Human Fertilisation and Embryology (Amendment) Regulations 2024
Debate between Baroness Merron and Lord Evans of Rainow(1 month ago)
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Lord Evans of Rainow (Con)
My Lords, when I came here today, I did not think I would be hearing about Enoch Powell. I think that, if he were here today, he would be very interested in what we have been debating. Enoch Powell’s consistency was Wolverhampton South West. In the 2010 election, a colleague of mine of Asian background, a Sikh, won by the same majority as Enoch won it by in 1950. I am glad to say that Mrs Enoch said that Enoch would have been delighted by my Conservative colleague Paul Uppal winning that seat. It shows that people change over time. I wish he were here to hear what I am about to say.
I welcome these regulations laid before us by His Majesty’s Government. They bring forward the plans from May this year that were established by the Conservative Government. Now, as then, we believe that equality under the law is a long-established principle in this country and any improvement towards this end is to be lauded. I am sure that can receive support from all noble Lords.
These regulations mark a further step towards ensuring equal access to IVF services for people living with HIV and for female same-sex couples. It is another stage in the process of ensuring that as many people as possible can fulfil their dreams of parenthood, and it builds on the incredible work done to reduce the stigma associated with HIV, which has for so long prevented people getting tested and seeking treatment. With these changes, we will make it clear that people with HIV can live happy and fruitful lives.
The conditions in these regulations limit donation to those with an HIV viral load of no more than 200 copies per millilitre, meaning that the infection is undetectable and therefore non-transmittable. This requires the donor and recipient to have a personal relationship with one another and ensuring that safeguards are in place to minimise any risks associated with partner donation from people diagnosed with HIV. This will benefit hundreds of couples who have been trying in vain to become parents, and it will also reduce costs relating to IVF.
I hope that His Majesty’s Government will continue in the steps of the previous Conservative Government with efforts to help those living with HIV to have equal access to healthcare services.
Baroness Merron (Lab)
My Lords, I am glad to sense not just support for this draft statutory instrument but recognition in this debate. Following the comments of the noble Lord, Lord Evans, I acknowledge the contribution of my predecessor as Minister responsible for this area, who pressed on with the SI and ensured that it was laid. I am glad to be speaking to it today, as I know he is. I am also pleased to note that Adam Freedman from the National AIDS Trust is with us today. He is most welcome to the Committee. He has come to see the statutory instrument debated. He and his colleagues have patiently encouraged the previous Government and this Government in the right direction, and I thank him for that.
On the points raised by noble Lords, the noble Lord, Lord Wigley, asked whether the devolved Governments were content. I delighted to tell him that they are. He also asked about additional costs. A de minimis assessment was carried out, and it estimates £46,000 to £92,000 for the impact on the fertility sector. Obviously, as has been evidenced and described in this debate, there is a hugely positive impact from the measures within this draft statutory instrument.
I note what the noble Lord, Lord Wigley, said. I put down that he, along with the noble Lord, Lord Winston, and other parliamentary colleagues past and present, are veterans of change and of the Acts we are talking about. As the noble Lord, Lord Scriven, said, this is a journey—one that I suspect is not at its end, although I am pleased to take us further on that journey today. I also pay tribute to the contribution in this area of the noble Lord, Lord Winston, over many years, and to the contributions of other colleagues, who have given it their support and professionalism.
The noble Lord, Lord Winston, asked what the case would be if a recipient were HIV positive. The answer is that they will be able to get IVF. They are not actually affected by these regulations, which impact donors, not recipients. I assure the noble Lord that he was far from wasting the Committee’s time with his comments. I heard clearly his comments about counselling and the need for support. I will look closely at that with officials, following his remarks. I clarify that the £1,000 I referred to was not for IVF. It was an estimated cost for the additional screening required for female same-sex couples, which we are now seeking to correct.
On funding and the issue of availability on the National Health Service, as noble Lords will know, funding for IVF is devolved to ICBs. I am very well aware of the differential provision to different groups and individuals. I will consider future policy options, having picked up this part of the brief and spoken to a number of people about their concerns.
The noble Lord, Lord Scriven, also asked about access to IVF on the NHS. In addition to the point about consideration of advice that I will be getting about improving the service, I want to share his comment about this being just one more step in a positive direction. It is about supporting the fact that families come in all shapes and sizes. A family or a household is a family or a household, and parents are parents. They are there to support and bring up their child in a positive way, and we want to support that too.
I finish by thanking the noble Lord, Lord Evans, for reminding us that one thing that these regulations will do is take us a step on another journey—that of reducing the stigma for those who live with HIV. There have been so many medical advances, which is why we are able to bring this instrument forward today. But attitudes continue to be something to be challenged at times, and I am glad that noble Lords recognise the contribution of the legislative change we seek to make.
We want to ensure that those who want to start a family do not face barriers where there is no reason for those barriers. I place on record my thanks to the organisations who have pushed for and supported these reforms, particularly the National AIDS Trust, Stonewall, the Elton John AIDS Foundation and the Human Fertilisation and Embryology Authority. As I said earlier to the noble Lord, Lord Wigley, I thank all those parliamentarians and others along the way who have got us to this place today.
Human Medicines (Amendments Relating to Naloxone and Transfers of Functions) Regulations 2024
Debate between Baroness Merron and Lord Evans of Rainow(1 month ago)
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Baroness Merron (Lab)
That is understood. I am sure that the noble Lord will be delighted to know that this is to be established, but he is certainly quite right to raise that point. I will ensure that, once that detail is established, it is made known.
On the point about a potential additional burden on services, which the noble Lord, Lord Evans, raised, we certainly recognise the fact that there are challenges in the scope of these regulations. Our intention—I stress intention—is not to create any additional burden. I think I was quite clear in mentioning that these are enabling, not compulsory, requirements. That is important, because it means that no service or individual professional will actually be required to give out take-home naloxone as a result of these regulations. That potentially allows a more gradual introduction of this.
