Abortion (Disability Equality) Bill [HL]

Baroness Chisholm of Owlpen Excerpts

2nd reading (Hansard): House of Lords
Friday 21st October 2016 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, I start by congratulating my noble friend Lord Shinkwin on securing time for the consideration of this Bill. We have had a very interesting and thought-provoking debate on a subject that remains a sensitive area of public policy and on which we have heard a range of strongly held views.

I should start by setting out the current legal position regarding abortion for foetal abnormality and the possible introduction of non-invasive pre-natal testing—NIPT—for Down’s and other syndromes. Under the Abortion Act 1967, women have early access to safe, legal and regulated abortion services. In each case, there should be careful and sensitive inquiry as to the reasons for requesting an abortion. These reasons will be particularly complex in the case of abortions for foetal abnormality, where the pregnancy is far more likely to have been planned and where the woman and her family will need information on and time in which to reach a decision with her doctor and other health professionals.

It is a sad reality that not every pregnancy goes to plan, and foetal abnormalities of varying degree of severity occur. Abortion is currently available where two doctors agree that,

“there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities to be seriously handicapped”.

In 2015, 3,213 abortions were performed under those grounds on women resident in England and Wales. Some 230 of those were performed at gestations of 24 weeks and over.

Antenatal screening enables practitioners and maternity teams to monitor the development of the foetus throughout pregnancy, and as technology continues to progress, the ability to detect foetal abnormalities increases. Non-invasive prenatal testing, also known as cell-free DNA, is a relatively new test that can identify pregnant women who have a higher chance of having a baby with certain genetic and chromosomal conditions, such as Down’s, Patau’s and Edwards’ syndromes. So far, non-invasive prenatal testing has been used by the NHS in special circumstances; for example, to detect genetic changes leading to specific skeletal abnormalities and certain forms of cystic fibrosis. In addition, non-invasive prenatal testing for Down’s, Patau’s and Edwards’ syndromes is currently available privately.

On 15 January 2016, the UK National Screening Committee announced its recommendation that non-invasive prenatal testing should be introduced as an additional test into the NHS foetal anomaly screening programme in England as part of an evaluation. That is because the evidence suggests that non-invasive prenatal testing is much more accurate than the current testing used in screening and can substantially reduce the number of pregnant women needing an invasive test, which carries a high risk of miscarriage. The introduction of non-invasive prenatal testing would not alter fundamentally the choices currently available to pregnant women who opt to take up the offer of screening. We want women to make informed decisions and access safe and appropriate tests. We are considering the recommendation from the UK National Screening Committee carefully and will make an announcement in due course.

Appropriate information and support should be offered to all women undergoing antenatal screening. Regardless of how an abnormality is detected or suspected, a woman has to be given time to understand the nature and severity of the condition so that she is able to reach an informed decision about how to proceed and whether to continue with the pregnancy or seek a termination.

It is an understatement to say that the decision to end what is usually a wanted pregnancy is extremely difficult and painful for most parents. The severity of the prognosis has a major bearing on their decision-making. Once an abnormality has been confirmed, arrangements should be made for the woman to see an expert who has knowledge about the abnormality and the options available. All staff involved in the care of a woman or couple facing a possible termination of pregnancy must adopt a non-directive, non-judgmental and supportive approach.

In addition, Public Health England, which takes the lead on the NHS screening programmes, recently met stakeholders from the Down’s Syndrome Association to understand where further improvements can be made to ensure that prospective parents get the right information and support throughout the screening process when making these very difficult decisions.

Sometimes, the diagnosis or prognosis does not give the whole picture of each individual case. In 1990, when the grounds for abortion were amended, Parliament agreed that doctors were best placed to make these decisions with the woman and her family. In 2010, the Royal College of Obstetricians and Gynaecologists published updated guidance on the termination of pregnancy due to foetal abnormality. This guidance concluded that it would be,

“unrealistic to produce a definitive list of conditions”,

and that,

“the seriousness of a fetal abnormality should be considered on a case-by-case basis, taking into account all available clinical information”.

I must make it clear that as they are matters of conscience, the Government maintain a neutral stance on abortion issues. We have had a good debate, and I look forward to hearing what my noble friend Lord Shinkwin has to say in response to the points that have been raised.

House of Lords Bill [HL]

Baroness Chisholm of Owlpen Excerpts

2nd reading (Hansard): House of Lords
Friday 21st October 2016 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, let me start by congratulating my noble friend Lord Elton on securing time for the consideration of this Bill. My noble friend’s proposals address a matter that continues to be of interest to us all. I thank him for his thoughtful contribution to this debate and all noble Lords who have taken part, with many excellent and amusing speeches. I am humbled to be answering this debate following speeches from many noble Lords who have been part of this House for far longer than me. I, too, am pleased that, as the noble Baroness, Lady Hayter, mentioned, two women are speaking from the Front Benches but I make no further comment on this.

This is a subject that we have debated many times before and will continue to debate in the future. It goes without saying that this House plays a vital role in the scrutiny of legislation and in holding the Government to account. It is crucial that it continues to undertake that role effectively. We therefore welcome this debate and the commitment of Peers from all sides of the House in contributing to it. We are aware that consensus is a crucial component of any proposals for reform, if they are to progress past the stage of debate. As many noble Lords will no doubt recall, in 2012 the House of Lords Reform Bill was withdrawn not for lack of commitment from the Government but because there was no overall agreement on what shape any reform should take.

We have many pressing constitutional reforms on which we should focus our attention in this Parliament—not least devolving more powers to Wales and delivering all that is necessary for the UK’s exit from the European Union. However, that does not mean that we should rule out further change. It seems logical that this House should continue, as it has for centuries, to question whether there are better ways to work and whether we can find ways of fulfilling our role more effectively. Where there are ideas for change and improvement that command consensus, we would welcome working with noble Lords to take them forward.

We know that change is possible. The Government supported the Bills introduced by the noble Lord, Lord Steel, and the noble Baroness, Lady Hayman. Those Bills enabled Peers to retire for the first time and provided a mechanism for the House to expel Members where their conduct fell below the standards that the public have a right to expect from those who make laws in this country. I am glad to say that we have not had to use the latter power. However, 52 Peers have taken the opportunity now open to them to permanently retire from this House, reflecting a real cultural change among our membership of which we can be proud.

Turning to the detail, my noble friend Lord Elton’s Bill would introduce elections every five years to elect Members of the House from among existing life and hereditary Peers who were Members of the House. Only those Peers who were already Members would be able to vote. The provision in Clause 2 would cap the number of Members elected to be Members of this House at the number of seats in the House of Commons. Currently that is of course 650, although under the Parliamentary Voting System and Constituencies Act 2011 it will reduce to 600. The Bill does not seek to amend the process for appointing life Peers or their right to membership of this House, although Clause 1 would prevent their remaining a Member after the first Session of the Parliament after they first receive a Writ of Summons. The effect of this would be that any new peerages conferred would take the overall membership above the 650 cap for the duration of that Parliament. It also means that some Members may serve as a Member of this House for only a very short period.

The Bill would also amend the House of Lords Act 1999 to ensure that the 90 hereditary Peers provided for by that Act to sit in this House becomes a maximum of 90 since, depending on the outcome of the elections, all 90 provided for in the 1999 Act may not be elected. The Bill would not otherwise amend that Act, so it would appear that the process by which a hereditary Peer is replaced through a by-election remains intact and that if a hereditary Peer died, they would be replaced by another hereditary Peer. As we heard in debate on the Private Member’s Bill introduced by the noble Lord, Lord Grocott, a number of weeks ago—and during the debate today—this is an area where noble Lords have slightly differing views. The Bill also provides for Peers who are not Members of this House, in accordance with the provisions in Clause 1, to vote in elections to the House of Commons and to stand for election to that House. Currently, those Peers who are not Members by virtue of being excepted, expelled or resigned are able to vote. This provision would extend that to those Peers who are not Members by virtue of having not been elected under the Bill.

As a Government, we agree that the size of the House cannot grow indefinitely. However, the kind of fundamental change to our composition that the Bill outlines would represent comprehensive reform of this House and, as noble Lords will not be surprised to hear me say and as my noble friend Lord True said, at a time when there are many pressing challenges facing us as a country, not least in giving effect to our withdrawal from the European Union, we do not believe that now is the right time to embark on such reform. I must therefore express reservations about the Bill.

However, that does not mean that we should not continue to work to make sure that your Lordships’ House continues to work well. Indeed, it is vital that this House continues to work effectively in holding the Government to account and scrutinising legislation, given the challenges ahead of us, and as a House we should always consider whether there are ways for us to do our job more effectively. Where there are reforms which can command the consensus of the House and improve how we work, we would be interested to work with noble Lords in taking them forward.

