Brexit: Risks to NHS Sustainability

Baroness Ludford Excerpts

Wednesday 12th July 2017 Lords Chamber

[Baroness Ludford (LD)]

My Lords, I warmly thank the noble Lord, Lord Warner, for initiating this important debate. As he said, we are very reliant on EU workers in the NHS and social care, which includes around 10% of doctors and 7% of nurses. Sadly, there is already evidence that they are leaving or not coming to the UK. As well as the alarming drop in nurses cited by the noble Lord, more than half of the 10,000 European doctors working in the NHS are now considering leaving, according to a survey conducted by the General Medical Council.

In social care, 7% of staff, or 90,000 people, are from elsewhere in the EU, but numbers are already dropping. The Brexit squeeze on social care workers is likely to hit the elderly hardest, as it is predicted that there will be almost 3.5 million more over-65s by 2030. That figure could be supplemented by many UK pensioners returning from places like Spain if their rights to residence, public services and especially to healthcare are not safeguarded. We could be losing fit, younger skilled workers just as the pressure of more older people needing the NHS and social care builds ever higher. The exodus of EU staff exacerbates the shortage of doctors, nurses and care staff, which puts a heavy workload on current staff, causing many to leave the service. So we absolutely need to attract EU workers into the NHS and social care rather than deterring them in order to fill the vacancies.

The Liberal Democrats regard the Government’s proposals on EU citizens’ rights as inadequate, and in particular are calling on the Government to guarantee an immediate “NHS passport” for the 60,000 EU nationals who work directly for the NHS. In the future under Conservative plans, the NHS faces an “immigration skills charge” of £2,000 a year for each doctor, nurse and health worker that it brings in from the continent. Will the Government exempt the NHS from this charge?

Then there are all the teachers and academic staff in universities helping to train the next generation of medical professionals. We are already short of STEM specialists and Brexit is going to make this even worse. We will also be outside the EU systems for mutual recognition of qualifications, which will make it more difficult to recruit as well as more difficult for our UK citizens to get experience in other EU countries. As was said by the noble Lord, Lord Warner, both the NHS and social care are already underfunded and they both need immediate injections of cash as well as long-term sustainable funding. Brexit puts this at risk because of the threat to the British economy and the tax take. You cannot have a hard Brexit and a strong NHS.

Some 190,000 pensioners live in other EU countries and can use local health systems thanks only to reciprocal EU arrangements. If those arrangements fall away, UK citizens will have to pay for their treatment abroad, and many may choose to return to the UK. The cost to the NHS of the return of all UK citizens of pension age would be nearly half a billion pounds a year.

As soon as the result of the referendum was announced, there was an immediate effect on international collaborative research projects involving UK researchers. Our scientists were asked to withdraw from funding applications, as it was seen that their presence in a team could put an application at risk. The UK has done extremely well from EU funding for life sciences research, receiving almost €9 billion between 2007 and 2013. How do the Government plan to replace all this money in the future? Apart from the money, the medical, scientific and industry benefits from international collaboration are enormous and I do not know one single scientist who is other than deeply unhappy about Brexit.

I am associated with the Juvenile Diabetes Research Foundation, which has told me that:

“Without EU funding a number of vital research programmes would not exist, as comparable funding, especially to support consortia, is not available elsewhere”.


The foundation participated in a €6 million award for immunotherapy to treat type 1 diabetes, which involved small and medium-sized firms as well as research institutes. It also said that researchers,

“depend on personal funding from the EU, including Fellowships, to enable them to pursue a career in research and start-up their labs”.

I understand that the European Research Infrastructure Consortium, which facilitates cross-border research partnerships, requires that all signatories have to accept the jurisdiction of the European Court of Justice for arbitration. How will our researchers continue to participate in this consortium post Brexit? How will British researchers and those coming here from the rest of the EU be able to move seamlessly across borders in an era without free movement? The then Minister, the noble Viscount, Lord Younger of Leckie, told us in March about a high-level stakeholder working group for universities, research and innovation that the Minister, Jo Johnson, had established to look at the risks and opportunities of Brexit—although no one has actually suggested any opportunities to me. What are the conclusions so far of that working group?

