Brexit: Health and Welfare

Baroness Jolly Excerpts

Thursday 29th March 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I am very grateful to my noble friend Lady Brinton for calling this debate—and very timely it is, too. The repercussions of the UK’s decision to leave the European Union spread far and wide. That is why it is especially important that we are here today to debate the critical subject of UK health and social care in a post-Brexit world. The issue of health touches the lives of every citizen, and the gravity of our situation just cannot be denied. I shall mention some of the issues I raised in Committee on the EU withdrawal Bill, but we should not forget the huge role that EU workers play in both the health and the care sectors. I am going to look at some numbers too. Mine are not quite the same as those given by the noble Baroness, Lady McIntosh of Pickering, but they are all really big numbers.

My research has suggested that 5% of the UK’s health and care workers now come from the EU. Five per cent might seem a small number, but 5% of 4.5 million is considerable: 225,000 doctors, dentists, nurses, dieticians, therapists, care workers and cleaners—I could go on. According to a November 2017 survey conducted by the British Medical Association, nearly one in five EU doctors working here had actually taken steps towards the possibility of leaving the UK. The NHS, with its already existent staff shortages and funding cuts, really cannot afford to lose any more numbers or expertise within its hard-working personnel. Royal College of Nursing chief executive Janet Davies said that the NHS “cannot afford” to lose EU staff, with 40,000 nursing vacancies in England alone. She said:

“The Government is turning off the supply of EU nurses at the very moment the NHS is in a staffing crisis”.


I understand that the Minister has said previously that the number in training is considerable, but it is sadly not enough to fill the gap. It is a fact that merely the decision to leave the UK, and the agonising uncertainty that has accompanied that decision, moulds the future nature of our health workforce. The Minister has addressed this issue at the Dispatch Box many times, but I would be grateful if, for those who neither hear it nor believe it, he would send a message that they are still welcome to remain, and remind the House of other avenues of recruitment that are being considered.

I mentioned earlier that I put my name to several probing amendments to the EU withdrawal Bill, and I express my continuing support for the public health “do no harm” amendment, as tabled by the noble Lord, Lord Warner, to be included. It is based on Article 168 of the Lisbon treaty, which is longer than “do no harm”, but we are just calling on the Government to consider health issues and make sure that any decisions made at any government level do not impact on the health of our nation. At the recent meeting of Peers, Ministers and officials to discuss the withdrawal Bill, it even gained the support of the noble and learned Lord, Lord Mackay of Clashfern. He is a really good ally to have.

The desire to ensure the level of progression and sustainability of public health in our nation is not a divisive issue. There is no pro-remain or pro-leave precedent required to support the universal notion that the protection of our citizens’ health is, and must always remain, supreme. No Member of the House would deny the key three prongs of this proposal: first, ensuring the well-being of UK citizens; secondly, protecting citizens in times of public health hazards and crises; and, thirdly, continuing the drive towards equality of healthcare and access. This amendment would offer us a great opportunity. We have the chance to express to the people of the UK that we care about the well-being of each individual member of society and, more importantly, we will prove that commitment through legislation.

Moving to over-the-counter medicines, general sales lists or GSL medicines are thoroughly integrated into the EU model of research—design, production, packaging and distribution, just like cars. Any one product may pass through several borders before finding its way on to the pharmacist’s or the local supermarket’s shelves. The noble Lord, Lord Callanan, on the second day of the Committee the Bill, assured me, when I asked about the implausible timeline for changing regulations on these medicines and the practice I have just described, that the Government are indeed working hard to ensure that research groups and trade industries are offered,

“sufficient time to implement any changes necessary”.—[Official Report, 26/2/18; col. 451.]

The notion that the Government desire to continue a close relationship with pharmaceutical and trade industries on exit is understood. The issue, then, is simply that time is running out. The Minister claimed that industries will be given sufficient notice to recognise, address, deliberate and solve any licensing or manufacturing issues that may arise. Yet the time to offer sufficient notice was yesterday. Will the Minister today clarify these issues for the House? Is there a detailed timeline for ensuring that over-the-counter medicine licensing, manufacturing and trading issues that have arisen from Brexit can be clarified, and that no patient will suffer as a result of this quandary? Can he share the rationale for excluding GSL medicines from the Department of Health and Social Care’s ongoing review of the implications of EU exit on the continuity of medicines supply to the UK, and what plans the Government have to explore those implications?

To help the Minister, I wonder whether he would be happy to meet me and the relevant trade body, the Proprietary Association of Great Britain. The PAGB represents the manufacturers of branded over-the-counter medicines, self-care medical devices and food supplements —they would all be household names.