So while I express reservations about the Bill before us today, I welcome again the spirit of the debate and the quality of the contributions we have heard. The best step forward from here would be to harness the enthusiasm around the Chamber to explore the options available. That is something I will absolutely take away to discuss with my Front-Bench colleagues, as we move forward, and I would also welcome further conversations with many of those involved today.

Community Pharmacy in 2016-17 and Beyond

Baroness Chisholm of Owlpen Excerpts

Thursday 20th October 2016 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, with permission, I will repeat a Statement made by my honourable friend the Parliamentary Under-Secretary of State in the other place on community pharmacy in 2016-17 and beyond. The Statement is as follows:

“In December 2015 the Government set out a range of proposals for reforming the sector. Our intent was to promote movement towards a clinically focused community pharmacy service that is better integrated with primary care and makes better use of pharmacists’ skills. I now wish to update the House on the outcome of this consultation and the measures we intend to take forward.

Let me be clear at the outset. The Government fully appreciate the value of the community pharmacy sector. There are now over 11,500 pharmacies, up by over 18% over the last decade. Indeed, the overall pharmacy spend has increased by 40% over the last decade and now stands at £2.8 billion per annum. However, we do not believe that the current funding system does enough to promote either efficiency or quality; nor does it promote the integration with the rest of the NHS that we, and pharmacists themselves, would like to see.

The average pharmacy receives nearly £1 million per annum for the NHS goods and services it provides, of which around £220,000 is direct income. This income includes a fixed-sum payment—called the establishment fee—of £25,000 per annum for most pharmacies, regardless of size or quality. This is an inefficient allocation of NHS funds when 40% of pharmacies are now in clusters of three or more, which means that two-fifths are within 10 minutes’ walk of two or more other pharmacies. Instances exist of clusters of up to 15 pharmacies within 10 minutes’ walk.

At a time when the overall NHS budget is under pressure and we need to make £22 billion in efficiency savings, it is right that we examine all areas of spend and look for improvements. The measures we are bringing forward today have at their heart our desire to be more efficient and spend precious NHS resources properly. Community pharmacy must play its part as the NHS rises to this challenge.

I am today announcing a two-year funding settlement. In summary, contractors providing NHS pharmaceutical services under the community pharmacy framework will receive £2.687 billion funding in 2016-17 and £2.592 billion in 2017-18. This represents a 4% reduction in 2016-17 and a further 3.4% in 2017-18. Every penny saved by this reset will be reinvested and reallocated back into our NHS to ensure the very best patient care. Furthermore, separately commissioned services by NHS England, clinical commissioning groups and local authorities will not be affected by this change. I want this commissioning of services to continue to grow.

From December 1 2016, we will also simplify the outdated payments structure and introduce payment for quality so that, for the first time, we will be paying pharmacies for the service they provide, not just the volume of prescriptions they dispense. We will also relieve pressure on other parts of the NHS by properly embedding pharmacy in the urgent care pathway.

As we continue the path of reform, we will be informed both by the review of community pharmacy services being carried out by Richard Murray of the King’s Fund and stakeholders such as the Royal Pharmaceutical Society. NHS England is investing £42 million in a pharmacy integration fund for 2016-17 and 2017-18. This will facilitate the faster movement of the sector into value-added services.

As an example, last week, I announced two additional initiatives to improve our offer to patients. First, those who need urgent repeat medicines will be referred by NHS 111 directly to pharmacies, not out-of-hours GPs, as at present. Secondly, NHS England will encourage national roll-out of minor ailment schemes already commissioned by some CCGs. This is expected to be complete by April 2018.

We are confident that these measures can be made without jeopardising the quality of services. In fact, we believe that the changes will improve them. To safeguard patient access, we will be introducing a pharmacy access scheme in areas with fewer pharmacies and higher health needs. We are today publishing the list of pharmacies which will be eligible for funding from this scheme. Copies are available on gov.uk and from the Vote Office. This list includes all pharmacies which are more than one mile from another pharmacy. These pharmacies will be protected from the full impact of the reductions.

In addition, we will have a review process to deal with any unforeseen circumstances affecting access, such as a road closure. We will also review cases where there may be a high level of deprivation but where pharmacies are less than a mile from another pharmacy, if that pharmacy is critical for access. This will cover pharmacies that are located in the 20% most deprived areas in England, are located 0.8 miles or more from another pharmacy and are critical for access. Additional funding over and above the base settlement will be made available as needed.

We have already announced NHS England’s proposal significantly to increase the number of pharmacists working directly in general practice, with a budget of £112 million to deliver a further 1,500 pharmacists in general practices by 2020.

Colleagues will be aware that the Government consulted the Pharmaceutical Services Negotiating Committee and other stakeholders, including patient and public groups. I am grateful for the responses received, which reinforced the value of community pharmacy and confirmed its front-line role at the heart of the NHS. The consultation also confirmed that there is potential for the sector to add even more value. However, we are disappointed by the final response from the PSNC. We endeavoured to collaborate and listened to its many suggestions over many months. Sadly, we were unable to reach agreement. Its role is, in the end, to represent the business interests of its members, and I respect that. My role is to do the right thing for the taxpayer, the patient and the NHS.

I close by setting out my firm belief that the future for community pharmacy is bright. These vital reforms will protect access for patients, properly reward the quality of services delivered by pharmacists for the first time, and far better integrate care with GP and other services. That is what the NHS needs, what patients expect and, I believe, what the vast majority of community pharmacists are keen to deliver. I commend this Statement to the House”.

[Lord Kennedy of Southwark (Lab)]

My Lords, first, I thank the noble Baroness, Lady Chisholm, for repeating the Statement made by her honourable friend in the other place. Community pharmacies play a huge role in our health and social care system. It is estimated that 80% of patient contact in the NHS is with community pharmacies. Elderly people and those with long-term conditions, in particular, rely on the service provided by their community pharmacy.

For all the warm words and reassurance from the noble Baroness, nothing in the Statement gives comfort to anyone. It confirms, despite concerns raised in this House and the other place and the concerns of the pharmacy sector, patients and the general public, that the Government are carrying on as before. Policy option 2 in the impact assessment, the Government’s preferred policy option, states that,

“there is no reliable way of estimating the number of pharmacies that will close as a result of this policy”.

So we have spending cuts—12% for the rest of this year, 7.4% for next year—and an impact assessment in which the Government admit that they have no idea how many pharmacies will close, but we are supposed to accept the claim at the end of the Statement, that

“my firm belief that the future for community pharmacy is bright”.

To make that claim have an ounce of credibility, the Government will have to do a lot better than the Statement produced today for the House.

We face unprecedented demand on health and social care services, and the importance of local pharmacies is greater than ever. When I go to my GP or my local pharmacy, there are always posters up telling people to go to their local pharmacy for a variety of conditions, not the GP or A&E.

Can the noble Baroness tell the House what she estimates the effect of the spending cuts will be on GP services in general, the out-of-hours service in particular, and on pressure on A&Es, where there is already a problem with people seeking treatment who should really be dealt with by other parts of the NHS?

There is very little information about the effect of these cuts, but some research has been commissioned on the effect of cuts to the pharmacy sector. The results are staggering: 36% of pharmacies could be forced to reduce their opening hours; 76% might have to limit currently free services, such as deliveries to housebound patients; 52% could reduce access to the pharmacist; and 76% could reduce staffing levels.

That does not sound like a bright future for community pharmacies to me; that sounds more like putting patient safety and welfare at risk with ill-thought-out plans. Can the noble Baroness say more about the effect of the Government’s plans on areas of greatest deprivation? Has she come across the pharmacy care law, a product of research undertaken by Durham University, considering the relation between community pharmacy distribution, urban areas and social deprivation in England? What evidence can she provide that the targeting of clusters in areas of the highest deprivation will not affect people who need healthcare services the most, and potentially further widen healthcare inequalities?

Can the Minister tell the House about the effect of the measure contained in this Statement on rural areas? We have heard the statement from the Government that no community will be left without a pharmacy. So can the noble Baroness, Lady Chisholm, give a commitment today that no rural area will lose its pharmacy as a result of these measures and tell us what specifically the Government will be doing to deliver on that commitment, as we need more than warm words? Has the Minister considered the impact that these measures could have on other NHS services? How does she square the desire from the Government for community pharmacies to do more to relieve pressure on GPs and A&E services when, as a result of these actions, opening times, services and the viability of these pharmacies could be put at risk?