For example, I know that the noble Lord, Lord Scriven, mentioned that there may be differences in the level of take-up across the country. I suspect that may well be the case. It will be our job not just to encourage it to be taken up but to work out why it is not being taken up. We will not just bring in this instrument; we will seek to actively promote it. As I said, we are confident that there is a high level of support for these changes and we will continue to work closely with services and professionals to support them with provision.
The noble Lord, Lord Evans, rightly said that the previous Government undertook the consultation. I am most grateful for that because it has informed where we are today. That consultation under the previous Government received significant positive support from the sector, with the overwhelming majority of respondents agreeing with the set-up of the changes.
The noble Lord, Lord Evans, raised a question about costs. There is no direct cost to the Government associated with these changes since, as the noble Lord will understand, this is only an enabling provision. It will be for services to determine whether they use this power and give out take-home naloxone. At the moment, local authorities provide funding for naloxone, which is supplied through drug treatment services based on their assessment of local need. Although local authority public health services will want to support the wider provision of naloxone, I recognise that their resources are limited; I am sure that many of them will tell me that. This will potentially mean that there is an additional call on their resources and they may need to pay for it through their own funding streams. However, we will monitor demand and engage with services and local areas to understand where any pressures may be.
Another point here is that this is not a neutral act. There will be benefits, in relation not just to personal health and saving lives but to costs associated with dealing with overdoses. I hope that will be seen.
The noble Lord, Lord Evans, also asked whether the methods of administration are permitted only by medical professionals. It is already the case under current regulations that naloxone can be administered by anyone. I emphasise the point about high levels of safety and that it can be administered by a lay person.
I think I have picked up most of the points raised, but as I said, if I have not I shall be very pleased to look further into any other points and to write.
To summarise, the changes we are proposing will allow more services and more professionals to give out take-home supplies of naloxone without a prescription. As I said, it can already be administered by anyone but having more services with the ability to supply it will mean easier access for the people who are at risk of overdose. It will support them and those around them, as has been generously welcomed and acknowledged by the noble Lords, Lord Scriven and Lord Evans.
In short, these changes will widen access to a life-saving medicine. I am sure we can all agree that any death from an illicit drug is tragic and preventable, and we should take every step we can to reduce drug-related deaths; that is what we are doing today. On this basis, I hope that noble Lords will join me in supporting these important regulatory changes. I commend these draft regulations to the Committee.
Lord Evans of Rainow (Con)
I thank the Minister for her responses. In Australia, Canada and some states in the United States the nasal spray is available over the counter. Does the Minister have any knowledge of any plans to administer it via our pharmacies?
Baroness Merron (Lab)
I am waiting for inspiration, as the noble Lord will realise. In fact, I would rather write to him, as he has made an important point and I want to be quite clear on it. I thank him for reiterating the point.
NHS Hospitals: Apheresis
Debate between Baroness Merron and Lord Evans of Rainow(1 month, 1 week ago)
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Baroness Merron (Lab)
I thank my noble friend for raising that important point. I will be very pleased to look into this further, so I can answer him in full.
Lord Evans of Rainow (Con)
My Lords, I pay tribute to the noble Baroness, Lady Ritchie, for her work in this area. In England, leukapheresis can be performed only by the NHS Manchester apheresis unit, and the Birmingham unit can carry out only three of the apheresis services. Are His Majesty’s Government committed to expanding the range of apheresis services available at each unit?
Baroness Merron (Lab)
Further to my answer to the noble Baroness, NHS Blood and Transplant is seeking to expand capacity in the way I outlined. It is probably worth going back to the point about the apheresis working group. It met for the first time last month to determine the extent of the capacity issues which we know exist. It will also be looking at who delivers what, how and for what uses. It will identify the issues in respect of workforce, machinery, finance and efficiency, and seek to come up with a recommendation. It will report in spring of next year, so we have a route forward.
Palliative and End-of-life Care: Funding
Debate between Baroness Merron and Lord Evans of Rainow(2 months, 2 weeks ago)
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Baroness Merron (Lab)
As the noble Baroness said, in 2024-25 the £25 million in funding from NHS England was distributed, for the first time, via integrated care boards. As I understand it from the previous Government, that was in line with NHS devolution. We will carefully consider the next steps on palliative and end-of-life care funding much more widely in the coming months and will take on board the comments of the noble Baroness and other noble Lords.
Lord Evans of Rainow (Con)
My Lords, everyone should be able to access quality palliative and end-of-life care and patient care in their local area. Under the Conservatives, we made integrated care boards legally responsible for commissioning palliative care services to meet the needs of the local population. What assessment has the Minister made of access to palliative and end-of-life care across the country? What steps will the Government take to ensure that everyone, especially those living in rural areas, can access quality end-of-life care?
Baroness Merron (Lab)
As the noble Lord will be aware, statutory guidance and service specifications are provided to support commissioners in ICBs to meet their duty. As I am sure the noble Lord is also aware, NHS England has developed a palliative and end-of-life care dashboard that brings all the relevant local data together and helps commissioners to understand the situation so that they can provide for their local populations. This is part of ongoing work for this new Government to see how we meet requirements to provide dignity, compassion and service at the end of life and just prior to the end of life.
NHS: Breast Screening Programme
Debate between Baroness Merron and Lord Evans of Rainow(2 months, 2 weeks ago)
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Baroness Merron (Lab)
I am sure that the noble Lord, Lord Darzi, is listening, but if he is not I will ensure that the noble Lord’s comments are drawn to his attention. I can say to your Lordships’ House that this Government intend to transform the NHS from a late-diagnosis, late-treatment health service to one that catches illness earlier and also prevents it in the first place. It is that shift that will make the greatest change. I have been interested to see that, across all the screening programmes, something like 15 million people are invited for screening and 10 million take it up. That still leaves us with 5 million people to work on. It is important to note that the 10 million take-up figure for screening saves a considerable number of lives. We need to continue to drive up the take-up on screening, across the various cancers and not just breast cancer. As noble Lords will know, there are programmes in respect of cervical and bowel cancer, and there will be a lung cancer screening programme as well.