There is great concern that Brexit will mean increased cost, reduced access for UK patients to new medicines and medical devices, reduced patient safety and damage to business prospects. Leaving the customs union will cause delays and extra costs in medical devices and access to medicines. Most of these products cross country borders several times during the process of development, clinical trials, licensing and regulation. The single market has built up a complex and detailed web of protection.

The coalition Government carried out reviews on the balance of EU competences. The review on health noted how collaborative action at European level on medicines and medical devices can be more effective and thus beneficial for patient safety because the EU can,

“effectively tackle … counterfeit medicines, which involve complex global supply chains; share safety information on medicines once they are on the market and quickly detect”,

risks to safety. Far from wanting to pull out of this system, industry welcomed it, stressing,

“the advantages of the common regulatory framework for ensuring a high level of patient safety and secure supply”.

Not only are we losing 2,000 jobs through the loss of the European Medicines Agency, but, as the Association of British Pharmaceutical Industry told that review in 2012:

“The introduction of the centralised procedure, along with the creation of the EMA, not only greatly simplified”,


the processes,

“but also resulted in a system where medicines information such as the patient information leaflet are consistent across all EU Member States, which is good for public health protection”.

How do the Government plan to recreate the regulations that will allow us to buy and sell medicines in the EU? What system will be put in place to ensure that UK regulations keep up with those in Europe? Can the Minister explain more fully what the Secretaries of State for Health and for Business had in mind in their wish expressed in a letter to the Financial Times last week for,

“deep, broad and dynamic cooperation”?

The MHRA chairman, Professor Sir Michael Rawlins, has warned that withdrawing from the EMA could put the UK behind Japan, the US and EU nations in the queue when new drugs are introduced.

Brexit will mean that dangerous or defective drugs that pose a threat to patient safety may be available to British consumers for longer than on the continent. Leaving the EU medicine safety system means the UK will be slower to respond to safety issues, putting patients at risk. Relevant to research and clinical trials is the framework for data protection. How will the Government ensure that UK law keeps up with the future development of EU regulation and ECJ case law, without which we could be excluded from collaboration?

I will not mention Euratom as other noble Lords have done so and we are fortunately going to have a debate, initiated by my noble friend Lord Teverson, next week, but I will mention the business opportunities for our pharmaceutical and life sciences industries, which not only EU research collaboration but EU common regulation open up. They have been very vocal in insisting on those opportunities in improving competitiveness and exports. What will the effect be of the UK losing the life sciences section of the EU patent court if we can no longer participate?

How will all these benefits of being part of the single market in health be replicated if we are outside the EU? No free trade agreement will cover the myriad networks and systems that 45 years of EU membership has created. Finally, the Brexit Secretary, David Davis, says it is an aspiration to keep the benefits for individual travellers of the European health insurance card. A lot of people will realise just how useful European red tape is if they lose the EHIC.

NHS and Social Care: Impact of Brexit

Baroness Ludford Excerpts

Thursday 21st July 2016 Lords Chamber

[Baroness Ludford (LD)]

I, too, thank the noble Baroness, Lady Watkins, for initiating this important debate. I declare that I am married to a health trust chairman.

As if the current pressures on the NHS’s finances and ability to cope were not bad enough, they now have the hammer blow of impending Brexit. Clearly, there needs to be much better workforce planning and support. But at present we absolutely need EU staff and it is as a result of the shortage that the Migration Advisory Committee recently advised the Government to keep nurses on the shortage occupation list. Everyone is calling out for EU workers to get the clarity and reassurance they deserve regarding their future status in the UK. This is particularly vital in key public services such as the NHS to aid workforce planning and ensure that safe staffing levels are maintained. It was reported last November that eight in 10 hospitals missed their target for day and night nurse staffing.

The Health Secretary himself said on 5 July in the other place:

“It is fair to say that the NHS would fall over without the incredible work”—[Official Report, Commons, 5/7/16; col. 730.]

that EU workers do in the NHS. I am not sure I heard that from his lips or those of any other Minister before 23 June. In a similar vein, the chairman of the Tavistock and Portman Foundation Trust, Paul Burstow, said:

“Without EU care professionals our NHS and social care sector would struggle to function”.

So we are not talking about a contribution from EU nationals at the margin. It is core. This is one of the many reasons why I am not a Brexiteer now and remain a remainer.