Under the European health insurance card scheme, British tourists and residents in the EU can access free healthcare, as can EU citizens when visiting the UK. I cannot imagine—I am still struggling with this issue—what it would be like to go on holiday without the EHIC in my wallet alongside my passport, tucked away in case of an emergency. However, as the EU Home Affairs Sub-Committee stated in its report published the day before yesterday, if the Government insist on bringing an end to free movement,

“it follows that one of the fundamental rationales for reciprocal healthcare arrangements … will disappear upon Brexit”.

The loss of the EHIC would create enormous barriers for UK nationals abroad and hurdles for EU nationals living in the UK. It is critical that UK and EU patients do not lose out on access to the best treatments and medical devices as we leave the EU.

We want to make sure that patients continue to benefit from early access to new health technologies and cutting-edge medicines, and that includes being able to take part in international clinical trials. For this reason, the Government must prioritise alignment with the new EU clinical trial regulation and commit to adopting it when implemented in March 2019.

The UK’s health and social care sector has benefited enormously from our EU membership. As British tourists and residents across the EU, we rest assured that our healthcare will be covered. At home in the UK, we take for granted the host of hay-fever tablets, cold and flu treatments, painkillers and indigestion remedies that line the shelves of our local pharmacies. We benefit from the latest in health technologies and cutting-edge medicines, as well as the dedicated care of over 60,000 NHS staff in England who are EU nationals. Exactly a year from now, on 29 March 2019, how many of these benefits will remain available to us? Will we be denied access to free healthcare in the EU? Will Calpol and Strepsils—other medicines are available—be available only on mainland Europe? As regards clinical trials, what confusion! At the meeting with Ministers and officials this week, I confess that I left feeling that the situation was about as clear as mud, so clarity from the Government on this and all these issues would be appreciated.

HPV Vaccinations

Baroness Jolly Excerpts

Monday 26th March 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right that equality is an issue, and an equality analysis will take place. That can be completed only once we have the final advice from the joint committee. I can also promise her that we will publish that analysis, so that will be able to be scrutinised. As for legal advice, it is subject to threats of judicial review at the moment, so I cannot go any further than that, but I can promise that equality considerations are very high on the list of the issues that we are dealing with.

[Baroness Jolly (LD)]

My Lords, we welcome the decision to vaccinate gay men in England, but sex and relationships are no respecter of national borders. Has NHS England had any conversations with the NHS in Northern Ireland, Scotland or Wales to ensure that gay men are protected right across the UK?

[Lord O'Shaughnessy]

We are beginning a national rollout of the programme for men who have sex with men in terms of the provision, because of course they are not necessarily getting the indirect benefits from the girls’ immunisation programme. I do not have the details of the working relationships with the devolved Administrations, but I shall write to the noble Baroness with details.

NHS: Staff Pay

Baroness Jolly Excerpts

Wednesday 21st March 2018 Lords Chamber

[Lord O’Shaughnessy]

I thank the noble Baroness for her perhaps less than fulsome welcome for what is a fantastic deal, not least for the lowest paid staff in the NHS, some of whom will see very significant pay rises. They certainly deserve them; I do not think anyone disagrees with that. We have been able to find the additional money in the NHS budget to do this precisely because of good economic stewardship, rather than relying—as others would—on trees, magic or otherwise. That stewardship has meant that we have been able to provide the money while taking our fiscal responsibilities seriously.

The noble Baroness mentioned the joined-up staffing strategy. She is absolutely right that it is very important. I hope she knows that Health Education England has included work on the social care workforce in its draft strategy. We all understand that we need increasingly to view these workforces together—not just people such as nurses, who can work in both sectors, but carers and allied health professionals and so on. Frankly, there is more work to do on the social care workforce strategy. In the health service, we are starting from a lower base in terms of having a national picture, precisely because it is generally delivered locally. However, we are providing that strategy. I would encourage all parties who want to make sure that the strategy is joined-up to contribute their ideas, because there is a genuine willingness to make sure that we can do it.

[Baroness Jolly (LD)]

My Lords, I echo the Minister’s remarks about NHS staff working hard all year round. I welcome this agreement. The RCN and Unison must have worked very hard with the DoH to get this nailed, but the devil is in the detail and we have yet to see the detail.

Agenda for Change was implemented in 2004 when I was chair of a primary care trust. It was really difficult to get the various levels of NHS staff in the various strata. Can the Minister confirm that Agenda for Change will be revisited along with the skills and knowledge framework? The Secretary of State also talked about putting appraisal and continuous professional development at the heart of pay progression, so that may indicate that the skills and knowledge framework might need to change. On the same topic, echoing what was said just a moment ago, can the Minister shed light on whether care workers’ salaries will be included in the Green Paper on social care? At the moment, they are feeling very undervalued and underpaid.