In conclusion, if in the time allowed the Minister cannot answer all the points that I have raised today, I hope that she will give a firm commitment from the Dispatch Box to write to me and place a copy in the Library.

[Baroness Chisholm of Owlpen]

I thank the noble Lord for his questions. These reforms will make the necessary modernisation to provide the best possible service for the patient. He mentioned the problems with pharmacies closing and asked where that was going to leave us. We are investing £112 million to deliver a further 1,500 pharmacies in general practice by 2020. The NHS England pharmacy integration fund will be focused on the deployment of clinical pharmacies and pharmacy services in the community and primary care settings, including groups of general practices, care homes and urgent care settings, such as NHS 111. This will improve access for patients, relieve the pressure on GPs and A&E departments, ensure optimal use of medicines and derive better value, improving outcomes for patients.

The noble Lord also asked about pharmacies in deprived areas and rural communities. That is why we are setting up the primary access scheme and are today publishing the list of those pharmacies that will be eligible for funding from the pharmacy access scheme. These pharmacies will be protected from the full effect of funding reductions, and the scheme will include a review process to deal with any inaccuracies in calculations or any unforeseen circumstances. I hope that that answers the noble Lord’s questions.

[Lord Rennard (LD)]

The noble Baroness said in answer to my question on Tuesday:

“We are not suggesting that any pharmacies close”,—[Official Report, 18/10/16; col. 2225.]

but then went on to imply that some of them would be closed. Does she agree with the former Health Minister, Anna Soubry? She said in the House of Commons on Monday that,

“there is great concern about the proposals”,

and that if,

“there was ever a time to argue to increase the role of pharmacies, it is now”.—[Official Report, Commons, 17/10/16; cols. 593-94.]

Does the Minister accept that it will often be the smaller, independent pharmacies that will be under threat of closure and that closing them will reduce competition, restrict choice and increase prices? Can she say a little more about the integration fund? I understand that it was originally announced as being worth £300 million over five years, but it now seems to be worth £42 million in the next two years. Has the promised cash disappeared?

Will the Minister confirm that the access fund is largely coming out of the general pot to support pharmacies and that most of the expenditure through it will therefore be at the expense of support for other pharmacies? When local authority funding is being reduced for public health projects as a result of cuts in funding from NHS England, is not this another example of a false economy—making short-term savings that will lead to greater costs and pressure on the health service in future, in particular on GP surgeries?

[Baroness Chisholm of Owlpen]

It is important that we offer a level of certainty and stability to pharmacy businesses and contractors providing NHS pharmaceutical services under the community pharmacy contractual framework, which will receive £2.687 billion funding in 2016-7 and £2.592 billion in 2017-8. The pharmacy integrated fund, as I said earlier, will make a huge difference to the NHS integrated fund, which will focus on the deployment of clinical pharmacy services in the community and primary care settings.

[Baroness Seccombe (Con)]

My Lords, as a great supporter of pharmacies, especially in rural areas, may I draw my noble friend’s attention to one rural area where a pharmacist wished to open a pharmacy, but it was objected to by doctors, because they had their own pharmacies in their practice? That is a great disservice to the community, which had to go six miles to find a chemist’s shop.

[Baroness Chisholm of Owlpen]

That is why the pharmacy access scheme is very much there to make sure that pharmacies in these rural areas will be fully protected from any funding reductions. But the competition is there. Pharmacies on the whole are privately owned. It is important and only fair that, in these strapped times for the NHS, private companies should in some way also help the publicly funded NHS.

[Lord Lea of Crondall (Lab)]

My Lords, my question is in the same territory as the previous question. It is not just the nomenclature but the knock-on effects between this Statement and GP dispensaries that is concerning. Have I understood this correctly? On the one hand, the Government expect more traffic to be diverted into GP dispensaries but, on the other hand, people will ultimately pay more—someone is paying—through a mixture of pressure on the big chains, supermarkets and, of course, A&E.

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[Baroness Chisholm of Owlpen]

The point about the pharmacy integration fund is that we want to think up more joined-up ways in which we bring everything together. That is why we very much focus on the deployment of clinical pharmacies and pharmacy services in the community and primary care settings. It will include groups of general practices, but it also includes care homes and urgent care settings, such as NHS 111.

[Lord Lansley (Con)]

I am grateful to my noble friend for repeating the Statement. She has rightly highlighted that over recent years the number of community pharmacies has increased—indeed, by more than 1,000 pharmacies in the last five years. That is welcome, because it is a means by which there is a reach into the community that is unparalleled elsewhere in the health and care services. But it is about how we go about diversifying pharmacy income. For a long time, it has been clear that it should not be wholly reliant on dispensing fees and the global sum, as it has been in the past. We need additional services, enhanced and locally commissioned services, to grow. My noble friend’s Statement said exactly that, but the question is how we do it. By and large, it will not be done out of the public health budget of local authorities, although some will be. It is potentially mainly out of things such as the better care fund, enabling us not just to have pharmacies embedded in GP and other health services but using the community pharmacies’ reach in the community to deliver support to people with chronic conditions. Will my noble friend say that there will be an effort to promote this? At the moment, we have no good data from the past two years on local commissioning of those enhanced services. Can we get those data sorted out so that we can see whether pharmacies are being used as they should be and diversifying their income?

[Baroness Chisholm of Owlpen]

I agree with everything that my noble friend has said—data are extremely important. Of course, with those new reforms we will have the opportunity to make changes and be absolutely sure that the integrated services are working as we want them to work.

[Baroness Donaghy (Lab)]

My Lords, this is beginning to sound like the fate of the post offices. In my local urban chemist—as we still call it; I have not quite got used to calling them pharmacies—I do not think I have ever seen anybody pay for their prescription, because the area is poor and has a high proportion of elderly and long-term disabled people. It already performs a very good public service in an integrated way as far as it possibly can. It seems to me that it is being asked to do even more. My concern is that none of the questions asked by my noble friend on the Front Bench was answered by the noble Baroness. She also did not give any assurance that she would answer his questions in writing. I am particularly concerned about the comments that he made on the impact assessment—it seems that it is not just the data that are very woolly, but the government thinking.

[Baroness Chisholm of Owlpen]

As I said, the impact assessment was published today. I think that I did answer the noble Lord’s questions. He asked how pharmacies were going to be looked after in deprived areas and I explained about the pharmacy access scheme and how these pharmacies will indeed be protected. He also asked about the integrated pharmacies and as I said there would be £112 million to deliver a further 1,500 pharmacies. They will be integrated into general, joined-up practices within the NHS. This has to be the way to go—multidisciplinary areas where we will be focused on the deployment of clinical pharmacies and pharmacy services in the community and primary care settings. This will make a difference to groups of general practices, care homes and urgent care settings that all have pharmacies within them.

[Baroness Masham of Ilton (CB)]

My Lords, how will the community pharmacies be saved in rural areas? The numbers are very small but the people—such as elderly and disabled people who may not drive—are absolutely stuck. As it is, the pharmacies in my local villages are not open on Saturday afternoons or Sundays, which makes things very difficult, particularly in the summer when there are tourists around. As the surgeries are shut as well at weekends, the only alternatives are the A&E departments.

[Baroness Chisholm of Owlpen]

Pharmacies are privately owned and there is competition among them. On the whole, it is beneficial for them to provide the necessary services but, as I said earlier, as far as keeping pharmacies open in rural areas is concerned, we are absolutely committed to that with the pharmacy access scheme.

Franchise: British Citizens Abroad

Baroness Chisholm of Owlpen Excerpts

Thursday 20th October 2016 Lords Chamber

[Lord Lexden]

To ask Her Majesty’s Government what plans they have to extend voting rights in parliamentary elections to British citizens who have been living abroad for 15 years or more.

[Baroness Chisholm of Owlpen (Con)]

My Lords, I have good news. I am pleased to confirm that the Government have published details of their approach to removing the current 15-year rule on British citizens living overseas voting in parliamentary elections. I informed this House of that by means of a Written Statement on 10 October. The policy statement sets out in detail how we plan to remove the current rule that means British citizens overseas can vote only for 15 years from the point they were last registered to vote in the UK. The Government intend to give the right to vote to all British citizens overseas who were previously resident or registered to vote in the UK. The Government welcome feedback on these proposals from any interested party.

[Lord Lexden (Con)]

My Lords, the policy document to which my noble friend made reference is most welcome but do the Government understand the deep concern that has arisen among British citizens living overseas given that the legislation so clearly promised in the Conservative election manifesto has not yet been introduced? When will it see the light of day? Can the Government give an absolute commitment that all our fellow countrymen and women living abroad will be able to vote in the next general election?