Some of the facts have been cited. Overall, 5% of NHS staff in England are from EU countries but in London they represent 10% of the NHS workforce. While 10,000 doctors from other EU countries are reported to be working in the NHS across England, the GMC says there are 30,000 EU doctors in this country altogether; perhaps they are working as locums or in private practice or are registered but not practising. There is an interesting extra 20,000 doctors somewhere. There are 6,500 scientific and therapeutic staff across England from other EU countries.

EU staffing is particularly significant for London and for specialist trusts. The Royal Brompton & Harefield NHS Trust has over 15% of its workforce from other EU countries, while for Great Ormond Street Hospital the figure is 11%. The top 10 all have between 11% and 15 %. But those proportions are for all staff. At Great Ormond Street, a quarter of doctors, 16% of nurses and nearly a quarter of research staff are from the EU. No wonder its chief executive has expressed deep concern about the impact of Brexit. He said that the rare and complex diseases seen in children treated at his hospital required clinical and research collaboration across Europe and, of course, worldwide.

Last but certainly not least, 6% of the social care workforce in England is from other EU countries—80,000 people in England alone. According to the King’s Fund, there are also regional variations: the figure is 12%, or 20,000 jobs, in London and 10%, or 21,000 jobs, in the rest of the south-east.

In the light of the catastrophic risk to the NHS from losing EU workers, it is frankly not good enough for the Health Secretary to say, as he did on 5 July in the other place:

“As long as the UK is subject to EU law, current arrangements remain in place”.—[Official Report, Commons, 5/7/16; col. 728.]

Yes, they do, but if he expects us and the staff to be reassured by statements by the Foreign Secretary and Home Secretary that the Government want to find a way of allowing those people to stay in the UK for as long as they wish to, we are not reassured at all by this promise of possible jam tomorrow. Staff are very unsettled, trusts report.

The Health Secretary also acknowledged that the issue of whether or not the £500 health surcharge on non-EU migrants on long-term visas would apply to EU nationals currently living in the UK,

“would obviously be subject to the negotiations”.—[Official Report, Commons, 5/7/16; col. 729.]

What kind of clarity, certainty and reassurance is that?

The NHS Confederation is surely right to insist that immediate steps should be taken to assure staff from other EU countries who are currently working in the NHS and social care that they will be able to remain in the UK indefinitely. I add that this should be on current conditions, including free access to healthcare. The uncertainty created about our ability to recruit from other EU countries in future is also deeply worrying NHS leaders, given current staff shortages. We have an immediate and pressing need for clinical staff, which cannot be met from our domestically trained market. It is a disincentive to EU staff when they do not have certainty on their future residence. The drop in the pound means less purchasing power to send money back to families, which is demotivating as well. It is also predicted to increase the NHS bill by £900 million, as suppliers will have to increase their prices to account for the drop in the pound.

The message from NHS and staff bodies is a united one: given the length of time taken to train a nurse, and even more a doctor, a failure to offer staff from the EU certainty about their future status risks not only undermining workforce planning in the NHS but the ability of the health service to maintain safe staffing levels and patient safety. If social care struggles to deliver services, the knock-on demand for NHS care will increase still further. Mencap has advised that there are already established and well-known difficulties in recruiting and retaining a sufficient number of doctors, nurses and care staff and that any disincentive or impediment to recruiting staff from EU countries will serve only to stretch these services further.

This House has on many occasions expressed its worry about the impact of Brexit on all scientific research, both staffing and funding, and that applies not least to the medical and life sciences sector. The BMA says it is concerned that as a result of the ongoing uncertainty, there is a significant risk of a loss of capacity within the UK medical research community. It is also aware of anecdotal evidence that people are turning down job offers because of the lack of security following the referendum.

Many of us want to hear the Government not only give that certainty which the NHS and others are crying out for but to articulate loud and clear an acknowledgement of the contribution made by highly skilled migrants, including doctors, nurses and researchers, in delivering and sustaining public services and the public good. Incredibly and despicably, there have been xenophobic attacks by patients—the noble Baroness, Lady Watkins, mentioned this—who have taken the referendum result as a green light to attack the NHS staff who care for them. The Government need to send a very clear message condemning such appalling attacks.