Lord Evans of Rainow (Con)
My Lords, I begin by paying tribute to the noble Baroness, Lady Morgan, for her excellent work with Breakthrough Breast Cancer and more recently with Breast Cancer Now. We are very lucky to have her in your Lordships’ House. We know that the NHS wants to shift the emphasis from cure to prevention and screening, which, whether for breast cancer or other conditions, is a vital part of prevention. The previous Conservative Government took action to drive up breast cancer screening, with new breast cancer screening units and our community diagnostic centre programme. What steps will the Government take to further increase the uptake of breast cancer screening?
Baroness Merron (Lab)
The measures that the noble Lord refers to did indeed assist, but as I mentioned earlier we have a stubborn problem in returning to pre-Covid rates. The improvement plan that exists sets out the priorities and the interventions, but also the monitoring of what is working and what is not. The kinds of things that are being tested and introduced now include, for example, new IT systems to enable communication with women in 30 different languages, and new IT systems that mean people know when their appointment is and are reminded of it. All these things sound quite straightforward, but they have not been in place across the country and it is important that they are. I mentioned the importance of addressing fears and embarrassment, improving information and reassurance to women, as well as more convenient times and booking systems. It is very important that we make better use of mobile screening units, so that screening is near to where women are.
NHS Continuing Healthcare
Debate between Baroness Merron and Lord Evans of Rainow(2 months, 2 weeks ago)
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Baroness Merron (Lab)
As the noble Baroness is aware, the responsibility for this lies with integrated care boards and a framework applies to both adults and children and to young people. It is for NHS England to ensure that the framework is properly applied. Certainly, the framework for children and young people has not been revisited since 2016 and we need to look at whether it is doing the job it is intended to do, because we want people to be getting the care they need. Each case is unique and complex and, as a person-centred service, that brings its own complexities. We should therefore ensure that the frameworks are applied correctly and get to the right people at the right time.
Lord Evans of Rainow (Con)
My Lords, I take this opportunity to warmly welcome the noble Baroness to her place; I look forward to working with her. During consideration of the Health and Care Act, the last Government committed to moving away from care homes. Are this Government also committed to allowing those needing care to be given support to live at home? What changes do they believe need to be made to the NHS continuing healthcare programme to allow them to stay at home, rather than be in care homes? The noble Baroness and I have exchanged comments about this in private, and I am very happy to discuss it again with her at a later date.
Social Care Reform
Debate between Baroness Merron and Lord Evans of Rainow(2 months, 2 weeks ago)
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Baroness Merron (Lab)
The noble Baroness raises an important point about actually making it work, but certainly the fair pay agreement is crucial to professionalising the care service and, indeed, raising the visibility of and regard for those who work in this sector, which is nearly 1.6 million people. We will be working closely, as I mentioned, with trade unions, local authorities, the sector and all those with an interest to make sure that the first ever fair pay agreement for care professionals can work and will deliver what we want, which is a stable, well-regarded and well-trained workforce.
Lord Evans of Rainow (Con)
My Lords, during the passage of the Health and Care Act, the previous Government came up with a compromise solution to fund healthcare for an ageing population. It was by no means perfect but it made a start, while addressing the concerns of the Treasury. The new Government have scrapped this scheme but have not yet proposed an alternative. A report from the Health Foundation claimed that Labour’s plans for social care are the most general, with a headline commitment to create a national care service but no detail about timescales or resources. Can the Minister give us any indications on the timeframe, such as “the end of 2024”—preferably a date, rather than “in due course” or “in the fullness of time”?
Baroness Merron (Lab)
I welcome the advice from the noble Lord and I will resist using those terms, which I am sure he will appreciate. However, as noble Lords have already understood, this is not going to be done overnight; we are talking about a 10-year vision but we will be talking about steps along the way. I think it is very important that we make progress on the national care service in the short term, because we have to build the foundations, by working with the sector and those with lived experience, to develop those new national standards. It will be work in progress and I hope that noble Lords will be patient but also press me about what progress we are making.
National Immunisation Programme
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
The noble Lord is absolutely right to raise this. As I said in the previous answer that I gave to my noble friend, the Government are investing significantly in the manufacturing capacity and the supply chain within the United Kingdom. In the event of an emergency, we have a supply chain within the United Kingdom so that we can supply the vaccines needed for its population.
Baroness Merron (Lab)
My Lords, last year, the noble Lord told the House that he was hopeful that an RSV immunisation programme for babies and older adults would be available for this winter, having overcome any potential barriers to implementation. Can he assure this House and my noble friend Lady Ritchie—who he has already acknowledged as such an effective campaigner on this matter—that all is on track for that to start later this year?
Lord Evans of Rainow (Con)
I thank the noble Baroness for that question. The Government have made a policy decision on the eligibility of a potential respiratory syncytial virus programme, which is in line with the JCVI’s comments made in September 2023. We are working through the full business case, with costings and operational delivery, for final agreement in line with an autumn start. It is agreed by the Government that any potential RSV programme and its sidelines will be announced in the summer.
Whooping Cough
Debate between Baroness Merron and Lord Evans of Rainow
Baroness Merron
To ask His Majesty’s Government what recent assessment they have made of the prevalence of whooping cough.
Lord Evans of Rainow (Con)
My Lords, data published by the UK Health Security Agency shows provisionally that whooping cough cases are continuing to rise, with 2,793 cases in England between January and March 2024. Tragically, there have also been five infant deaths in England in this period, and our deepest sympathies are with those families. We are urging pregnant women to protect their baby by getting vaccinated and encouraging parents to ensure that young infants receive their vaccinations at the correct time.