[Baroness Chisholm of Owlpen]

I thank my noble friend for that. Introducing votes for life will require primary legislation to amend the Representation of the People Act 1985 and associated secondary legislation. There is no current timetable for introducing the Bill but the intention is to have the new arrangements in place ahead of the next scheduled general election in 2020.

[Lord Grocott (Lab)]

Has the Minister heard the ugly rumour that the reason the Government are proposing to extend the franchise to people who have not lived, worked or paid taxes here for decades is not because of an important constitutional principle but because they think they are more likely to vote Tory? In order to dispel that ugly rumour, will the Minister tell the House from the Dispatch Box that no such consideration has ever entered her or any other Minister’s head?

[Baroness Chisholm of Owlpen]

I certainly cannot speak for anybody else but it had not entered my head. This will allow everybody who was resident in the UK and is now living abroad, but has been living there for more than 15 years, to vote in UK elections. It does not matter what party they vote for; we welcome them all.

[Lord Tyler (LD)]

My Lords, will the Government examine all the options when they prepare this legislation? For example, will they examine the case for distinct, separate constituencies for our fellow citizens who now live abroad? Does the Minister recognise that there are Members on all sides of the House who have served as MPs and will know the advantages of being able to really speak for those people? As it stands, the average Conservative, Labour, Liberal Democrat—or whatever—MP will undoubtedly find it difficult to represent the voices and views of a small number of overseas electors when they have thousands of others who still live in their constituency. After 15, 20, 30, 40 or 50 years it would be very difficult to represent them.

--- Later in debate ---

[Baroness Chisholm of Owlpen]

We have set up consultations and are hoping to get responses from everybody who might be involved in this. That will no doubt be one of the things that comes up.

[Lord Kilclooney (CB)]

My Lords, as Irish citizens in the United Kingdom have exactly the same electoral rights as British citizens, will the removal of the 15-year ban apply to Irish citizens abroad as well as British citizens?

[Baroness Chisholm of Owlpen]

My Lords, the noble Lord has slightly got me on that one. I will have to write to him.

[Lord Cormack (Con)]

My Lords, has it occurred to my noble friend that, had we given due priority to this manifesto commitment, British history might be a little different?

[Baroness Chisholm of Owlpen]

This has nothing to do with the EU referendum. That was run under the Westminster franchise. This is a completely different set of rules, and the idea is to bring it in with primary and secondary legislation.

[Baroness Hayter of Kentish Town (Lab)]

My Lords, I have twice asked the Minister’s predecessor—or perhaps three times—whether this means that such people will then become permitted donors. This is serious: it means that non-doms, who may not have lived here for 50 years, who may not have paid income tax for 50 years and who have no real interest in this country, would be able to be permitted donors, and foreign money could pour into our political parties.

[Baroness Chisholm of Owlpen]

All those things are under consideration. I think that what the noble Baroness says is unlikely to be the case, but I will get back to her to make sure that that is correct.

[Lord Forsyth of Drumlean (Con)]

My Lords, what is the possible justification for allowing people who have no contact other than past contact with this country and who pay no taxes in this country to have votes? Will my noble friend tell me which other countries in the world have such a system?

[Baroness Chisholm of Owlpen]

I think that quite a lot of people who live abroad still have houses and relatives here, and come here quite a lot. They still have a lot of connection with this country. There is no reason why they should not be allowed to have a view on the elections.

[Lord Foulkes of Cumnock (Lab)]

Following the noble Lord, Lord Forsyth, if British citizens who have gone abroad to avoid paying British tax are allowed to vote, but EU citizens living and working in Britain, who pay tax, are not allowed to vote, what has happened to the principle of no taxation without representation?

--- Later in debate ---

[Baroness Chisholm of Owlpen]

These people have not necessarily gone abroad to avoid taxes: they might be working. I have a son who has lived abroad for 13 years; he will soon be coming up to 15 years. He is there because of his job, but he still has a lot of interest in the UK. It is not only about taxes.

NHS England: HIV Prevention

Baroness Chisholm of Owlpen Excerpts

Tuesday 18th October 2016 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether NHS England is informing patients that lifesaving drugs will be denied them if funding has to be made available for pre-exposure prophylaxis (PrEP) for HIV prevention.

[Baroness Chisholm of Owlpen (Con)]

Clinicians can apply for funding for the drugs in question where there is a clinically exceptional or clinically critical need. Each year NHS England receives many proposals for investment in specialised services. Difficult decisions then have to be made on behalf of taxpayers about how to prioritise the funding available.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Baroness. She will know that evidence from clinical trials shows that PrEP can be highly effective in reducing the spread of HIV when given to those who are at most risk. Quite disgracefully, NHS England has sought to avoid funding responsibilities by saying that it is the responsibility of local authorities, at a time when there have been big cuts in the public health budgets of those councils. Even more disgracefully, government sources appear to have briefed the media that if they were forced to fund PrEP, treatments for serious conditions would have to be stopped, including treatments for children with cystic fibrosis. This was deeply unpleasant, caused great offence and may well have added to the stigma faced by many living with HIV. Will the Government assure the House that this will not happen again, and instruct NHS England to fund the drug forthwith?

[Baroness Chisholm of Owlpen]

The decision on which drugs to prioritise and how it should happen should surely be made by clinicians and NHS England, and not by politicians. As with all new drugs, PrEP needs to be properly assessed in relation to cost and effectiveness to see how it could be commissioned in the most sustainable and integrated way, and how it compares with other cost-effective approaches.

[Baroness Walmsley (LD)]

My Lords, if the court’s decision on the appeal upholds the original decision of the court, NHS England is clearly responsible for providing PrEP. Will the Minister emphasise to NHS England that it should be considering PrEP as a highly effective preventive measure in the same vein as the highly effective vaccinations of babies?

[Baroness Chisholm of Owlpen]

Yes, certainly if they lose their appeal, it goes back into the normal commissioning process. Of course we recognise that studies have shown that PrEP has been a success, but we also need to remember that it is a matter of how it is used. There are several ways that we have been tackling HIV until now, and PrEP is only one in a range of activities to tackle it. We need to remember that, for it to work, PrEP needs to be taken daily, and sometimes it is difficult to get this group always to take it daily.

[Baroness Masham of Ilton (CB)]

My Lords, will the Minister give us an assurance that life-saving drugs will not be cut back for people with HIV and other life-threatening conditions?

[Baroness Chisholm of Owlpen]

As I said earlier, we have difficult decisions to take. It is not up to the Government to decide this. As with all new drugs, these are properly assessed for cost and effectiveness to see how they can be commissioned in the most sustainable and integrated way.

[Lord Lexden (Con)]

Are the Government content to let expensive legal wrangling on this matter continue? Is it not time that the Secretary of State thought of using the powers that he possesses to intervene in this tragic and costly dispute?

[Baroness Chisholm of Owlpen]

I think that we are about to get a decision on the dispute; in fact, we thought it would be this week. It will probably be by the end of this week or the beginning of next.

[Lord Patel (CB)]

My Lords, this method of preventing HIV is highly effective: one tablet taken a day has a success rate of 99%. The lifetime cost of treating one patient with HIV is more than £300,000. Are we not talking about a false economy here when we could prevent some 300 or more new cases a year and avoid the risk of these high-risk individuals passing on the HIV? This decision has been based on fundamental disputes about who should be funding it and not by the logic of successful treatment.

[Baroness Chisholm of Owlpen]

Truvada is clinically effective for HIV, as we know, but a number of other issues are also important to consider, including uptake and adherence, sexual behaviour, drug resistance, safety and prioritisation for prophylaxis and cost effectiveness. Clinical trials certainly did find that Truvada reduced the relative risk of acquiring HIV for between 44% and 86% of cases, and the PROUD findings showed the figure was 86%.

[The Lord Bishop of Chester]

My Lords, the Minister has twice referred to difficult decisions. Are the Government sure that spending about half the proportion of GDP on health that North America spends and significantly less than, say, France or Germany spends will enable us to make the right decisions in the face of these difficult ones?

[Baroness Chisholm of Owlpen]

I agree with the right reverend Prelate, but it is necessary for these drugs to be properly assessed in relation to cost and effectiveness, as I said. It is not up to government to decide this; it must be done between the clinicians and the NHS.

[Baroness McIntosh of Hudnall (Lab)]

The Minister referred to the difficulty, as she saw it, of getting people who might benefit from PrEP to use it effectively. I am not entirely sure what that has to do with the Question. However, does she not think it more likely that people will make proper and effective use of these drugs if they are available on the NHS, so they do not have to go through a much more complicated and much less well-funded system to get them?