Recruitment through EU or EEA free movement is much less burdensome in bureaucracy than for migrants from non-EU countries, so those Brexiteers who claimed that EU red tape was stifling us were barking up the wrong tree on this topic, as on so many others. The chief executive of the Nursing and Midwifery Council, Jackie Smith, said recently that there would be a major impact on the regulator’s ability to process applications if it were required to apply its current approval procedures for nurses from the rest of the world to those coming from the EU, and that it would create greater costs for her organisation in verifying documentation, securing visas and administering the skills test. The mutual recognition of professional qualifications actually speeds up recruitment and training. Would EU staff in future have to go through the tier 2 process and if there is a salary threshold of £35,000, how are nurses whose average pay is £30,000 to be treated under that system?

I read the same remarks as the noble Viscount, Lord Bridgeman, quoting the president of the Royal College of Surgeons, Clare Marx. She said that Brexit would help patient safety by toughening language tests, enabling the UK to enforce a higher quality of surgical tools and instruments than EU standards and boosting surgeon training, which she claims is impeded by the working time directive. Does the Minister agree with those comments and know whether the Royal College of Surgeons agrees, as a body, with its president on them? The working time directive and its protections against overwork will of course cease to apply if we leave the EU and the EEA.

The Government keep telling us that they cannot give guarantees to EU citizens until there are negotiations which also encompass Brits abroad. But they have unilaterally replaced our European Commissioner—appointing a civil servant in place of a politician and relinquishing the key financial services dossier—and they have renounced our presidency of the European Council next year.

When they want to, the Government are perfectly capable of taking unilateral action outwith any carefully prepared Brexit strategy, so the case against unilateral and unconditional guarantees for EU staff in the NHS and elsewhere gets weaker by the day. I want to hear such unconditional guarantees. As an early win, we need to give a commitment to staff from other EU countries very quickly that they will be afforded indefinite leave to remain, with no new red tape or health surcharge; a message about how valued staff from other EU countries working in health and care are; and a commitment that nurses, and other health-related occupations as and when relevant, will remain on the shortage occupation list.

I am sure there will be other occasions when we might have to discuss a longer-term approach to migration policy, but in the immediate term we need that certainty and that reassurance. We need guarantees for the EU staff we have currently and those whom trusts are seeking to recruit, as well as similar guarantees on the funding and staffing of medical and scientific research. I hope the Minister will be able to give those.

NHS: Diabetes

Baroness Ludford Excerpts

Thursday 26th May 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, diabetes is a key priority of the Government and part of the mandate that was given to NHS England for this year. The noble Lord is right—the direct cost to the NHS of treating diabetes is actually about £5 billion every year. Variation is the critical aspect that we should focus on. Whether it is foot care or the incidence and treatment of diabetes, across the country there is a huge degree of variation. The work being done with Diabetes UK on a national audit for diabetes will play a big part in reducing that variation.

[Baroness Ludford (LD)]

My Lords, are the Government satisfied with the overall cost-benefit analysis of the provision of insulin pumps and continuous glucose monitors? I should mention that my own husband has those. NICE guidelines are quite restrictive, and only a fraction of those who qualify get them. Many people self-fund, yet the long-term cost savings to the NHS of good blood glucose control and avoiding organ damage are enormous. Will the Department of Health look again at whether the benefits outweigh the relatively small costs?

[Lord Prior of Brampton]

My Lords, there are clear NICE guidelines on the use of insulin pumps and blood glucose monitoring equipment. For type 1 diabetes, NICE does not recommend their use unless there is clear evidence that the patient will comply with such use at least 70% of the time. The advice from NICE is clear on the use of both.

Royal National Orthopaedic Hospital: Redevelopment

Baroness Ludford Excerpts

Thursday 17th March 2016 Grand Committee

[Baroness Ludford (LD)]

My Lords, I, too, thank the noble Baroness, Lady Dean for this vital and timely debate. I am pleased to speak in the presence of the chairman and the chief executive. I am very glad to count myself among the friends of the RNOH. I have absolutely no experience or knowledge of the NHS, but I am speaking out of gratitude because my husband is a very appreciative patient at the royal national hospital, so I am in a similar position to the noble Lord, Lord Tebbit.

