Lord Dykes (CB)
My Lords, it is a great pleasure to follow the speeches so far in this debate, which has been serious and solemn but also moving. I am very grateful, like others who have expressed their gratitude, to the noble Baroness, Lady Brinton, for launching this important debate.
If I may say so, without sounding in any way unctuous or sentimental, I was struck by the fact that not only are there eight noble Baronesses speaking in this debate but, just behind the Clerks’ table, we have three of the experts in this House on the National Health Service, because of both their own personal experiences and their deep knowledge of all the subjects that come within the NHS ambit. I was very moved by the description from the noble Baroness, Lady Masham, of her earlier years and how she coped with them. Those things will register, too, because the NHS is a most precious institution in this country, which the Government tamper with or undermine at their peril. People would not forget it if they did it any damage in the future.
Having said that, I am also grateful to the noble Lord, Lord Balfe, a colleague for many years, and the noble Lord, Lord Brooke, for being among the three mere males in this debate. It is an interesting reflection that women really know far more about the National Health Service than men do. That is a silly comment on my part, and I apologise for the tweets and comments that I may get on the internet from male practitioners in the NHS, saying “That’s not fair”. However, there is some connection there with the knowledge women have, given that so many women work at all levels of employment, including as technicians or the so-called unskilled. But as someone said earlier in the debate, those workers are very skilled in their work even if they are cleaners, because cleaning medical premises is a skilled job. The majority of all those people tend, I believe, to be women, including those who come from overseas.
The National Health Service is a precious institution. I was going to say that everybody in the debate is anti-Brexit except the Minister, who has to pretend to be in favour of Brexit because that is his portfolio task. I thank him for being here.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)
It is worse than that; I am in favour of it.
Lord Dykes
The Minister has confirmed that he is in favour of Brexit. It is nice to have the odd view given in a debate where everybody else is in favour of staying in the European Union, but I thank him for his personal efforts in this field as a Minister. I attended the meeting he held at the beginning of this week on the new death certification procedures that are coming in. We were grateful, since he is very busy. He is highly regarded in this House for the detailed and caring answers he gives to many complicated NHS questions. In that spirit, I hope that he will forgive my frivolity in referring to his official duties. We will see what happens in the future with those.
It is important for us to reflect on what is at stake here, with the damage done by this foolish decision to proceed with Brexit. There are still Ministers who are in denial psychologically about the damage already done to this country. The economy is already in the beginnings of what might even be a slight recession because of the decisions made by enterprises of one kind or another, mainly putting a halt to their long-term investment plans or transferring overseas.
I share the contempt enunciated by previous speakers—including the noble Baroness, Lady Brinton, herself—for the infamous red bus used in the pro-Brexit campaign, with Boris Johnson triumphant and chortling at the untruths written on its side; we now know that to be so. As a keen European as well as a patriotic Britisher, I am glad to say that there is now a different red bus travelling around this country with a different slogan for Europe. It is getting a tremendous reception everywhere it goes and has been a great success so far.
The NHS does millions of transactions every week. Most of them are carried out very well despite the pressures on employment, the reduction in the number of staff and so on and the huge pressure that NHS staff, doctors and specialists are experiencing because of the Government’s austerity cuts. There are millions of successful transactions every week. They are not noticed by the right-wing papers in this country, which pounce on the slightest unfortunate incident. Incidents are bound to happen, given the many different transactions that take place in our wonderful NHS. It is probably the best in the world, although there are many other good examples in smaller countries and in Scandinavia. In this country we are lumbered with six extreme right-wing newspapers—whose overseas owners do not pay UK personal taxes—with repetitive and boring editorials urging us all to be very patriotic. They always pounce, whenever they can, if something goes wrong in the health service. It is quite right for the press to follow up legitimately, but not when saying that there is something wrong with the National Health Service is propagandistic; millions of satisfied patients and customers—if I can use that word—know what it is like.