[Baroness Chisholm of Owlpen]

As I said, it is up to NICE and NHS England to decide whether these drugs can be used. Until we know the result of the NHS appeal, it is difficult for me to comment further.

Health: Diabetes

Baroness Chisholm of Owlpen Excerpts

Tuesday 18th October 2016 Lords Chamber

[Lord Harrison]

To ask Her Majesty’s Government what plans they have to extend podiatry care for diabetes.

[Baroness Chisholm of Owlpen (Con)]

My Lords, the NHS Operational Planning and Contracting Guidance 2017-2019 announced NHS England’s intention to launch a £40 million programme of investment to support the CCGs to improve the treatment and care of people with diabetes. This includes improving access to multidisciplinary foot care teams for people with diabetic foot disease.

[Lord Harrison (Lab)]

My Lords, given the fast-rising numbers of those with diabetes, which now absorbs over 10% of the national health budget—four out of five lower-limb amputations on a daily basis could be preventable—is it not time wisely to invest in podiatric care for diabetics in order to save not only money but the heartache from the loss involved in those lower-limb amputations?

[Baroness Chisholm of Owlpen]

The Government are absolutely committed to preventing more amputations, but we believe very strongly that money should go towards multidisciplinary teams. These have been seen to be a huge success in various initiatives taken by the likes of King’s College Hospital in Sheffield, where multidisciplinary teams were put together. It has been shown that, in Sheffield for instance, there was a 45% reduction in the number of amputees over three years, along with significant financial savings and a 90% patient satisfaction rating. This is the way to go.

[Lord St John of Bletso (CB)]

My Lords, given the high prevalence of type 2 diabetes and the associated inactive lifestyle of patients, what measures can be taken to promote more exercise of these patients?

[Baroness Chisholm of Owlpen]

The noble Lord is absolutely right: a key issue in dealing with diabetes is education. We have put together several packages. For instance, Public Health England, NHS England and Diabetes UK are working together on Healthier You, which seeks to educate people who might have type 2 diabetes. We are also looking at how we can get to these people in different ways, such as web-based approaches, apps and joined-up thinking. It is sometimes difficult for people to get to clinics, and it might be easier for them to look at digital or the web.

[Baroness Young of Old Scone (Lab)]

My Lords, in the face of investment in diabetes care and the strong priority being given by the Government to multidisciplinary teams for foot care, why can there not be a directive from the Government to ensure that all CCGs commission to that standard? Currently, two out of five patients are not seen within the recommended NICE guidelines on treatment for foot care. Unless local health economies are required to deliver to that standard, I believe that we will continue to see loss of feet as well as a huge increase in costs to the NHS. What are the Government going to do to make this a universal provision?

[Baroness Chisholm of Owlpen]

As I said, we are encouraging all NHS trusts to take up the multidisciplinary approach. We are disappointed in the take-up, and we think there are several reasons for it. The Department of Health and Diabetes UK are working together on ways to improve the take-up of structured education and considering more diverse provision in this area. It is also important to remember that a lot of people, when they go to see the doctor, do not say that they have a problem with their feet. We need to educate healthcare professionals to be able to ask the right questions, one of which should be not, “Have you got any problems?”, but, “Do you have a problem with your feet?”. A lot of people are embarrassed to say that they have a problem, so education could be done on both sides.

[Lord Rennard (LD)]

My Lords, the Minister will be aware of the importance of community pharmacies in supporting people with diabetes in relation to their foot care. Does she accept that the planned significant reduction in the budget to support community pharmacies will force many people who have foot complications to try to go to overcrowded GP surgeries, adding to the problems there? That could mean more long-term complications being treated later in hospital, in the secondary sector. The planned reductions are a completely false economy that should not be made if they are going to force more people to seek treatment other than in their community pharmacy, as at present.

[Baroness Chisholm of Owlpen]

I think the noble Lord was in the House yesterday when I repeated an Answer to an Urgent Question on this subject. We have to think of the most effective ways to save money in the NHS. We are not suggesting that any pharmacies close, as the noble Lord knows. We are suggesting savings for pharmacies over the next two years. That is not to say that there will be any pharmacies closed, but we need to make them more efficient. There are some places where there are three pharmacies in one high street, which is slightly ridiculous. However, we are ensuring that rural pharmacies will be in place.

[Baroness Wheeler (Lab)]

My Lords, NHS England needs 12,000 podiatry practitioners but has only an estimated 3,000, and that number is declining. Next year podiatry trainees, like nurses, lose the state bursaries that help to contribute towards the cost of training, so fewer are expected to apply. What specific plans do the Government have to ensure that high-risk diabetic patients receive the checks and care needed to avoid serious deterioration in their foot health and possible amputation?

[Baroness Chisholm of Owlpen]

On the question of training for podiatrists, Health Education England is leading on commissioning a study of recruitment to small and vulnerable professions such as podiatry; the Higher Education Funding Council for England and the College of Podiatry are contributing to the funding of that piece of work. The intention is to make the interventions where necessary to ensure that students are not put off from applying.

On the second part of the question, health checks are indeed very important and we are encouraging as many people as possible to take them up. As I said, there is a problem with some people being willing to take them, and we are looking into how we can improve that.

Disability: Premature Deaths

Baroness Chisholm of Owlpen Excerpts

Monday 17th October 2016 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, I congratulate the noble Baroness, Lady Hollins, on securing this debate on an issue of great importance that is rightly of concern to your Lordships and indeed to the Government. I begin by paying tribute to the noble Baroness for her unfailing commitment to highlighting the inequalities, experiences and poor outcomes that people with learning disabilities and their families have faced for many years. I echo her and other noble Lords’ tributes to Lord Rix, who we are certainly going to miss enormously.

I also take this opportunity to congratulate my noble friend Lady Fall on an excellent maiden speech. My noble friend will be a great addition to this House and I greatly look forward to her contributions in the future. Also, let me thank all noble Lords for their contributions this evening.

We know that there are people young and old who die from what are often referred to as avoidable and premature deaths—which, I think we would all agree, need not happen if care, safety and the way in which people are treated were consistently good across the whole of the healthcare system. The Government are clear that the lives of people of all ages with learning disabilities matter. We are working with partner organisations, professionals and people with learning disabilities and their families to respond to issues that are important to, and have a big impact on, people’s lives.

As my noble friend Lady Rawlings mentioned in her speech, we know that people with learning disabilities experience significantly worse outcomes than the rest of the population. Our activity therefore extends beyond health and care and must also encompass the education of healthcare professionals, employment and housing. To this end, NHS England has a wide-ranging programme of work on learning disability designed to transform care and improve outcomes, driving up the quality of clinical and nursing care and reducing health inequalities. The NHS Five Year Forward View highlighted the need to improve learning disability services, with the NHS driving improvements in culture and behaviours towards people with learning disabilities.

The NHS published shared planning guidance in September with the aim of improving learning disability services, including reducing premature mortality, one of only nine “must dos” in the guidance. As my noble friend Lady Rawlings also mentioned in her speech, the clinical commissioning group improvement and assessment framework was launched in March. This Ofsted-style assessment will allow us to see how clinical commissioning groups are performing in key areas. It includes two indicators on learning disability: reliance on specialist in-patient care and the proportion of people on GP learning disability registers receiving an annual health check.

The noble Lord, Lord Hunt, and the noble Baroness, Lady Tyler, both spoke about NHS foundation trusts, and my goodness there are lessons to be learned. The Government have asked whether the issues raised in the Mazars report might be found in other providers across the country. The Care Quality Commission’s review into the investigation of deaths includes a sample of all types of NHS trusts in different parts of the country and will assess whether opportunities for the prevention of death have been missed—for example, by late diagnosis or physical healthcare problems. We expect the Care Quality Commission to publish its findings in December.

The noble Baronesses, Lady Hollins and Lady Tyler, asked what the Government were doing to provide full information on an ongoing basis on trends in the age of and causes of death of those with learning disabilities, and how those trends can be monitored. In answer, I can say that the Department of Health is working with Public Health England and NHS Digital to address the lack of reliable data, which are so important to ensuring that the right decisions can be made by healthcare professionals. A number of approaches are being considered, but the lack of progress has been frustrating. Noble Lords will be aware, however, of the wider issues surrounding the safe and secure use of health and care information, and here I cite the work undertaken by the National Data Guardian for Health and Care, Dame Fiona Caldicott, to ensure that the public can make informed choices about how their data are used. The Department of Health ran a public consultation on those proposals and is currently analysing the responses received. In addition, the department sponsored a study in this area undertaken by Public Health England, and the findings were published by the Journal of Intellectual Disability Research in July. They indicate the extent of premature mortality and its major causes.