My husband has an NHS position, which I should mention: he is chair of Whittington Health, a trust in north London which consists of a hospital and community services. He was initially treated at the Whittington last autumn for a very serious, life-threatening infection and received the most marvellous and dedicated care from the medics there, whom he and I cannot thank enough. Thanks to them and his own fighting spirit, he pulled through, but his leg had to be amputated, so he passed into the care of the royal national hospital, Stanmore, initially as an in-patient for five days. To be frank, my only personal experience derives from being a visitor there for those few days.

I was, it is fair to say, aghast when I first saw the hospital. “It’s a bunch of Nissen huts”, I exclaimed, which is, of course, precisely what much of it is. I did not see the whole estate, but as it was built in the 1940s, I think that that was fair comment. We went in through a heavy, plastic door, which was all that kept the winter winds from the ward into which we entered directly. So my second thought on arrival was, “What on earth are the heating bills?”. My third thought was that, on a dark winter night, having to find the visitors’ loo outside, across the road and down some steps was less than congenial.

So my first point is that this is no way to treat a national, indeed, an international, centre of excellence. The staff are first class and deliver excellent care, as recognised by the “outstanding” rating given to the hospital by the Care Quality Commission in 2014 for its medical care, which includes the rehabilitation from which my husband is benefiting. However, the staff, the patients, their families and the community are being horribly let down by the appallingly bad, old and decrepit physical conditions. The CQC said the hospital’s premises were,

“not fit for purpose – it does not provide an adequate environment to care and treat patients”,

which is, no doubt, why the ratings for out-patients and children’s services were, “requires improvement”. I did not see the children’s wards but I am told that they are the worst of all.

What is it doing to staff morale and the ability to attract the brightest and the best that the powers that be are stalling over the green light for desperately needed redevelopment? With the best will in the world, the morale of patients and their families, at a time when they may be very vulnerable, whether after an amputation or for another reason, will not be increased by such grotty surroundings.

Secondly, I want to express deep frustration at the delay in getting the go-ahead from the NHS Trust Development Authority. This unelected quango— I use that term not to be abusive but as a statement of fact—seems to be the body on which everything now depends. It approved the outline business case a year ago, and I do not understand why it takes so much to get to the final sign-off and permission to borrow.

When the local MP, Bob Blackman, with whom I have been fortunate to have a word, initiated a short but very valuable debate a year ago, the Minister, Dr Daniel Poulter, rightly said of the RNOH:

“With the care it provides to its patients, it is one of the best centres in the world … a leader in the field of orthopaedics in the UK and worldwide”—

including through training and research, and—

“produces the very best possible care and results for patients … The RNOH is renowned worldwide for its clinical excellence”,

He said:

“I am aware that most of the buildings at Stanmore date from the 1940s, and many are no longer appropriate or fit for purpose for the high-quality care and excellent clinical outcomes that the RNOH provides for its patients”.

He agreed:

“The RNOH’s proposed redevelopment of the Stanmore site is key to ensuring that it can continue to improve the care it provides”.

I was a little worried by his comment that the RNOH,

“manages to maintain high standards of outcomes despite the condition of the estate ”.—[Official Report, Commons, 4/3/15; cols. 350-51WH.]

That is only through the heroic efforts of its staff, which no doubt cannot be taken indefinitely for granted. If they are being heroic about rising above their surroundings, I would prefer their heroic efforts to go into patient care.

Dr Poulter acknowledged the frustration at the delays, saying that due diligence was necessary to ensure financial viability. That is understandable, but the TDA has been on the case for three years, asking for more and more information. As we have heard, the deliberations have gone on for 30 years. Planning permission was received three years ago, which was, of course, the result of a transparent and democratic process by the London Borough of Harrow.

Given the high degree of centralisation of the NHS, I am bemused by the gap between expressed ministerial support and the lack of speedy output from the TDA. Surely the Government cannot be saying that they have no levers to encourage the TDA to get on with it. The medical case for a modern, state-of-the-art hospital seems unanswerable, and it seems that the financial case is equally sound and straightforward. It was given by the noble Baroness. The debate that Bob Blackman MP held was followed five days later by TDA approval of the outline business case. Let us hope that we, through this debate, thanks to the noble Baroness, Lady Dean, might have a similar catalytic effect on its final decision. I look forward to hearing from the Minister that this will indeed be the case.