My personal experience has been twofold. I have had to go to A&E at St Thomas’ several times and I have used the European health insurance card, which other speakers in this debate have mentioned. The way St Thomas’ A&E is organised is utterly brilliant—it is fantastic. I have been there late at night when it is under huge pressure, and I pay tribute to it. There are numerous other examples of A&Es that are under very severe pressure nowadays that manage to cope. The European health insurance card is precious to so many British people and has reciprocal effects for those coming here and using our facilities. The idea that it would be in any way dented at the margin because of this foolish Brexit plan would be intolerable for many members of the public.
I apologise to the noble Baroness, Lady McIntosh of Pickering, for missing the last two minutes of her speech because I had to take an urgent phone call. I shared the pleasure of the noble Lord, Lord Balfe, at the fact that she has medical connections and connections with Hamburg. She is a great European spokesman and I thank her for what she did in the European Parliament. I know she has always been interested in the health service and therefore believes that these things matter.
Are we not lucky in this House to have the excellent Library briefing service? The document on health and welfare in the UK is outstanding, and I shall refer briefly to two items in it. I could mention its author but perhaps I should not in this parliamentary forum, because she is an official of the House; however, I thank her for the quality of the report. In the third paragraph on page four there is a reference to the December 2017 agreement that the Government reached with the EU negotiators:
“that EU citizens living in the UK before the UK withdrawal date of 29 March 2019 would have the right to remain and to apply for settled status after a period of five years. In a subsequent document, the Government proposed that EU citizens who arrived in the UK after the withdrawal date … but before the end of the subsequent transition or implementation phase should be allowed to enter the UK on the same terms as before the withdrawal date”.
I hope that will not change and that the Minister can confirm that that is the position, to reassure the many people who have been so worried about it that they have already left this country, having given good service and paid taxes as NHS workers, or in the care services in general.
Page six of the Library Note refers to the total budget. There is always the canard, the misleading reference to one of the richest countries in the EU, like Germany, France and now Italy, I believe, paying more into the EU budget—which is a very virtuous budget because it has no deficit and its receipts equal its payments—because it is wealthier than new countries coming in that need money to go to them. We now see, therefore, that an enormous amount of that money has to be deployed in the future in the health service in this country. The Government need to reassure us on this; I hope they will also have second thoughts and stop this nightmare happening at all.
Lord O’Shaughnessy
My Lords, first, I congratulate the noble Baroness, Lady Brinton, on initiating this debate and express my gratitude to her. I commend her contribution and those of all noble Lords, who have touched on many health issues. They have occasionally strayed into the kind of Second Reading speeches we may have heard a few of in the last 11 days in Committee on the EU (Withdrawal) Bill, but I think more or less everyone has retained their discipline and focused on health issues. That is absolutely right as these essential topics will be affected by our withdrawal from the European Union and we need to debate them. It is important to be as clear as possible both about what has been achieved through negotiations so far, what we intend to achieve and what the consequences of that are.
Before I get into the meat of my response, I express my particular thanks to my noble friend Lady Chisholm. She will not thank me for this, I am sure, as she is not always keen to put herself in the spotlight. However, it is her last day on the Front Bench as a Whip. As noble Lords know, she has been a great servant of the House and a great friend and support to me, and I want to place my thanks on the record.
Noble Lords
Lord O’Shaughnessy
All noble Lords clearly agree with that. I reassert and reaffirm that no one disputes the importance of health in the Brexit process. It is only right that we are all concerned with protecting and promoting our wonderful NHS in its 70th year. I take noble Lords back about nine months, when the Secretary of State set out three guiding principles to govern our future relationship with the EU on health. First, patients should not be disadvantaged in any way. Secondly, it should be no more difficult for industry and others to get medicines, devices and other treatments to those patients than it is now—of course, ideally, it should be better. Thirdly, and very importantly, the UK will continue to play a global role in public health, as it always has and will. Throughout that process, patient safety is our number one priority. I also know that it is the main priority of the Commission, from talking to the EU Health Commissioner and other Commissioners, and of the Governments of the other EU 27. We want to make sure that patients and citizens are safe throughout this process. The reason for that, of course, is that, as we all know, health is different. It is not the same as any other traded good or service. You cannot just pay a little bit more for it or take a little bit less for it, if you are undergoing a course of treatment which is essential to deal with a disease, so health is different. I think that is recognised by everybody from the Prime Minister downwards.