As noble Lords have mentioned, people with learning disabilities have a life expectancy on average approximately 20 years less than other people. Public Health England also publishes a digest of the most up-to-date mortality statistics in People with Learning Disabilities in England. The 2016 edition of this will appear later this year.

The noble Baronesses, Lady Hollins and Lady Rawlings, asked whether it was time to mandate reviews into the deaths of all people with learning disabilities. Several other noble Lords mentioned this, too. In March 2015, NHS England commissioned the learning disability mortality review programme, which aims to support local and regional areas conduct reviews of deaths of people with learning disabilities and implement any recommendations and plans of action. Every NHS region is testing the review process and by March 2019 we expect every area to have established a mortality review process.

On the important matter of drugs, excessive use of psychotropic medication is known to be a specific factor in the premature death of people with a learning disability. Several royal colleges have signed a pledge to stop overmedication and have developed plans to deliver on the pledge, including issuing guidance for pre-registration nurses and psychiatrists; producing accessible information on medication for people and their families; and publishing guidance for prescribers. NHS England will also look regularly at primary-care prescribing of psychotropic drugs to monitor progress nationally.

As I mentioned earlier, the NHS mandate includes a requirement to reduce health inequalities for people with a learning disability. The noble Baronesses, Lady Redfern and Lady Hollins, mentioned annual health checks, as did the noble Baroness, Lady Walmsley. A key objective of this work is to increase the number of people on primary care registers and to ensure that as many of those people as possible get an annual health check. The ambition is for 75% of people on GP registers to receive an annual health check by 2020. Specific work under way includes: standardised letters to improve advice and guidance on health checks; pre-health check questionnaires; health check templates linked to people’s care records; and health action planning, including a focus on key issues that need to be followed up.

NHS England is working to improve how people with a learning disability access health services. This includes: developing care pathways for health conditions affecting people with a learning disability such as diabetes, epilepsy, heart disease and dysphagia; improving patient experience and outcomes; and sharing good practice to reduce variation in quality and make reasonable adjustments to services.

Education is hugely important and was mentioned by virtually every noble Lord. We have recognised that there needs to be a significant improvement in education of healthcare professionals. Health Education England, together with Skills for Health and Skills for Care, launched in July 2016 the learning disabilities core skills education and training framework, which was mentioned by several noble Lords. The framework provides the knowledge and skills needed for those delivering training to health and care professionals.

The noble Lord, Lord Addington, and the noble Baroness, Lady Hollins, mentioned the difficulties in communicating. Some universities such as St George’s, with the help of the noble Baroness, Lady Hollins, lead the way. Here, students receive training from training advisers who themselves have learning disabilities.

We are also taking steps to help people understand and access the right care and support, including by trialling the idea of “named social workers”, and, as part of the transforming care programme, establishing the role of “care and support navigators”. These will also support the aims of integrated and personalised care.

The provision of accessible information and people’s ability to communicate with staff have a key impact on their care, experiences and outcomes. In July 2015, NHS England published the accessible information standard for the NHS and social care services to help organisations identify and meet an individual’s communication and support needs.

As the noble Lord, Lord Addington, and the noble Baroness, Lady Fall, mentioned—the noble Baroness, Lady Hollins, mentioned it in the debate last Thursday on libraries and again tonight—the provision of books beyond words for those who have visual learning but difficulty with words can make a real difference. It is important that every possible healthcare professional has this at their side whenever they are dealing with people with learning disabilities.

I want to make sure that I cover all the questions, because, as always, I am running out of time.

The noble Baroness, Lady Hollins, asked what the Government are doing to improve our knowledge and understanding of the needs of this vulnerable group. GPs, under the quality and outcomes framework, have to maintain a register of their patients who have learning disabilities. The new Care Quality Commission arrangements for inspections for acute hospitals explicitly examine how patients with particular needs, such as learning disabilities or dementia, are identified. As the noble Baroness, Lady Hollins, also mentioned, the Government will regularly inform Parliament of the progress that has been made. I think the noble Baroness, Lady Tyler, also mentioned this. Public Health England’s Learning Disabilities Observatory team review each year and are covered in local and health authority joint strategic needs assessments. This team will continue, funding will continue for this team and the Secretary of State for Health reports annually to Parliament his assessment of NHS England’s progress.

The noble Baronesses, Lady Tyler and Lady Hollins, also wanted to know whether the Government can give a clear message to local authorities and special care agencies about their expectations that staff will be released to contribute to lead reviews of deaths. We agree that there should be the local capacity to undertake high-quality reviews which will yield the best possible learning. However, we have no plans to legislate to make such participation a statutory duty. There is already a strong expectation in the CQC guidelines that providers will participate in relevant clinical audits. Additionally, there is participation in the NHS England-commissioned audit and outcome review programme, which the Learning Disabilities Mortality Review programme is carrying on.

I will have to write to the noble Lord, Lord Hunt, on the 18 recommendations, if that is all right, and on the funding attitudes.

There is work in progress which will, in time, have a positive impact on the safety and quality of care.

[Baroness Walmsley]

I am sorry to interrupt, but when she is writing her letters will the Minister please also reply to my questions about learning disability nurses?

[Baroness Chisholm of Owlpen]

Yes. I am so sorry—I had the answer and I will make sure that I get it to you.

We give thanks to the noble Baroness, Lady Hollins, and people like her who keep pushing the barriers facing this vulnerable group. The Government are focused on making changes happen, stopping variation in care and championing those with learning disabilities being able to live full and happy lives, knowing that support is there when needed. Once again, I thank all noble Lords for taking part tonight. I am sorry that I have not had time to answer all the questions, but I will make sure that the letters get to noble Lords.

House adjourned at 9.08 pm.

Community Pharmacy

Baroness Chisholm of Owlpen Excerpts

Monday 17th October 2016 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, with permission, I will repeat an Answer given by my honourable friend the Parliamentary Under-Secretary of State to an Urgent Question in the other place on community pharmacy. The Statement is as follows:

“Members of the House will have seen there has been media coverage over the weekend about our consultation on the community pharmacy contractual framework. I will now set out the current position, the process going forward and how the final decision will be announced to the House.

In December 2015, 10 months ago, the Government set out a range of proposals for reforming the community pharmacy sector. Our intent was to promote the movement of the sector towards a future based on value-added services together with much stronger links to the GP sector. We also proposed ways to make a reduction to the £2.8 billion currently paid to the sector. Part of the rationale for this was the increase of 40% in the budget and 18% in the number of establishments over the past decade or so.

Each establishment now receives an average of £220,000 of margin over and above the cost of drugs disbursed. Many of these establishments are in clusters. The 2015 spending review reaffirmed the need for the privately owned community pharmacy sector to make a contribution to the publicly owned NHS efficiency savings which we need to deliver. We are confident that the changes proposed will not jeopardise the quality of services required or patient access to them. Some services will be delivered differently, which is why we have set aside £112 million to recruit a further 1,500 pharmacy professionals to be employed directly by the NHS and GP practices.

The Government have been consulting on these reforms since December 2015. On 13 October this year the PSNC rejected our proposed package and sent a list of remaining concerns. We are now in the process of considering its final response and expect to be in a position to make an announcement to the House shortly”.

[Lord Kennedy of Southwark (Lab)]

My Lords, I thank the noble Baroness for repeating the Answer to the Urgent Question that was given in the other place earlier today. It is much appreciated by me and other Members. The stated aim of the Government has been to put pharmacies at the heart of the NHS. However, the proposals here will have serious and far-reaching consequences for patients, local communities and the NHS. Can the noble Baroness tell the House when we can expect to see the full impact assessment of these proposed cuts? What steps have been taken to ensure that the pharmacy access scheme is available to all community pharmacies based on the size and need of the population they serve? Does the noble Baroness see the contradiction in claiming to put pharmacies at the heart of the community while implementing arbitrary cuts? Finally, what steps is she taking to prevent the closure or the reduction of opening hours of community pharmacies?

[Baroness Chisholm of Owlpen]

I thank the noble Lord for those questions. The decision on the impact assessment has obviously not been made yet because the Government are thinking about the problems that have just arisen due to the PSNC not accepting the decisions that we thought had been made. There is no reason why this package should in any way affect the efficiencies of pharmacies at the moment. It is important to remember that the Government fund community pharmacies to the tune of £2.8 billion, and the average pharmacy receives £220,000 per year in NHS funding. We believe that the sector, which is made up of private companies that are often densely clustered together, can withstand this, and that the quality of services provided to patients will not be affected as a result. We know that 40% of pharmacies are in clusters of three or more, which means that two-fifths of pharmacies are within 10 minutes’ walk of two or more other pharmacies.