National Health Service

Baroness Ludford Excerpts

Thursday 14th January 2016 Lords Chamber

[Baroness Ludford (LD)]

My Lords, I also thank the noble Lord, Lord Turnberg, for this important debate. I have my own recent family reasons for having the deepest gratitude to wonderful NHS staff, who deploy life-saving skills. I also have a niece who is a junior doctor.

However, I want to concentrate on diabetes. There is huge potential—it is a no-brainer—to spend more wisely. Four million people live with diabetes, and they cost the NHS £10 billion a year—£1 million an hour—which is 1/10th of its budget. The total cost to individuals and society is £24 billion and rising fast. My particular focus is on those who are insulin-injecting, predominantly with type 1 diabetes. I have some, albeit second-hand, experience of this, having been with my husband for the 40-odd years since he was diagnosed. The NHS has never included me or learnt from me; for example, when it comes to coping with hypos. I should mention that my husband already has access to the technology I will refer to, that he is chairman of a health trust and that he was, for several years, chairman of the UK branch of the Juvenile Diabetes Research Foundation.

NHS England’s Five Year Forward View last summer referred to diabetes only as a preventable illness resulting from,

“the nation’s waistline … piling on the pounds”.

This completely ignored and insulted those with type 1, whose diabetes is not caused by obesity. As well as the integration of services, I urge an “invest to save” approach to both research and care. Around 400,000 people have type 1 and although they account for only one in 10 of those with diabetes, they consume, on some estimates, half of the £10 billion that diabetes costs the NHS annually. As much as 80% of the cost of treating people with type 1 is spent on avoidable complications. Two reports from the National Audit Office, and one from the Public Accounts Committee of the other place—a second is in progress—have been scathing about NHS care failures.

How do you invest to save? First, you do it in research. The glittering prize is a cure. JDRF and the researchers it funds do excellent work, but the UK Government spend only £6.5 million a year—10p per head of population—on diabetes research, backed up of course by crucial EU funding that Brexit could put at risk. This spending is puny and inexplicable.

Secondly, you invest to save in devices for self-management. The key to keeping type 1 diabetics well and avoiding debilitating and expensive complications of organ damage is good blood glucose control through self-management. Insulin pumps and continuous glucose monitors have proven benefits in the management of type 1 diabetes, and NICE guidance attests to their cost-effectiveness. Testing without finger pricks now exists, and NICE needs to look positively at this. Yet only 7% of people with type 1 in the UK have a pump, compared to 15% in Germany and 40% in the US. Only 1% or 2%, mostly self-funded, have a CGM.

I conclude by saying that spending to save on diabetes is an easy win; there is no excuse not to do it.

Health: Detection Dogs

Baroness Ludford Excerpts

Thursday 17th September 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, interestingly, the human nose contains some 5 million scent glands but a dog’s nose contains many more. In fact, the sniffing ability of a dog can be up to 10 million times that of the ability of a human being. Therefore we should not underestimate the contribution that dogs can make in this field. The trial being conducted at Milton Keynes University Hospital, which involves 3,000 patients giving urine samples, with nine dogs in a controlled environment over the three years, could indeed make a huge a contribution to the early detection of certain cancers. Therefore we will follow that trial with keen interest.

[Baroness Ludford (LD)]

My Lords, I thank the noble Lord, Lord Astor of Hever, for asking this Question, and also Claire, a young diabetes nurse with type 1 diabetes, who told me about her dog, Magic, which helps her avoid hypos—hypoglycaemic incidents. I declare an interest in that I have been married to someone who has had type 1 diabetes for nearly 45 years. Is the Minister aware that if the NHS did a serious cost-benefit exercise on type 1 diabetes, its investment in measures to assist strict blood glucose control and prevent hypos would be transformed? However, it seems to have a blind spot. Type 1 diabetes accounts for a large chunk of the 10% of NHS spending on diabetes but is not even mentioned in the NHS Five Year Forward View. Will the Government seriously look at extending access to technologies and, for people whom they would assist, access to detection dogs?

[Lord Prior of Brampton]

It is interesting that the cost of training a dog is some £11,200—considerably less than the cost of training a doctor, I might add. Unquestionably there is considerable evidence to suggest that dogs can make a real contribution as regards people suffering from diabetes and low-sugar problems, whom the noble Baroness mentioned. Decisions in this area are for local CCGs to make, but it is something that we will certainly encourage.