It is also worth saying that our regulatory system and our research staff in the NHS and elsewhere are the envy of the EU. We make an enormous contribution through agencies such as the MHRA and through the European reference networks and the GMC to patient safety. It is our very strong desire to continue making that expertise available for the benefit of EU citizens. That is why, as the Prime Minister has pointed out, we want continued collaboration with the EU 27, the Commission and the whole EU, and that is supported by those organisations. It is also widely supported by industry and charities, which are taking this message across the world, as well as Europe, for the benefit of a strong and deep future partnership.
Inevitably, the legal basis of our relationship will change but there is every reason to believe that we will strike a deal that delivers on the principles I have talked about, not least because of the progress we have made to date. As I will set out, I believe there is good cause for optimism. I know that optimism on this issue is sometimes in short supply—I think back to the last debate, which was marginally less gloomy than this one—but I cannot help but think that, as has been revealed in some speeches today, it is a prejudice about the benefits of Brexit in general that informs some of the opinions on the risks here, and I hope to alleviate some of that concern in my comments today.
It is also worth pointing out, as the noble Lord, Lord Brooke, did, that from a domestic point of view we had a very important statement from the Prime Minister about her intentions for the long-term funding and success of the NHS. I know that the Liberal Democrats like to think that they had a critical role in getting her to that point but I assure them that she is more than capable of reaching that conclusion on her own. What I cannot promise is that, whatever funding for the NHS is decided—and like the noble Lord, Lord Brooke, I hope it comes soon—we will be putting the figure on the side of a red bus. However, it will build on recent real-term increases, as well as Agenda for Change funding, to reward our wonderful NHS staff.
Inevitably, people and the workforce have been a big part of our debate today, and I want to use this opportunity, as I hope I always do, to thank and express my admiration for the approximately 150,000 EU nationals who work in our NHS and care services. As my noble friend Lady McIntosh pointed out, I have particular cause to be thankful, and other noble Lords, including the noble Baroness, Lady Masham, very movingly described their gratitude.
It is important to point out that there are more EU staff in the NHS since the referendum. That is true of every single specialty and every type of staff, apart from nurses—we know that the impact on nursing numbers has been driven in large part by the introduction of the language test—so we are continuing to welcome them. Indeed, just this week I chaired a Brexit round table with those who are interested in workforce issues. The message is going out very clearly through the Royal College of Nursing, NHS Providers and so on that we value the work that EU nationals do and their presence in our society.
I believe that noble Lords have welcomed the agreements that we have made on citizens’ rights, not only for after withdrawal but for during the implementation period. I can confirm to the noble Lord, Lord Dykes, that the more generous offer of citizenship rights during the implementation period has been agreed. Clearly, we also need to make sure that we have an immigration system that supports our shortage subjects. We have had the MAC interim report and we will have a future report. I can promise noble Lords that the department is contributing to that work to make sure that we do not run short of the staff we undoubtedly need to serve people in the health and care sector.
Nevertheless, it is true that we need to do more to grow our own. I do not agree with my noble friend Lord Balfe that that is jingoistic or narrow-minded; I think it is our obligation to the 1.5 million people who are still unemployed in this country, despite the fantastic growth in employment here. That is why we are increasing nursing midwifery places and doctor training places. I know that there is a particular concern about unskilled or low-skilled labour. This is a thorny issue, not least because it was concerns about that kind of uncontrolled labour coming through immigration that was a driver of people’s desire to vote leave—to get back control of the immigration system. Therefore, there is a balance to be had and things such as the apprenticeship route, Skills for Care and nursing associates offer us a way through.
Several noble Lords asked questions relating to issues in this area. We want to continue with mutual recognition, although, again, there are concerns about language requirements. Social care is undoubtedly an issue and we are trying to deal with that through Health Education England’s workforce strategy, covering health and care, as well as through the social care Green Paper. That of course focuses mainly on older people but there is a separate strand of work looking at, for example, adults with learning disabilities and others. This was mentioned by the noble Baronesses, Lady Masham and Lady Thomas.
