offer deferred payments in appropriate cases. In our view, if local authority policy is never to offer payments, that is likely to be unlawful and would be taken to the courts. However, I undertake to take back the noble Baroness’s question about this issue, because I think that we need to look at the guidance again against her specific point about the downturn and the problems in the housing market. I want to make sure that the guidance does the job that it was intended to do.
The NHS is the largest employer in the country and so makes a key contribution to the economy. It has many jobs which would be suitable for the newly or long-term unemployed, and we are committed to helping to maximise those opportunities. We are working with NHS Employers, Skills for Health, Jobcentre Plus—my noble friend Lord McKenzie is here—NHS organisations and others to develop a co-ordinated strategy. We announced on 23 February that we are going faster, starting with an additional 5,000 apprenticeships across health and social care in the next year.
The noble Lord, Lord McColl, and the noble Baroness, Lady Barker, asked what would happen to funding in the recession. My right honourable friend the Secretary of State told the Health Select Committee on 11 March:
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“We have looked at what happened in previous recessions, in the 1990s and the 1980s and we have looked at how government responded to those recessions and we are not going down that same route”,
which, in fact, is the route suggested by the noble Lord, Lord McColl. He continued:
“What happened in the 1980s and the 1990s, waiting lists grew longer—they just stopped operating and stuck them on to longer waiting lists; restricted the flow of new drugs on to the market and got rid of staff. We are not going to do that ... When I said in the 1990s and the 1980s that the way the Health Service dealt with this is by getting rid of staff ... [it] was because the government then chose to deal with [the recession] by cutting public services”.
We know that it will be tough, but it is doable. The way to deal with a recession is not to get rid of staff, restrict drugs or expand waiting times but to look remorselessly for internal savings, excluding from the very important developments in patient care—I again echo the noble Lord.
The issue of mental health was raised by my noble friend Lord Layard and the noble Baroness, Lady Barker. We know that we have an important role to play in protecting the mental health of people who lose their jobs so that they are in good health and can return to work when the economic situation improves. Since 2001-02, investment in mental health has increased by 45 per cent in real terms. We are expanding the availability of psychological therapies, aiming to train 3,600 extra therapists and treat 900,000 more people in three years. On 8 March, the Secretary of State for Health announced an additional £13 million in 2009-10 for a package of measures to help people who are experiencing distress, depression and anxiety associated with the downturn. This will fund a faster rollout of talking therapy services linked with employment support and health advisers on a dedicated NHS Direct phone line, trained to spot people who might be experiencing depression because of the economic problems.
On CAMHS, I am aware of my noble friend’s keen interest in and support for the Improving Access to Psychological Therapies programme. I am very grateful to him for sending me the improvement of tier 3 CAMHS, drawing on the IAPT experience, which he has also sent to my noble friend Lord Darzi and other Health Ministers. We are aware that my noble friend’s opinion is that we should not have pilots in this area but should just roll out the whole programme. He will appreciate that the evidence needs to include not only the possible benefits of taking action in this area but evidence on what form intervention should take. I know that Health Ministers are taking a keen interest in these developments. They have asked for my noble friend to be kept informed.
I can advise my noble friend that officials in the department are currently looking at what evidence is needed to support a bid in the 2010 Comprehensive Spending Review in this area. The successful bid would provide funding for three years—2011-12 and 2013-14.
My noble friend makes a very good point about the levers to improve the quality of CAMHS. I undertake to take that away and feed it back to the appropriate parts of the department.
The noble Baroness spoke about public health. I agree with her that we should not lose the progress that has been made in that direction. In difficult times,
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The noble Baroness also raised the issue of the third sector. The Government are committed to supporting the third sector through this difficult period. We have contributed significant financial resources to the delivery of the cross-government action plan. As the noble Baroness said, the £15.5 million community resilience fund contributes a significant amount to provide grant funding to small and medium providers in local areas that are most affected by the downturn.
As with all these things, the question is about delivery on the ground. We all need to keep a watchful eye to make sure that the decisions we take at a national level to provide funding result in that funding getting to where it is needed—to local providers of services. That could not only save jobs but ensure that services remain intact through the downturn. I have a large commitment to and interest in this, and we need to make sure that it happens. Those of us who are in contact with the third sector need to listen carefully throughout this period.
These are indeed difficult times. We know that the downturn is likely to increase pressure on health services, but we think that the NHS is in good shape to respond financially. The noble Baroness’s suggestion about discussing how we move forward deserves consideration, and again I undertake to feed it back. I do not know the answer to the question about how much consultation has taken place on that specific matter.
Since the NHS Plan of 2000, our health reforms have taken the long view. We will not jeopardise our vision and the nation’s health by taking short-term, knee-jerk risks with the momentum of reform, whatever the economic climate. The downturn will pose challenges for the NHS, as for any other organisation, but we think that we are in a robust position to meet them. I thank the noble Baroness and other noble Lords for their participation in this important debate.
Lord McColl of Dulwich: Will the Minister follow my request for every hospital that admits emergencies to have someone responsible for ensuring that the kind of thing that I described does not happen? This is a common problem, I am afraid.
Baroness Thornton: I beg the noble Lord’s pardon. I actually wrote a note to myself saying, “Lord McColl again points to the need for further efforts to be made in these directions in the delivery of services”. That is a very valid point, and I shall of course ensure that it gets fed back.
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Benefit Payments: Dyslexia and Hidden Disability
Question for Short Debate
4 pm
To ask Her Majesty’s Government what arrangements they have made for dealing with adult dyslexics and others with hidden disabilities, particularly those with late identification, throughout the benefits system.