[Lord O’Shaughnessy]

Like the noble Baroness, I think it is right to pay tribute to all the organisations involved in striking this deal. These things are never easy but it is a true partnership agreement that tries to work for everybody.

The Statement is explicit about linking pay progression with appraisals, which indeed means higher skill levels. I will write to her with the specifics of the skills and knowledge framework; I am not cognisant of that specifically, but clearly the intention is to move away from automatic progression to skill-based progression. One of the advantages of that is that it not only works for patients, but puts the onus on employers—she will see more detail of that—to make sure that there is proper professional development to help skill levels rise, so that staff can go through those gateways and progress.

Children and Young People: Mental Health Services

Baroness Jolly Excerpts

Thursday 8th March 2018 Lords Chamber

[Lord O’Shaughnessy]

I absolutely agree. This is why the changes that we are making to mental health awareness training in primary schools is critical. Most primary schools, through nurseries, take children from four—and even two or three—years old to make sure that staff can spot the signs in school and signpost to specialist services, where required.

[Baroness Jolly (LD)]

My Lords, I welcome the Minister’s Answer to the Question. I am sure that he will agree that mental health support teams will be critical in making all this work. However, CAMHS teams had huge problems in getting the workforce—and in getting it up to speed. What measures are being put in place to guarantee the resilience of these new teams?

[Lord O’Shaughnessy]

I agree that that is a challenge. There is a plan to create 21,000 new medical and allied posts by 2021, which would be the biggest expansion in mental health services that has ever taken place—certainly in this country but even in Europe. How we are going to achieve that is set out in the draft workforce strategy that Health Education England has published. A big part of that is the creation of mental health support teams in schools. That will take time—we need to be realistic—but it is an ambitious goal and we know that that support is wanted and needed.

General Practitioners: Workforce

Baroness Jolly Excerpts

Monday 5th March 2018 Lords Chamber

[Lord O’Shaughnessy]

I agree with the noble Lord: we need to crack down on agency and locum spend. That has been falling in recent years. The way we will fix this issue and the demand for general practice in a sustained way is to increase the number of GPs coming into the service, and, as I said, that is exactly what we are doing.

[Baroness Jolly (LD)]

My Lords, there should be a move to recruit newly-qualified doctors to general practice and to prevent GPs retiring earlier and earlier, but that is not as easy as it sounds. Can the Minister therefore tell the House what work has been done to enable job-sharing, so that part-time GPs balancing a family life can partner with older GPs who want a less full-time commitment?

[Lord O’Shaughnessy]

I shall have to write to the noble Baroness with the specifics on GP flexibility. However, one of the reasons that GPs take early retirement to take advantage of their pension is that it enables them to work flexibly afterwards.

Alcohol: Minimum Unit Pricing

Baroness Jolly Excerpts

Wednesday 28th February 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend speaks with great wisdom about making sure, not just with alcohol but with other health issues around food and drink, that we have a look at making those kinds of promotions not possible.

[Baroness Jolly (LD)]

My Lords, the Minister has acknowledged that the evidence is absolutely there and that he will look at it in the near future, but when might a decision be made? How long does he need the Scotland experiment to last before he actually makes a decision?

NHS: Waiting Lists

Baroness Jolly Excerpts

Monday 26th February 2018 Lords Chamber

[Lord O'Shaughnessy]

Vacancy data is available. If it was not available on the particular footprint that the noble Lord asked for, I would point him in the direction of data published last week by NHS England on vacancies, which is always a topic of much interest in this House. Over the past three quarters, that shows a slightly improving picture, but clearly there is a lot more to do.

[Baroness Jolly (LD)]

My Lords, under the NHS constitution, no patient should have to wait more than 18 weeks for any treatment. However, there are no specific national standards for waiting times for CAMHS patients, only guidelines, except for under-18 year-olds with psychosis and those treated in the community for eating disorders. What proportion of those CAMHS patients are seen within the agreed times, when does the Minister expect we will see a significant improvement and is sufficient funding earmarked to achieve it?

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight this issue. There simply are not equivalent waiting times for CAMHS. As she mentioned, we have introduced the first waiting times for eating disorders and early intervention in psychosis. I think she will have been pleased to have seen in the Green Paper published before Christmas that a new four-week waiting time for NHS children and young people’s mental health services will be piloted. That will be rolled out in the near future.