Baroness Merron (Lab)
My Lords, it is indeed extremely worrying that infants are dying in the biggest whooping cough outbreak in decades, while the UK Health Security Agency also confirms that the lowest vaccination rates are in the 10% most deprived areas, which experts caution should not be dismissed as just vaccine hesitancy. Have the Government assessed the contribution of the cost of living, poor housing and the lack of GP access to disease outbreaks? Is it not time for the Government to show more flexibility and creativity in getting vaccines to those who experience greatest disadvantage?
Folic Acid Fortification
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
The noble Lord, as always, asks a very good question. The proposed transition period for industry to implement changes in the Bread and Flour Regulations review is 24 months. The provisions on folic acid fortification of flour will therefore become mandatory as of 1 October 2026, but there is nothing to stop earlier fortification, should industry wish to do so. I used to work in a bakery and I know that it is a very simple process to put the folic acid in. In my view, 24 months is a very reasonable time. There is nothing preventing the industry fortifying bread now.
Baroness Merron (Lab)
My Lords, I too look forward to the progress that we will make and will welcome the legislation when it comes before us. Will the data be in place to monitor the impact on preventing neural birth defects through the addition of folic acid to non-wholemeal flour? What are the plans to review it to see if any further steps might be necessary in the years to come?
Lord Evans of Rainow (Con)
The estimated figures show a reduction of 20% in neural tube defects with the introduction of folic acid into flour, but clearly that needs to be monitored—and from day one it will be monitored. That data will be collected and updated; it is very important that, for this to be successful, we need to know that there is a 20% reduction. That amounts to about 200 babies per year. Systems are in place to monitor the success—I hope—of this process.
Health Data: Research and Analysis
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
The noble Lord knows how to run a hospital, and I pay tribute to the work that he has done. On the point about a sovereign wealth fund, I shall take it back to the department—but this strategy will give the public greater access to and control over their own records. Healthcare staff will have easy access to the right information, and social care leaders and policymakers will have data to make effective decisions —so the noble Lord will know that the strategy will benefit all those who work in the NHS, but particularly it benefits patients in the United Kingdom.
Baroness Merron (Lab)
My Lords, the Lords Committee on the Integration of Primary and Community Care heard more frustration from witnesses on the inadequacy of data connectivity than almost anything else. What plans do the Government have to improve that situation, sooner rather than later?
Lord Evans of Rainow (Con)
The whole point of the government strategy with introducing this data is to improve the connectivity, similar to what the noble Lord was referring to, between GPs and primary care, and indeed into those ICBs and the trusts throughout the country. I totally agree with the noble Baroness on doing it sooner rather than later, but the Government are moving at pace, and this strategy will transform patient outcomes throughout the United Kingdom.
Medical Student Places
Debate between Baroness Merron and Lord Evans of Rainow
Baroness Merron
To ask His Majesty’s Government what progress has been made on plans to increase the number of medical student places in England.
Lord Evans of Rainow (Con)
My Lords, we are on track to meet the NHS Long Term Workforce Plan and aim to double the number of medical school places in England from 7,500 to 15,000 places a year by 2031-32. We have allocated 205 additional medical school places and provisionally allocated 350 more for the 2024-25 and 2025-26 academic years respectively. In 2020, the Government completed an expansion in the number of medical school places in England from 7,500 per year, a 25% increase.
Baroness Merron (Lab)
My Lords, may I start by saying on behalf of these Benches that we wish to express our deep condolences on the sad passing of Baroness Gardner of Parkes and our colleague Baroness Massey? May their memories be for a blessing.
Ministers recently advised the Office for Students that only 350 additional places for trainee doctors would be funded in 2025-26. On the basis that, at this rate, it will take over 21 years to meet the Government’s promise to double the number of medical training places, what assessment has been made of the effect this will have on medical schools, which had in fact been told to plan for considerably greater numbers? Where does this leave the Government’s promise to double medical places by 2031?
Lord Evans of Rainow (Con)
My Lords, I would like to follow the noble Baroness’s tribute to Baroness Gardner of Parkes and Baroness Massey. I also pay tribute to the late Doug Hoyle, an outstanding north-west MP and an outstanding public servant.
We remain committed to the long-term workforce plan’s target to double the number of medical school places by 2031 and are in fact ahead of schedule. The planned expansion is not uniform in each year; it increases substantially in later years. The timeline allows for new and existing medical schools to build the physical and teaching capacity needed, and to develop curricula and receive General Medical Council approvals where needed.
Human Medicines (Amendments Relating to Coronavirus and Influenza) (England and Wales and Scotland) Regulations 2024
Debate between Baroness Merron and Lord Evans of Rainow(8 months, 4 weeks ago)
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Baroness Merron (Lab)
My Lords, our health and care staff, scientists and others in public services, and those who volunteered, did so much to keep the public safe and to vaccinate millions across the country as quickly as possible to save lives and drive down cases of Covid-19. They finally allowed us to end lockdowns and reclaim our lives, and I pay tribute to them all.
I thank the Minister for setting out today the provisions of these regulations, which are to update legislation pertaining to the movement and supply of Covid-19 and influenza vaccines. The changes, as he said, seek to extend the sunset clauses of Regulations 3A and 19 to 1 April 2026 and to alter Regulation 247A to extend its provision, also until 2026, instead of the current restriction on its use to being only during a pandemic. Extending these provisions, which will also allow the NHS to continue to use an expanded workforce, is important to continuing to allow the deployment of safe and effective Covid-19 and influenza vaccines at the pace and scale required to keep us all protected. The draft regulations aim to build on the work of the Covid-19 vaccine rollout across the country, and we certainly support them.
As the Minister said, the consultation last year confirmed that the provisions have found considerable favour with stakeholders in the health and care sector. Regulation 247A appears to have reduced workforce pressures while increasing flexibility in the workforce and providing opportunities for career progression. On all fronts, that has to be a good thing.