In terms of our offer to Europe, my noble friend Lord Balfe talked about the GMC and sharing data on professional conduct. My understanding is that the GMC provides more professional conduct alerts to the European system than the other EU 27 countries put together—a figure provided to me by the BMA. Clearly that is a reflection not of the quality of our staff but of the rigour of our regulation. We want to continue to contribute to that. Our strong desire is to remain part of that registry so that we can share in the safety agenda across Europe.
The noble Baroness, Lady Tyler, asked about staffing in mental health. We do not need to rehearse the discussion we had yesterday about our desire to increase numbers. No Government in the EU have been more ambitious in their intentions on that. She asked specifically about the medical training initiative for psychiatrists and the length of time involved. I shall look into that issue as I understand it is a long training process.
The noble Baroness, Lady Thornton, asked about employment rights and health and safety issues emanating from the EU. These issues emanate from the EU because they concern competencies that it has taken for itself. They will be within our competence in future and, frankly, it will be our choice. That is the point of leaving the European Union. Woe betide any Government who tried to make life more difficult for staff, particularly when we are trying to recruit them. The point is that it will be in our gift and not in the gift of any other Government.
On reciprocal health work care—which, again, several noble Lords have mentioned—we have got a good achievement on both EHIC cards for people accessing planned care and for British pensioners living abroad accessing healthcare through the withdrawal agreement. I will not go into detail but I encourage noble Lords to look at that. It gives us confidence that we will be able to deliver a good outcome on continuing similar versions of the schemes. It is worth pointing out that EU countries have bilateral agreements with non-EU countries now and we had them before we entered the EU. It is a common arrangement that countries have with each other and much valued by people who are travelling abroad or looking to retire.
Another key issue that has been raised is the safety and availability of medicines. We have a fantastic regulator in the MHRA, with 30 years of knowledge as a lead regulator through the MA process and over 3,000 medicines. We will continue to play a role in the EMA during the implementation period to make sure that there is no interruption to supplies. We will support the transition of the EMA to Amsterdam. Some specific details still need to be worked out about membership of the committee, rapporteur rights and so on during that period. The noble Baroness is right, they will be less than we have at the moment, but their exact nature needs to be determined.
The big question concerns the future relationship. The Prime Minister has been admirably clear about her desire for associate membership but there is not a template we can follow for that. The MHRA makes a huge contribution to patient safety and we do not believe that the EU will want to jettison that ability. As I have said, we have a great deal to contribute not only in this area but in chemicals and airline safety. That will help not only for medicines but for blood, organs and, to some degree, medical devices.
Specifically on medical devices, there has been a good outcome on the continued flow of those during the implementation period. Two big questions remain: one is about the trading relationship we have; the other is about our regulatory environment. We have not touched much on trade but we have commissioned work on the supply chain in this area, which I have committed to share publicly once that investigation has taken place. There is, of course, a commitment from the Government for as frictionless and tariff-free trade as possible, and we have had meetings with HMRC to make sure that that can happen whatever the circumstances.
On the regulatory front, we have achieved mutual recognition of the work of notified bodies during the implementation period. Our notified bodies approve more high-risk devices than any other, so that is yet another element of our huge contribution to patient safety across the EU.
Clinical trials have been the subject of much discussion both in this Chamber and in meetings outside it. We all know that the UK is a leading centre for clinical trials. More than that, we helped to develop the Clinical Trial Regulation, which is a significant improvement on the directive that went before it. If, during the implementation period, the portal that is the final key which unlocks the door of the CTR becoming applicable is agreed, we will take part in it and continue to implement it after the implementation period.
There is of course the question of what will happen after 2021 because it is not solely in our gift to be part of this portal; it has to be a mutual decision. Again, it is our desire to continue to be part of that but it needs to be negotiated. Discussion is going on in government ahead of Report on the EU (Withdrawal) Bill so that we can give the kind of reassurances about the nature of our clinical trials environment that I know noble Lords and others are looking for. We want to make sure that we continue to increase the number of people who take part in clinical trials and have more trials in combination with EU and other countries.