[Lord Rennard (LD)]

My Lords, the Minister will be aware of the report, commissioned for the Pharmaceutical Services Negotiating Committee and published last month, which showed that in 2015 community pharmacies provided 75 million minor ailment consultations and 74 million medicine support interventions. Does she not think that reducing the provision of community pharmacies may make it even harder for many people to see their GP and will add to the already considerable problems at many A&E units?

[Baroness Chisholm of Owlpen]

The Government are modernising the pharmacy sector and are investing £112 million to deliver a further 1,500 pharmacies in general practice by 2020. We are ensuring that no area is left without access to community pharmacy due to the pharmacy access scheme, and as the Minister for Community Health and Care announced on 13 October we are also introducing the pharmacy urgent care programme, a pilot scheme which will embed pharmacy into the urgent care pathway by expanding the service already provided by community pharmacies in England for those who need urgent repeat prescriptions and treatment for urgent minor ailments and common conditions. The move means that, in pilot areas, patients who need urgent repeat medicines will be referred from NHS 111 directly to community pharmacies. NHS 111 will develop and evaluate a new approach that will ultimately enable the service to refer patients with urgent minor ailments such as earaches to community pharmacies.

[Lord Higgins (Con)]

Does my noble friend agree that the link between individuals and the pharmacy can be important, particularly for the elderly and those with long-term illnesses? On the whole, this may well be easier to facilitate in the case of small pharmacies rather than large ones in a larger shop that is engaged in other operations, not to in any way denigrate the important role which those shops may play. Does my noble friend agree that it is important that, in the course of this change, the position of the smaller pharmacies should not be undermined?

[Baroness Chisholm of Owlpen]

I absolutely agree with my noble friend. There is no reason why that should be the case. At the moment, as I am sure he is aware, there are sometimes up to three or four pharmacies on one high street. It is not necessary to say that with these proposals the pharmacies will close, because the majority of them are privately owned, but it is important to try to modernise the system as it is now. The integrated care fund is very much working towards joined-up thinking on this.

[Lord Blencathra (Con)]

Will my noble friend take a message back to my right honourable friend the Secretary of State to say that if the reports are true that we could end up losing 1,500 or 1,400 small, independent pharmacies, these plans are barking mad and should have no part of Conservative government policy? It is right to save money on drugs, but can we target the big pharmas which rip off the Department of Health and have been doing so for years, and call the dogs off the little, independent pharmacies, which are vital for rural areas and are important small businesses? I do not want to see only Lloyds, Boots and the supermarkets on the high street—we need the little independents as well.

[Baroness Chisholm of Owlpen]

There is no reason why this should stop that happening. As I mentioned, the pharmacy access scheme absolutely ensures that no area will be left without access to community pharmacy, and that targets the rural areas in particular.

[Lord Lansley (Con)]

My Lords, I know that my noble friend will agree that community pharmacy has a tremendous reach in that 1.6 million people every day visit a community pharmacy. It can play a vital part in enhancing care in the community, particularly, as my noble friend said, looking after those who are older and/or with chronic conditions. It tries to ensure that people are diagnosed and looked after, and that their needs are met in the community, not defaulting to costly hospital admissions. In that respect, my noble friend said that value-added services are key to this. They are, and for years we have wanted pharmacies to be able to diversify out of reliance wholly on dispensing fees and the allowable profit margin, to raise resources themselves by services provided to the NHS locally. Can my noble friend say to that extent how far clinical commissioning groups themselves use the opportunity of local pharmacies to offset what would otherwise be the pressures of demand upon NHS services?

[Baroness Chisholm of Owlpen]

I thank my noble friend for that question. On the last part, I may have to get back to him, because I do not know the answer to that. It is important to remember that the proposals that the Government have been consulting on are part of a wider package of reforms to ensure that the NHS funds are allocated in the most efficient way possible, while promoting a high-quality community pharmacy service which is fully integrated with primary and urgent care and which makes better use of pharmacies’ valuable skills.

[Lord Low of Dalston (CB)]

Does the noble Baroness agree that one of the most valuable services provided by pharmacies is the delivery of medicines to people who are elderly and housebound, and that it is vital that the funding proposals that the Government come up with do absolutely nothing to undermine that service?

[Baroness Chisholm of Owlpen]

The noble Lord is absolutely right. That service will not be undermined and it is extremely important that it carries on—again, particularly in rural areas.

[Viscount Hailsham (Con)]

My Lords, I echo the remarks made by my noble friend Lord Blencathra. Both of us represented rural constituencies: in my case for 31 years and in his case I think for nearly 30. The truth is that local pharmacies are terribly important in rural areas. I hope that my noble friend will have that in mind when the policies are addressed.

[Baroness Chisholm of Owlpen]

My noble friend is absolutely right. As I mentioned earlier, that is the point of the pharmacy access scheme, which is intended in particular to ensure that the right number of rural pharmacies are available in those areas.

[Lord Brooke of Alverthorpe (Lab)]

I know that my local chemist is very upset about what may happen to him. He talks about areas where money is wasted by the NHS and where efficiencies could be effected. Has the Minister had discussions with the representatives of pharmacists who have opposed this proposal, to see whether they can come up with ideas on how efficiencies can be achieved?

[Baroness Chisholm of Owlpen]

Certainly everybody was consulted during the process and that is why we were very disappointed with the attitude that has been taken. We took particular care to endeavour to work collaboratively and we listened to their suggestions and proposals over quite a long period.

I have just been passed something by my inspiration, who is not far from my left-hand side. As I am on my feet, I hope that noble Lords will not mind if I answer the question put by my noble friend Lord Lansley. Roughly 50% of local areas currently commission community pharmacies to provide minor-ailment services. As the Minister announced last week, we are committed to increasing the coverage to all areas by April 2018. This shows how valuable a resource pharmacies are for patient care.

[Baroness Oppenheim-Barnes (Con)]

Does my noble friend accept—

Clinical Pharmacologists

Baroness Chisholm of Owlpen Excerpts

Monday 12th September 2016 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, I begin by thanking the noble Lord, Lord Hunt, for securing a debate on this important subject. He has spoken today about the vital role fulfilled by clinical pharmacologists and the contribution they make to effective treatments for the population of this country.

As the noble Lord pointed out, pharmacology lies at the heart of biomedical science, linking together chemistry, physiology and pathology. Those that take up the speciality work closely with a wide variety of other disciplines, including neuroscience, molecular and cell biology, immunology and cancer biology, to name just a few. They improve the lives of millions of people globally by providing vital answers at every stage of the discovery, testing and clinical use of new medicines.

The ability to use medicines effectively, to optimise their benefit and minimise the risk of harm to people, relies on pharmacological knowledge and understanding. We hear much about new diseases such as Ebola and Zika and their emergence and also hear much about older medicines—most notably antibiotics—no longer working as well as they did, so the contribution of pharmacology to finding better and safer medicines continues to be vital.

While it is true that there has been a decline in the number of clinical pharmacologists practising in the UK, it is important that we recognise that the fall in numbers is relatively small. Data from the British Pharmacological Society and the Royal College of Physicians show that the number of CPT consultants in the UK fell from 74 in 2002 to 72 in 2013, and that 52 of the 72 consultants were based in England, but perhaps a drop of even that amount is important.

As regards the supply of the profession, as noble Lords will be aware, from being established in 2013, it has been Health Education England’s responsibility to ensure that there is sufficient future supply of staff, including those needed in specialist fields such as this, to meet the workforce requirements of the English health system. It is the responsibility of the devolved Governments to ensure their health systems have the staff they require. Each and every year, Health Education England produces a national workforce plan for England. This is built upon the needs of local employers, providers, commissioners and other stakeholders who, as members of the local education training boards, shape their local plans.

Health Education England therefore has a responsibility for ensuring an adequate supply of trainees to provide the consultant workforce of the future, but is not responsible for setting the number of consultant posts inside the NHS. As I have just set out, this is the role of trusts, commissioners and others. HEE annually reviews the number of training places in medical specialties in response to demand expressed by the NHS. It is therefore crucial that trusts have a clear view of how they wish to utilise and promote clinical pharmacology and therapeutics positions in their hospitals.

To its credit, HEE has increased the number of training posts available. However, not all of these have been filled. Clinical pharmacology and therapeutics has suffered in terms of its fill rates against other high-profile specialties. However, as my noble friend Lady Gardner of Parkes mentioned, there needs to be more recognition of the career, more involvement with related healthcare organisations and perhaps more understanding of how fascinating and interesting this career can be, as the noble Baroness, Lady Thornton, said. In an attempt to counter this, HEE has been working to make the profession more attractive to junior doctors as they begin to specialise, including making the role more flexible to trainees, offering joint training with other specialisms and actively promoting the role at careers fairs.