I note that the impact assessment highlights the positive expected value of these regulations and concludes that vaccinations are a powerful and beneficial tool in tackling viruses and diseases such as influenza and Covid-19. The impact assessment also refers to the work to move towards a permanent approach, which will likely alter these provisions again in the future. Can the Minister provide noble Lords with more detail about the progress the department has made in its planning for a more permanent approach?
The important matters of vaccine take-up, hesitancy and misinformation have of course come to the fore of late, given the recent measles outbreak across the country. All these matters have impacted in that too few have been protected against a potentially deadly virus. I recently asked the noble Lord, Lord Markham, as the Minister in the Chamber, about using pharmacists to vaccinate against measles through the delivery of the MMR vaccine, which he welcomed. I wonder whether the Minister today could undertake today to let me know what response the department gave to my suggestion. I appreciate that I had directed that question to the noble Lord, Lord Markham, but I am sure that the Minister will be able to assist, even if it is after this debate.
The Government have been called on to extend this winter’s Covid vaccination booster programme to 12 million people in the 50 to 64 age cohort. Can the Minister explain why the provision was not extended to that age cohort? What is the assessment of the impact of this on the health of both that group and those beyond it? Can the Minister share any details about whether and when Covid-19 vaccinations will be available privately?
Last winter, influenza admission rates were 2.6 times higher for those who live in the most deprived areas than for those who live in the least deprived areas, while Covid-19 admission rates were 2.1 times higher. The rate of emergency hospital admissions for influenza was 1.6 times higher for black British people and other minority ethnic groups than for white ethnic groups. What are the Government doing to address these inequalities?
Finally, can the Minister confirm what the Government are doing to tackle the vaccine misinformation that continues to be shared so widely across the country? As I said, we support this draft statutory instrument so that we can ensure the supply, and improve the take-up of, safe and effective Covid-19 and influenza vaccines at the pace and scale required.
Lord Evans of Rainow (Con)
My Lords, I am most grateful to noble Lords; in closing, I thank all noble Lords for participating in this debate. We always have healthy questions and, I hope, answers in this Room.
Extending these provisions will ensure that the important flexibilities established by these regulations are maintained, thereby supporting the continued safe and effective deployment of Covid-19 and flu vaccines to the pace and scale required. The Government will continue to work with system partners to consider fully a long-term mechanism to support the delivery and administration of Covid-19 and flu vaccines. This process is already under way; any new measures will of course be subject to public consultation. However, in the immediate term, given the high level of support expressed in the consultation, there is an ongoing need to support the continued safe and effective supply, distribution and administration of Covid-19 and flu vaccines by maintaining the existing provisions provided by these regulations to April 2026.
Let me answer to the specific questions that I was asked by the noble Lord, Lord Allan of Hallam and the noble Baroness, Lady Merron. They asked what the longer-term plans are for these regulations. It is important that we retain current flexibilities to continue to protect those at greatest risk, but we agree on the importance of long-term solutions, working with the system partners to undertake a fuller consideration of long-term plans. We do not want to pre-empt that process but can confirm that we will be informed by a full consultation, including in the House. We will certainly have opportunities to discuss this issue at length.
The noble Lord, Lord Allan, talked about his experience during Covid, as I presume most of us in this place experienced. He mentioned that he had injections from a solider, a nurse and another person, indicating that he had three injections. I remember, from my experience before I came to this place, how successful it was. It was a very British experience: it was in a community hall, with which we are all familiar, and a car park. We all queued in the rain, very British-like, ready to go in. We were met and greeted by volunteers; that was the first thing I noticed. The local CCG banners were around; it was very orderly and very dignified—very British. From what I remember, there was no soldier; they were NHS personnel, clearly identified, and we were all sifted through. The lessons that I took from it were that it is local but also national, and it is about volunteering as well. We have to work together on this, with government, local NHS provision and good vaccine provision working together, but you are reliant on volunteers to do it. In my experience, it worked very well.
As for who can deliver the vaccines and the flexibilities, as I indicated, in my experience and that of the noble Lord, it is healthcare professionals who deliver them. We discussed this yesterday in the Chamber, and the noble Baroness mentioned pharmacists. It is clear that other qualified and well-trained individuals, under supervision from healthcare professionals, can and should be able to do this. The lesson learned is that you can extend the number of individuals under supervision —who are very well trained—to make sure that there are no bottlenecks and you can open it up. That is the big lesson we can take from Covid.
This was introduced after the initial planning and preparation for a flu pandemic in 2016 so, on the noble Lord’s point about preferring to have pre-planned systems—the known unknowns, as he said—we have to be mindful of the unknown unknowns. We planned for influenza, not Covid-19. We in this House and elsewhere try our best to plan for the future but it is difficult. However, we can certainly learn from that and, as the noble Lord said, this has been well documented for the Government and the nation. So we have to learn the lessons from the planning for influenza from 2016 to 2019—only three years. God forbid that we have another pandemic, but we hope we will know about that. It is about making provision so that we can extend the workforce to deliver those vaccines.
On the specific question that the noble Baroness asked my noble friend Lord Markham, I will endeavour to get a specific answer if she has not already received one. She talked specifically about MMR, which we discussed previously. Some communities are perhaps vaccine-reluctant, for whatever reason. We mentioned that, in the black and ethnic minority communities, social deprivation has a lot to do with it in certain areas of the country—inner cities—as does misinformation.
Both the noble Lord, Lord Allan of Hallam, and the noble Baroness, Lady Merron, mentioned disinformation, which we have talked about before. Social media has a positive effect on our lives but, unfortunately, it is very easy to develop conspiracy theories from it. The Government are committed to tackling Covid-19 vaccine misinformation. At a national level, the Government, NHS England and UKHSA work together to create a range of personalised and accessible communications from trusted sources to maximise awareness, understanding and confidence in vaccines. At a local level, the NHS works with community leaders to design bespoke materials and services suited to their local populations, which may include outreach initiatives aimed at improving confidence and trust in the vaccines.