Health: Pelvic Mesh Implants

Baroness Jolly Excerpts

Tuesday 6th February 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend makes an excellent point. This is one procedure, and for some women it can be positive and life-enhancing. But we also know that it carries a risk of complications. That is one reason why we wanted to carry out the audit, because it will look not only at areas and procedures where there have been problems and complications but at where it has been successful, so that we can have a proper understanding of what the complication rate is and therefore what the safety concerns are.

[Baroness Jolly (LD)]

My Lords, the NICE guidelines that the Minister just referred to conclude that:

“Evidence of long-term efficacy is inadequate in quality and quantity. Therefore, this procedure should only be used in the context of research”,


as he said. But will he tell the House how confident we can now be that that is the case and that the information has been effectively disseminated? What is the mechanism for informing clinicians and women about this NICE guidance?

[Lord O’Shaughnessy]

The noble Baroness is quite right to say that it is not just about having the guidelines but making sure that clinicians follow them. Professional standards demand that clinicians do follow them, and indeed a clinician would need to be strongly justified in using mesh implants outside of the guidelines. They include things like gaining consent, providing information and registering operations that have been carried out. The guidelines are very strict and we expect clinicians to follow them.

NHS Winter Crisis

Baroness Jolly Excerpts

Monday 5th February 2018 Lords Chamber

[Lord O'Shaughnessy]

My Lords, I thank the noble Baroness for her questions. I agree with her that we are all proud of our NHS, on all sides of this House, and I am sure that we all have great pleasure in stating that through whatever means we are required to. I also join with her in paying tribute to the staff, who do such a fantastic job, often in challenging circumstances.

She asked first about urgent operations. It is clear in the guidance that they should not be cancelled when it would negatively affect patients’ outcomes. If that has happened, NHS England is investigating and reinstating those operations. The guidance is quite clear and NHS England has followed that up.

As for A&E targets, we know that they have not been achieved recently. It is important and instructive to look at the extraordinary increase, not just in winter but overall, in the number of episodes that are happening. They really are increasing at a very high rate. Demand is very high—higher than I think could have been anticipated—and it is a credit to the NHS that it has produced the performance that it has. The aim now, with funding given at the Budget, is to get us back to the four-hour target that we all agree ought to happen. That is what will be happening over the coming year.

[Baroness Jolly (LD)]

My Lords, this morning I visited a suburban hospital in London, with an almost brand new A&E unit and a well-managed winter crisis. But despite all that, it has still had to face a bed occupancy rate of 97% on several days, which is stretching its ability to make this work. Money was clearly an issue—the hospital was quite anxious about what its end of year accounts might look like. Today, the Liberal Democrats launched a report looking again at a different way of funding the NHS through the creation of an office of budget responsibility for health and care, long-term health and care funding, and a ring-fenced tax to replace national insurance. Also, there is a clear need for some sort of short-term fix, and we have suggested that £2 billion should be raised by adding a penny to our income tax. Has the Minister looked at this report and will he agree to meet with me to discuss it?

NHS and Social Care: Winter Service Delivery

Baroness Jolly Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, this has been an interesting debate. There are many experts and much experience in this House. There is also a great deal of passion and it is not surprising that there is a lot of agreement.

I start by thanking all care workers who, on low wages and often with little thanks, do a splendid job, day in and day out, whether in a hospital, residential or nursing home, or in a domiciliary setting. There are 1.4 million people employed in social care roles, caring for more than 1 million adults. The winter period is often challenging. Certainly in the rural area where I live, these people have to cope with bad weather, dark morning starts and dark evening finishes, and, invariably, with clients who are less well.

The other unsung heroes in the world of care are the carers. I echo the call of the noble Baronesses, Lady Pitkeathley and Lady Wheeler, for the carer strategy and the action plan, long promised and long overdue. These carers are selfless family members or friends, who often work without help, payment or support, rarely getting respite.

The carer’s allowance, for those who take it—a lot of people are not even aware that there is an allowance that carers can take—is £3,260.40 a year. The winter bit is that there is a £10 Christmas bonus. I wonder: do we value our carers? Your Lordships will know, because the noble Baroness, Lady Pitkeathley, reminds us on a regular basis, that were this huge army of carers to be paid just the living wage, it would cost the Exchequer much the same as the annual national health and social care budget. That is their value, but what are they worth?

Recent research shows that more than half of us believe that we do not know a single family member or friend who cares, while as many as three in five believe that they do not know any work colleagues who help look after a loved one. In reality, one in 10 people in the UK are carers and one in nine people in the workforce are juggling their paid job with unpaid caring. I remind the House that the Care Act calls for carers’ needs to be assessed alongside the needs of those they support. Could the Minister tell the House when the most recent report on this was published? Is this being met right across local authorities? When would he expect the next one, so we can measure improvement?