The noble Lord, Lord Hunt, mentioned people not coming forward because of the uncertainty of a job. That is why some clinical pharmacologists already train towards a dual CPT, which then broadens the scope of their practice, making them more desirable to employers due to increased flexibility. I am aware that HEE has also been undertaking a review of this area and will, in due course and upon completion, share these findings with stakeholders, including the British Pharmacological Society. Leading on from that, the role has also been promoted by the chair of the British Pharmacological Society and is supported by the four UK health systems.

It may be interesting to note that the supply of clinical pharmacologists is primarily domestic, with only a very small number coming from overseas. In the three years 2012 to 2015, only one of the newly appointed consultants was trained outside the UK. Both the Royal College of Physicians and the British Pharmacological Society feel that there is a need for growth in this area and assert that current and predicted supply is insufficient to support that growth, and as such are calling for more training posts. There is, though, a lack of consensus between the Royal College of Physicians and the British Pharmacological Society about the level of future demand and the numbers required. This is perhaps an indication that it is not easy to evaluate future demand or possibly indicates a lack of understanding of these roles out in the wider health system.

Given the need to spend taxpayers’ money responsibly —and the difficulty filling the existing training posts—HEE is not able to increase the number of training positions until the demand is signalled by the NHS. At this stage, no significant increase in demand has been signalled in HEE’s annual collection of forecast demand from providers, which forms the basis for the annual training commissions for medical specialties.

In summary, I strongly encourage professional bodies with an interest in this field of medicine to actively engage locally with NHS trusts to ensure that where there is a need for additional clinical pharmacologists, they feed this in to the HEE workforce planning process. This process is the fundamental bedrock for NHS workforce planning. HEE actively engages with its stakeholders in developing its annual workforce plan, and any change in workforce planning numbers needs to be debated and resolved through this process. It is interesting that this is obviously not only a problem in the United Kingdom, because several reports have come out of the United States which show that it is having similar difficulties.

I thank the noble Lord, Lord Hunt, for giving us the opportunity to discuss this important matter.

[Lord Hunt of Kings Heath]

I am most grateful to the Minister for giving way and for the eloquence of her response. From what she said, the Government’s view is that this is solely a matter for Health Education England, and I understand that. However, does she accept that because HEE is concerned only with the accumulation of the local plans, it is not able to take any account of the national significance of this clinical speciality, and that there is a risk here because local employers do not see this as particularly important, although nationally we can see that it is vitally important? Is there a case for asking HEE to look at the national strategic importance of the professions? That would be one way of looking at this from a rather different viewpoint.

[Baroness Chisholm of Owlpen]

The noble Lord stopped me just as I was about to say that very thing. This is one of the important problems. There is not joined-up thinking—certain bodies are not aware of the importance of this—so it becomes a kind of vicious circle. I was going to say that we need joined-up thinking, and I hope that debates such as this will increase awareness and get people to think further. I will be happy to meet those bodies involved; they might well prefer to meet my noble friend Lord Prior but I will be happy to accept on his behalf.

I thank all noble Lords who have taken part in this debate.

Electoral Fraud

Baroness Chisholm of Owlpen Excerpts

Monday 12th September 2016 Lords Chamber

[Lord Rennard]

To ask Her Majesty’s Government what plans they have to amend electoral legislation as a result of the report of Sir Eric Pickles’ review into electoral fraud.

[Baroness Chisholm of Owlpen (Con)]

The Government have received Sir Eric Pickles’s review and will carefully consider its findings and recommendations. We are committed to tackling any form of fraud in the UK polls and this report will help inform the debate to ensure that our elections have the highest integrity. We will look closely at the proposals set out in the report and provide a full response in due course.

[Lord Rennard (LD)]

My Lords, does the Minister accept that a report proposing changes to the way in which we conduct our elections would have greater credibility if it was not simply the work of a former chairman of the Conservative Party? Why does she think that the report did not look into such important issues as the underregistration of voters, which distorts the outcome of our elections and the Boundary Commissions’ processes?

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[Baroness Chisholm of Owlpen]

I think there were two questions there. Sir Eric, as the anticorruption champion and as a former Minister for communities and local government, is the ideal person for the job. He has taken a close interest in election fraud for many years and noble Lords who have read the report will surely agree that it has been conducted in a completely independent way. On the second question, there are indeed vulnerable people who are not on the register; that is why the Government have funded civil society organisations to engage with groups which are known to be reluctant to register. In fact, the Cabinet Office is supporting an innovative research project in Grampian, which is looking into how trusted data sources can be used to target canvassing activity more effectively. We are also exploring ways to limit the number of frequent home movers who drop off the register, particularly those in the private rental sector, by piloting ways effectively to move your home address on to the electoral register when using local authority services, such as council tax.

[Lord Cormack (Con)]

My Lords, I ask my noble friend yet again: what is the logical argument against compulsory registration? There are penalties for those who do not register; surely it is right to make this compulsory.

[Baroness Chisholm of Owlpen]

We do not plan to make registration compulsory.

[Lord Campbell-Savours (Lab)]

My Lords, why do we not stop wasting public money on a national individual registration scheme and target the resource on those areas where there is a real problem? Is political correctness getting in the way of pursuing that approach?

[Baroness Chisholm of Owlpen]

I cannot agree with the noble Lord. The principle of IER was supported on a cross-party basis when it was introduced. It brings us into line with every other serious democracy in the world, and it meets the expectations of British citizens who live fast-paced digital lives and expect to be able to interact with public services digitally. It is important that we carry on with this reform.

[Lord Collins of Highbury (Lab)]

Individual registration has been speeded up by this Government and the coalition Government. It is a principle that we can all support, but if it is being forced through at a speed that means that people will be dropped off the register, that is totally unacceptable, especially as this Government are pushing through boundary changes that will be impacted severely by the figures of this registration. Why do the Government not delay the process and give proper time to it?

[Baroness Chisholm of Owlpen]

The Government are currently looking at how electoral registration could be made more efficient. Officials are piloting changes to the annual canvass this year. We are concentrating on making sure that it is quick, convenient, easy to use, reaches everyone, is digital by default, data driven, transparent, more affordable and, importantly, outcome based, not process based.

[Lord Robathan (Con)]

My Lords, is not the real problem with electoral fraud based on postal voting on demand? Should we not get rid of that? That would sort out much of the electoral fraud.

[Baroness Chisholm of Owlpen]

Postal voting is incredibly useful for many people. It would be disastrous to get rid of it.

[Lord Maxton (Lab)]

My Lords—

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[Baroness Janke]

My Lords, given that the only two Members of Parliament who gave evidence to the report were Conservatives, and given the Minister’s statement about the independence of the report, will she say what evidence will be taken from other parties on the incidence of electoral fraud, which is the main thrust of the report?

[Baroness Chisholm of Owlpen]

We are pleased that Sir Eric Pickles has produced this report. It is now up to us to look at it and decide the way forward. We will be reporting back on it soon.

[Lord Maxton]

My Lords, is it not the case that the most obvious way to reduce electoral fraud across the board is the compulsory introduction of an ID card with smart card technology and an identity built in—either fingertip, eye or, preferably, genetic material at birth—and then that card has to be used before you can vote? Eventually, that will lead to electronic voting as well.

[Baroness Chisholm of Owlpen]

This is obviously one of the things that will be looked at following the report. We will report back further on better ways of making sure of people’s identity when they go to the polling station.

[Lord Goodlad (Con)]

My Lords, why do we not do what the Australians have happily done very successfully for 90 years and make voting compulsory as a civic duty?

[Baroness Chisholm of Owlpen]

As I said in answer to my noble friend Lord Cormack, we have no plans for that. In fact, the Australian system has not been absolutely perfect. There are still quite a lot of people who do not vote. It is not failsafe.

[Lord Harris of Haringey (Lab)]

My Lords, the Minister talked about the integrity of the voting system, and that is obviously something that we all want to see. Why, then, are the Government pressing ahead with boundary changes on an electoral register which they know is out of date given that so many extra people registered in time to participate in the European referendum? Would it not be better for the integrity of the voting system to use a register which is more current than the one they have chosen to use?

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[Baroness Chisholm of Owlpen]

I do not think this is anything to do with the Question, but I am very happy to answer. Parliament has already agreed that 15 December should be used as the date for the registers for this review. Unless you have a defined date and set of registers to assess it, it is impossible to run a review. Registers used for the boundary review are necessarily a snapshot, and the registers have always continued to change while the review is taking place.