The conspiracy theories come from all sorts of places. The vaccines are perfectly safe. There may be occasions when individuals have allergic reactions to them, but this does not mean that people should not be vaccinated or that your children should not be vaccinated for MMR. I am afraid that one of the battles of the 21st century is trying to make sure that that disinformation does not have a detrimental effect on our children.
On what the Government have been doing, over 149 million Covid-19 vaccination doses were administered in England between December 2020 and 2023. This has saved tens of thousands of lives, significantly reducing the pressure on the NHS and allowing the economy and society to reopen. Since 11 September, when the latest autumn booster programme commenced, more than 11.8 million Covid-19 jabs have been delivered, providing vital protection to those at greater risk of severe illness.
To summarise, I believe that the long-term plan is to give that flexibility proactively. We cannot predict the future, but we can certainly learn from Covid-19, from 2020 to 2022, that the ability to expand a vaccine and its administration is critical, getting it in the right place at the right time. On the question asked by the noble Baroness, Lady Merron, about hard-to-reach communities, it is about communication and going through community leaders, but it is also about having the wherewithal so that people are not suspicious of going to a local community hall, where they will be welcomed by volunteers perhaps and injected by the appropriate people. We hope that can wear down this reluctance to take up life-saving vaccines.
Lung Cancer Medicines
Debate between Baroness Merron and Lord Evans of Rainow(9 months, 1 week ago)
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Lord Evans of Rainow (Con)
The noble Lord raises a good point, and I agree with it. Since 2016, the cancer drugs fund, worth £340 million per year, has delivered faster access for tens of thousands of NHS patients to some of the most promising new cancer medicines—in some cases, up to eight months faster, including for Pembrolizumab and Selpercatinib. These are two very important drugs, and the hope is that they will be successful moving forward. Only time will tell, but the Government are committed to introducing life-saving drugs.
Baroness Merron (Lab)
The Pharmaceutical Journal found last year that inequity of access through the compassionate use programme has become a significant issue, with some trusts not using the programme at all. What steps are the Government taking to ensure that new and existing patients across the country will be able to access Mobocertinib and other treatments for lung cancer?
Lord Evans of Rainow (Con)
I thank the noble Baroness for that question. As I have outlined in my previous answers, to the best of my knowledge, the existing drug will be allowed but some of the newer ones will be introduced and available. If the noble Baroness knows of specific trusts that do not make this available, I ask her to please let me know and I will look into it.
Child Obesity
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
I am not aware that I am painting a rosy picture. There are serious issues with childhood obesity in this country, as there are in other countries around the world. Nearly one in 10 children, 9.2%, start primary school living with obesity, and approximately one in five children, 22%, leave primary school living with obesity. Children living in the most deprived areas are more than twice as likely to be living with obesity as those living in the least deprived areas. Obesity costs the country an estimated £58 billion. The Government are doing all we can to help reduce that from an early age.
Baroness Merron (Lab)
My Lords, given the Minister’s response just now, does he acknowledge that the Government’s childhood obesity plan has presented us with what NHS England now describes as “a ticking health timebomb”? What assessment have the Government made of the impact of their own flagship sugar reduction programme managing only a 3.5% reduction and failing to meet its 20% target?
Lord Evans of Rainow (Con)
I am grateful to the noble Baroness, who raises a very important subject. It is not unique to the United Kingdom: many countries in the western world have this issue with childhood obesity. Sugar intakes in children aged one to 18 in the UK are double the recommended maximum level and more than 5% of daily energy intake. Consuming too much sugar can lead to weight gain, which in turn increases the risk of serious diseases, such as cancer, heart disease, type 2 diabetes and Covid-19. It also increases the risk of tooth decay. Modelling shows that children who are overweight or living with obesity consume between 140 and 500 excess calories a day, depending on the age and gender. The Government are working hard and doing a huge amount to reduce childhood obesity, but there is clearly a lot more to be done.
Measles Cases
Debate between Baroness Merron and Lord Evans of Rainow
Baroness Merron
To ask His Majesty’s Government what assessment they have made of the declaration of a national health incident by the UK Health Security Agency over a surge in measles cases across the country.
Lord Evans of Rainow (Con)
My Lords, the UK Health Security Agency declared a national incident on 8 January 2024. The government health system is taking control of the disease’s spread. Our aim is to protect as many individuals as possible through convenient vaccination, targeting our offer to low-uptake communities; to contain outbreaks by working with local partners to effectively contact, trace and reduce risk to the most vulnerable; and to promote vaccination through engagement and communication with GPs, teachers and trusted community leaders.
Baroness Merron (Lab)
My Lords, this is a grave yet preventable situation, especially as 80 countries across the world are measles-free while the UK has lost its status. I am sure that the Minister recognises that the Government should have read the warning signs and acted sooner to tackle vaccine hesitancy and low take-up. How will lessons be learned from the pandemic and used to focus on the communities, children and young people at greatest risk? Will a taskforce be established to co-ordinate relevant partners and oversee a rapid improvement to get to the WHO 95% target for take-up?
Lord Evans of Rainow (Con)
From 1 January 2023 to 30 November 2023 there were 209 laboratory-confirmed measles cases in England. Over three-quarters of those cases are from the West Midlands, predominantly Birmingham and Coventry. In the West Midlands, an NHS integrated care board system partnership group has been establishing and co-ordinating a regional response. Extensive local communications and engagement have been undertaken in the West Midlands alongside the immediate response to support the uptake of the measles, mumps and rubella vaccine. Nationally, the UK Health Security Agency has established an incident management team to oversee the public health response to the outbreak. The noble Baroness is exactly right: this country had a proud record on vaccination prior to Covid-19 but there has been a decline in recent years since the pandemic, and we have to do more to get back our status.