The solution to many problems is more money. More money can mean more staff and new preventive ideas. It could ease the way for primary care and community care to work more coherently with local social services. I acknowledge that more money has been made available to the care and health systems over the winter period. The better care fund increased social care funds by £4.4 billion over three years, as well as the adult social care support grant of £240 million in 2017-18. But work needs to be done in many parts of the country to improve existing systems—to look into data sharing between health and care as a matter of urgency, for example.

Before I address delayed transfers of care, I will talk about the reduction in social care support. Social care budgets have seen an estimated loss of more than £6 billion since 2010. Between 2010-11 and 2014-15, spending on social care fell by 7% even as demands increased over the same period. The social care precept allowed local authorities to raise council tax by up to 2%, and in December 2016 this was raised to 3%, but, as my noble friend Lady Pinnock and the noble Lord, Lord Smith of Leigh, explained, this tax is inherently regressive in its structure. Local councils in poorer areas are not able to levy an effective council tax as easily to meet social care demands.

Cuts to local authority funding, rationing and a reduction in the level at which support is available have reduced the number of care packages. This will invariably increase the likelihood that someone will become frail and so, when falling ill, will need hospitalisation. If care packages can enable someone to look after themselves, they often avoid going into hospital. Ironically, often self-funders fail to pay for as much support as they need. They can find themselves less able to self-manage and find themselves admitted.

There are financial and physical costs of the delayed transfers of care. The estimated annual cost to the NHS is around £820 million each year and the loss of 1.15 million hospital days in acute treatment—up 31% compared with 2013. There are physical costs. Each additional day in hospital is a higher risk of infection and rate of readmission. The amount of strength lost per day in hospital—I am talking about muscle strength of an elderly person—is up to 5%. Delayed transfers of care seem to hurt twofold: once on the bed shortage, but again on muscle loss. If elderly patients lose up to 5% of their muscle mass daily and constitute the majority of patients under delayed transfers of care, the NHS could indirectly be contributing to a number of falls and hip fractures in the long run.

A lot of delays are attributable to the NHS, with 58.3% of all delays in November, compared with 34% to social care, and 7.6% jointly, with social care’s share slightly falling over the last year. The noble Baroness, Lady Watkins of Tavistock, spoke about the primary reason for social care delays—35.4%—being due to patients awaiting the care package in their own home. Will the Minister explain why there is not enough capacity in the system? Could this be due to a fall in private investors who no longer see this as a good investment? What is the solution? We all know that local authorities have responsibility for market shaping, but what if the market does not wish to be shaped? Where do we find ourselves then?

I shall put in a plug for the local community hospital. Those in my own backyard in Cornwall, having been saved from cuts in 1996 in advance of the 1997 general election—I remember Frank Dobson coming down and waving his magic wand—are now coming into their own as a safe place to transfer patients to when they no longer need medical care but do need nursing and rehab. Additionally, they are a resource for the GP, who can admit a patient for as short a time as a few days to see them over a crisis, rather than have them go into the local acute hospital.

Integration of health and social care is the holy grail of care. We watch with interest devo-Manc, where there is a commitment to integration of health and care, and Cornwall, where there is a move to make the CCG a department of the council. We should also note that Torbay has been working for years like this, now under the auspices of the Torbay and South Devon NHS trust, which states that it provides acute health services, community health services and adult social care. It is not rocket science; others have done it.

I was surprised, and then on reflection pleased, that the Department of Health was to be renamed the Department of Health and Social Care, despite the fact that the Secretary of State has always had responsibility for social care albeit with the support of a Care Minister. However, I am disappointed that, since Mrs May became Prime Minister, the Care Minister has not been a Minister of State—what message does that send us? That particular Minister of State historically has also looked after mental health. Those are two areas where you need somebody with a bit of oomph in the department.

In the first week in January, an article in the Financial Times written by Sarah Wollaston, was headlined:

“Only political courage can save Britain’s health service—It will take a cross-party approach and a willingness to put public interest first”.


Along with others, we on these Benches eagerly await the Green Paper on social care funding and ask the Minister what other topics will be in it. Will it become a portmanteau paper?

But do the Government have the willingness? My honourable friend Norman Lamb visited the Prime Minister along with Liz Kendall and Sarah Wollaston to ask for her support in this cross-party look at the issue. They also asked her to consider raising income tax by a penny in the pound, which would raise £6 billion, which is the gap between where we are and where we need to be financially. Indications suggest that the public would warm to the idea. They see the system creaking and feel it is the least they could do. Those of us on these Benches agree.