Another issue that has been well covered in both the EU withdrawal Bill and discussions today is public health and the “do no harm” principle. I remind noble Lords of the principles I set out at the beginning from the Secretary of State about playing a leading role in public health, which this country has always done, whether in responding to the Ebola crisis or in domestic action on reducing smoking, drinking, sugar and salt in food and so on. We have a world-leading system that is admired around the world and that, as I said, makes a contribution to patient safety and health across the EU.
The noble Baroness, Lady Walmsley, asked about our desire to play a continued part in EU mechanisms such as ECDC, which provides surveillance, information sharing and action on antimicrobial resistance, where the UK has been in the lead. I can tell her that our desire is to continue to be part of those processes. We want to maintain our high standards. The phrase “a race to the bottom” has been used. We want the opposite: a race to the top. We will be able to say more about our intentions in this area in the coming weeks. We are, and will always remain, part of international agreements under the WHO’s auspices, as well as our own international health regulations. I make a commitment to the noble Baroness, Lady Masham, that it is our desire to continue to share data on the dangers and risks that we face—of course, diseases honour and respect no boundaries—to make sure that we can have the right information, through whatever means possible, to keep our people safe.
I want to touch on a couple of other issues. I am afraid that my noble friend Lord Balfe is quite wrong about Euratom; it does nothing to impact on the supply of medical radioisotopes. I implore noble Lords to be careful about the language they use so as not to create fear where it should not exist. We want to make sure that we have the right customs arrangements for those isotopes to come through quickly—as they do now if they come from outside the EU—and we will make sure, whether through the Euratom Observatory or the NCAs, that we agree with other countries so that we have the right level of information and, therefore, the correct supplies.
We have a world-leading research community and a leading role in Horizon 2020, which has been underpinned and underwritten by the commitment of the Prime Minister and the Chancellor to our involvement. We want to go on designing future arrangements with the EU, just as third parties and third countries do now. That would include being part of European reference networks; I believe that we lead more of those than any other country.
The noble Baroness, Lady Brinton, and the noble Lord, Lord Brooke, asked about procurement. I can tell them that we have implemented our obligations under the EU directive. The Government are absolutely committed that the NHS is, and always will be, a public service, free at the point of need. It is not for sale to the private sector, whether overseas or here. That will be in our gift and we will not put that on the table for trade partners, whatever they say they want.
Our ability to leave the EU successfully is dependent on having the right agreement with Ireland, where health services are co-commissioned. Primary care can span both borders, and there is trade in medicines and other things. I have met the Irish Health Minister to discuss these issues. We have a good working relationship and we are working hard to make sure that those cross-border issues do not disadvantage patients in the way we have talked about.
Finally, we are pushing ahead with the implementation of the falsified medicines directive that my noble friend Lady McIntosh asked about. I met SecureMed, the body implementing it, yesterday. The noble Baroness, Lady Thomas, asked about the welfare rights of disabled people and the European Social Fund. Those are policy areas for the Department for Work and Pensions, so I hope that she will forgive me if I do not answer specifically now; I will write to her.
The noble Baroness, Lady Walmsley, asked about food standards. I can promise her that they are on my radar; they were raised at a public health round table on Brexit that I held a couple of weeks ago. We want to maintain the highest standards through the FSA that we have at the moment.
I hope that I have been able to answer and, to some extent, alleviate anxieties expressed by noble Lords through the debate. I know that we will continue to have many discussions on these issues in the Chamber and privately. I hope that noble Lords also know that my door is always open to discuss these things. I want to make sure that we get the right outcome—as do all noble Lords, and I respect that.
The Government are undertaking a huge amount of preparatory work to mitigate the potential risks associated with leaving the European Union and to make sure that we can take the most advantage of the opportunities as well. I happen to be the lead Brexit Minister in the department, so I feel a very personal responsibility for getting this right. We want to continue to be global leaders in all the facets of health, as we are today. That is something that the Prime Minister has recognised—an important recognition. She said that our principle for how the UK approaches leaving the EU is to be,
“consistent with the kind of country we want to be as we leave … A country that celebrates our history and diversity, confident of our place in the world; that meets its obligations to our near neighbours and far off friends, and is proud to stand up for its values”.
Nowhere is this more important than in our commitment to continue meeting the health and welfare needs of the UK’s citizens and residents as we leave the European Union.