Deaths: Younger Age Cohorts
Debate between Baroness Merron and Lord Evans of Rainow(10 months, 2 weeks ago)
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Lord Evans of Rainow (Con)
I pay tribute to the noble Lord’s expertise in this matter. I cannot say that I am content, but I can say that the Government have improved the NHS health check, our national cardiovascular disease prevention programme, investing almost £17 million in an innovative new digital NHS health check to be rolled out from spring 2024, which is expected to deliver an additional 1 million checks in the first four years, and investing £10 million in a pilot to deliver up to 150,000 CVD checks in workplace settings. In the olden days, when we had manufacturing factories, the workforce had nurses who used to look after their health and well-being. Sadly, that is not the case these days and the Government are trying to replicate that in the workplace. But the noble Lord raised an important point, and I will take it back to the department so that I can be reassured about what he asked.
Baroness Merron (Lab)
My Lords, the Lancet found that deaths from cardiovascular disease among those aged 50 to 64 are one-third higher than over the previous five years. To what extent do the Government assess that this comes down to the relevant average ambulance response times being consistently above 30 minutes since the beginning of 2022? For those who are suffering heart attacks or strokes, how will the fact that the Government have now increased the target for ambulance response times help to ensure that lives are being saved?
Lord Evans of Rainow (Con)
The noble Baroness is absolutely right to raise this point. I am not aware of the significance of her point on ambulance times, but the NHS makes every effort, through rigorous contingency planning, to minimise the disruption. The ambulance service does a good job, but clearly it has to do more. I will write to her on the specific point about ambulance times.
Vector-borne Diseases
Debate between Baroness Merron and Lord Evans of Rainow(11 months, 1 week ago)
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Lord Evans of Rainow (Con)
The Government are doing exactly that and investing significantly into research. In terms of any private sector business that is looking into this, they should please contact me or the government department and we will work with them. If there is any research and development that we are not aware of, we are very keen to hear about it.
Baroness Merron (Lab)
My Lords, the analysis in the UKSA report referred to by the right reverend Prelate uses a high-end global warming scenario to represent a worst-case situation without mitigation and adaptation. Could the Minister advise how government planning is based on other scenarios at different rates of climate change? How are the agreements at the recent COP 28, and previously, expected to affect the conditions in which vector-borne diseases proliferate?
Lord Evans of Rainow (Con)
The short answer to that is that we cannot be sure. A noble Lord asked about London and the south-east: that is a worst-case scenario. It is predicted to increase in the second half of the 21st century. As I have said previously, we need to monitor it in 2023 and onwards. Certainly, the south of England is warmer than the north and north-west of England; we just need to monitor it. These are worst-case scenarios of these diseases coming into the country. It is right and proper that we monitor them, and that we monitor them at the ports of entry—but it is a worst-case scenario and it may or may not happen this century.
NHS: General Medical Practitioners
Debate between Baroness Merron and Lord Evans of Rainow(1 year ago)
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Lord Evans of Rainow (Con)
I am grateful to my noble friend. I am aware of the Armed Forces scheme—that if you train as a pilot, for example, you cannot leave the Royal Air Force to become an airline pilot. It is not the first time that this question has been asked, and I will feed it back to the department.
Baroness Merron (Lab)
My Lords, the Royal College of GPs reports that 40% of its members consider their premises not fit for purpose, something that is not addressed by the workforce plan. As the £10.2 billion backlog in maintenance continues to worsen as capital budgets continue to be raided for day-to-day spending, what strategy do the Government have to ensure that patients can receive care in modern, safe and properly maintained buildings, particularly where an increase in GPs and primary care staff teams is being promised?
Lord Evans of Rainow (Con)
The noble Baroness is absolutely right. GP practices’ premises vary throughout the country but, as I said earlier, there is capital funding available for new practices. From my own experience, when GP practices merge it gives an opportunity for them to have a purpose-built building. When I was a Member of Parliament there was a very good example of that where four GP practices throughout the constituency came together to form an outstanding modern GP practice with a new GP practice building.
NHS Waiting Times: Long-Term Sickness Absence
Debate between Baroness Merron and Lord Evans of Rainow
Baroness Merron
To ask His Majesty’s Government what recent assessment they have made of the impact of NHS waiting times on the number of people off work due to long-term sickness.
Lord Evans of Rainow (Con)
My Lords, I first pay tribute to the noble Baroness for her work on the Board of Deputies of British Jews at this very difficult time. We are very lucky to have her in this place.
Cutting waiting lists is one of the Government’s top priorities. We consistently assess the size of waiting lists and progress in reducing long waits. We are delivering our elective recovery plan and have virtually eliminated two-year and 18-month waits. The most clinically urgent patients continue to be treated first. We are working with the Department for Work and Pensions to understand and explore solutions to the impact of elective waits on economic inactivity.
Baroness Merron (Lab)
Before responding on the Question, I thank the Minister for his kindness, his generous comment and his support for the Jewish community and others at this time.
An all-time high of more than 2.6 million people do not have jobs because of ill health, including long Covid, while the CQC has found that two in five people admitted to hospital for planned care had their health worsen while they were on the waiting list. So does the Minister accept that ever-lengthening waiting lists and difficulties in accessing treatment are affecting people’s livelihoods as well as the economy? How do the Government plan to address this?
Blood Donation
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
I am grateful to my noble friend for her question and for describing her particular circumstances; I thank her for her donations. I will take her specific case back to the department and respond in writing.
Baroness Merron (Lab)
My Lords, last October included the first ever amber alert on blood stock shortages. More than 325,000 people registered to give blood; however, only one in four of those has attended an appointment since, and only one in five has donated blood since. Have the Government investigated why the numbers registering have not translated into blood donations? What steps are being taken to ensure that people not only register but follow through to make a donation?