Lord Addington: The Question I have tabled is one I have been haranguing Ministers about for some considerable time. The first time I asked what would happen if a dyslexic person went into a jobcentre or on to the benefits system was about 15 years ago in the Chamber. The noble Lord, Lord Henley, who was answering, got up and said, “Of course we will give assistance to anyone who cannot read”. That probably means that at the time the noble Lord was not familiar with what dyslexia was. Society and the machinery of government have come far since then. That has not been particularly dependent on the rosette that the person in charge wears on election day; it has been a cultural shift that has changed the nature of government.
I want to talk about training levels. The noble Baroness, Lady Hollis, and I developed a sort of ritual dance over this the whole time that we were going through the previous welfare experiment. I would say, “What is happening about training?”, the noble Baroness would tell me about how many hours or weeks of training there would be, and we would go around again. I am still worried about the level of training for this large, lead group of dyslexics. There are other groups involved and others on the sidelines, but I feel qualified to talk only about dyslexics.
I should declare my interest as a dyslexic and a vice-president and patron of various dyslexia organisations. If only there were a financial interest to declare, I would happily so do; all I can say is that I have raised some money for those organisations.
What happens is that not only do people have problems with literacy and filling in forms but they are told that they fail in those sorts of situations, which makes any interaction with a bureaucratic system potentially incredibly stressful and gives it the potential for failure and the miscommunication of information. That is what I am driving at.
Someone like me has problems not only with accuracy of spelling but with short-term memory, which is probably a bigger problem than the lack of spelling. I find the fact that I cannot remember numbers accurately to be the greatest bugbear of my life—as, it has to be said, do all those who have to deal with me. You cannot remember to look in diaries, so timekeeping is often poor among certain groups of dyslexics. There is a spectrum of dyslexia—no one size fits all. I tried to make it clear in the title of my Question that I do not think that the system has developed far enough, although I would have hoped that it would have done a few years ago, to be able to identify dyslexics in the cases I
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Why is that important? We have identified—I hope others in this debate will also call attention to this—that within the prison system there is an incredibly high number of educational failures and of dyslexics. One study, dating back to 2001, says that 41 per cent of those in pursuit of jobseeker’s allowance had major literacy problems, and a high percentage of those were found to have dyslexia as well. There is a high correlation between those who have found themselves seeking jobs and bad qualifications and literacy problems.
My first question for the Minister is: how confident is he in the system at the moment if someone going through Jobcentre Plus states or suspects that they are dyslexic? Given the good work that has begun on access to work, how confident is the Minister that most centres and most points of contact would know where to start? At what point will we have sufficient resources to say that, yes, we know what to do and can go through the system?
One of my arguments with the noble Baroness, Lady Hollis, was whether her people would be confident enough to say, “No, we do not know what we are doing. We will stop this and bring in somebody else”. Is there an automatic process for saying, “We will go no further because we may do harm”? That is incredibly important; giving the wrong advice can be incredibly negative. Think of somebody who has had a bad school experience and is told “Oh, you can’t write properly; here is a literacy course”. It sounds great, but unless you are taught phonics at the right pace for a dyslexic and told why you cannot achieve at the same pace as the others in your class, it is reinforcing an incredibly negative stereotype.
That is something that people have failed at. To go back to the example of prisons, most prisoners are educational failures who dropped out of school. Those dyslexics are having what is probably the worst experience of their lives reinforced. How is that helpful? If you do not know how to back off, when to keep out, you are capable of making things worse.
In this process, there is a danger of people who do not fill in forms or fulfil criteria losing benefits. If that happens, how does it help anybody? How is losing your home, and so on, helpful? To come back to economy, and to put it basically, these people have no capacity to save. They need all the money they have. If you want to stimulate the economy, there is a little way forward here. Can the Government please assure us that there is some way of monitoring the progress made here, and what progress should be made? What are the mistakes?
The Minister probably felt that I was being a little harsh about access to work when I once asked why we had not got to where we are now earlier. I made my first speech about dyslexia just over 22 years ago this month. It was then a case of, “Oh yes, everybody is brilliant with dyslexia”. We have then come down to the idea that everybody is a prisoner of dyslexia—a red and a blue corner, if you like. This group is in danger of going towards reoffending. Can the
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I have not given the figure: it is reckoned that 10 per cent of the population has dyslexia. It used to be said that 5 per cent had a meaningful degree of difficulty. We do not do that any more for the simple reason that dyslexia is a multiplier. For instance, middle-class dyslexics with resources and early support tend to do okay. They also tend to be much better at accessing any form of help throughout the system. Somebody who is unemployed with no background of qualifications or in how to play systems effectively is much more vulnerable. They may well be close to their lowest ebb when they have this interchange with the benefits system. How is that taking place?
I have one last query, which is probably a little off the Minister’s bailiwick. Can he please ensure that his other colleagues in government are aware that this goes across all departments? Those departments dealing with education, for instance, tend to be quite good at it but they also tend to make mistakes. A mistake that I am sure we will address is the new apprenticeship schemes. They have a minimum requirement for literacy and numeracy. The scheme aims to fill a skills gap but for the group we are talking about—those who may well have good intellectual ability but a problem with written skills—that minimum requirement may get in the way of them accessing the scheme. Will the Government make sure that this is pointed out to those in Jobcentre Plus and the other agencies who put people in touch with the scheme? Unless there is a perception of what is going on, unless a lateral vision is acquired across government, the good work that is done in the various departments will not cross-fertilise and we will continue to keep people in silence. What are the Government doing about ensuring that their staff are equipped to get the best out of these people?
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