Lord Evans of Rainow (Con)
I am grateful to the noble Baroness, who raises a very good point. Yes, there was an amber alert in 2022, when blood stocks fell below two days. That is not the case any more; stocks are currently at the target levels of six days. As the noble Baroness said in her very good question, some people register but either do not attend or attend for the first time only. The department is looking at the reasons for that, but that is why it has a thorough marketing campaign to write to people using social media. In my own case, I remember being telephoned on several occasions to go to donate. It is not easy and straightforward; I cannot say to the noble Baroness that there is a magic wand to prevent people registering but not turning up. This is a case of constantly keeping social media and marketing campaigns going to make sure that we get new donors. We need a new generation of donors; the average donor is, like me, over 45.
Metastatic and Secondary Breast Cancer
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
I bow down to the noble Lord’s expertise on this. What I said is that I did not have the answer at the Dispatch Box and that I would take the question away and report back to the department so that the noble Baroness can get a fulsome answer.
Baroness Merron (Lab)
My Lords, the number of breast screenings fell below acceptable levels in the years ending March 2021 and March 2022, when uptake at first invitation fell to under 50% across England for the first time. While this might be expected given the impact of the pandemic, what assessment have the Government made of the backlog and its implications, and what remedial steps are they taking to increase screening rates and decrease the cancer risk for women?
Lord Evans of Rainow (Con)
The noble Baroness is absolutely right. The Government are increasing the available sites for screening. In terms of specific details, I will come back to her in writing. We have expanded facilities across the United Kingdom to make sure that screening sites are readily available in local communities.
Drugs: Supply and Availability
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
My noble friend raises a very important point. Social media has a detrimental effect on the health and well-being of young girls—celebrities latch on to these things and it goes viral. The prescribers, whether NHS or private, are accountable for their prescribing decisions. They are expected to take account of appropriate national guidance. It is for the responsible clinician to work with their patient and decide on the course of treatment, with the provision of the most clinically appropriate care for the individual always the primary consideration. We will always work with clinicians to ensure that these drugs are prescribed as safely as possible, alongside specialist weight-management services.
Baroness Merron (Lab)
My Lords, a recent survey by the Pharmaceutical Journal listed serious shortages over the last year in the availability of treatments for common conditions, including menopause symptoms, high cholesterol, high blood pressure and osteoporosis, such that pharmacists were unable to provide the necessary medication. What assessment has been made of the effect of medicine shortages on people with those conditions? Does the Minister share my concern about the associated impact of these shortages on the NHS, in pressures as well as increased costs?
Lord Evans of Rainow (Con)
I share the concerns of the noble Baroness. Medicine supply problems can occur for a number of reasons, and occasionally the NHS experiences shortages of specific medicines, which may be temporary and localised. We want to assure people that the department has well-established processes to prevent, manage and mitigate medicine shortages. The noble Baroness mentioned HRT. There are 70 hormone replacement therapy products, and the vast majority are in good supply. There have been issues with the supply of a limited numbers of HRT products, primarily due to a very sharp increase in demand, but the supply position for the majority of HRT products has improved considerably over the last year.
Health: Economic Inactivity
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
The noble Lord is absolutely right to talk about data and how we can learn from it. It is currently difficult to quantity the direct effects of this, but it is indeed a factor. Data on employment rates suggests that those awaiting treatment were often already inactive before Covid, and it is therefore possible that longer waiting lists may be exacerbating this. But the noble Lord raised a good point, and I agree with him: that is what the Government will be doing, because it is important to take each patient on a case-by-case basis, rather than a one-size-fits-all approach.
Baroness Merron (Lab)
My Lords, ONS data shows that, for every 13 people working, one is suffering long-term sickness—a record number of people not in work due to ill health. So could the Minister commit to expanding and tailoring specialist help for those who cannot re-enter the workplace due to long-term ill health? What preventative provision will be made to tackle the increase in mental health issues in young people and the increased incidence of back and neck pain, which are major contributors to the unprecedented numbers of people who are unable to work?
Lord Evans of Rainow (Con)
New investment in the Spring Budget broadens access to additional work-coach support for disabled people and those with health conditions, it introduces a new supported employment programme and it focuses on providing faster access to joined-up work and health support, including for mental health and musculoskeletal conditions—the two leading causes of economic inactivity due to long-term sickness. But the noble Baroness raises an important point: the Covid period exacerbated all of this, and the system is under pressure. As I said in my earlier answer, the best way to do it is to take each patient on a case-by-case basis to ensure that there is help and support into work. Jobcentre Plus is doing an amazing job on that, working with the health service.
Secondary Metastatic Breast Cancer
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
The department has committed an additional £8 billion from 2022-23 to 2024-25, on top of the £2 billion elective recovery fund and the £700 million targeted investment fund already made available to the NHS. The Autumn Statement 2022 provided additional funding of £3.3 billion, and £3.3 billion for 2024-25, to support the NHS in managing the pressures that it faces.
Baroness Merron (Lab)
My Lords, modelling from Cancer Research UK shows that the number of cancer cases in the UK is projected to rise by as much as a third in the next 15 years. As it takes 15 years to train an oncologist, a pathologist, a radiologist or a surgeon, can the Minister assure the House that the Government’s very long-awaited workforce plan will give transparent and ambitious projections for 10, 15 and 20 years into the future, to reflect the time it takes to train the cancer specialists that patients need?
Lord Evans of Rainow (Con)
The target within the cancer workforce plan of more than 4,000 staff members for 2016 and 2021 was exceeded by 226, with an annual growth rate of the cancer workforce of 3% to 4%. The Government have committed to publishing an NHS long-term workforce plan for the next 15 years, covering doctors, nurses and other key professionals. This should be published in spring 2023. In 2023-24, NHS England will continue to make investments in education and training to increase capacity in the cancer and diagnostics workforce, building on the £81 million invested in 2022-23.
Brain Tumours
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
I thank my noble friend for that question. I was indeed running the London marathon yesterday and took note of all the wonderful cancer charities, including those that my noble friend mentioned, as they were running past me—which is an indication of how slowly I was going. They were going a lot quicker than I was. However, the serious point is that the London marathon is a wonderful British institution that raises millions of pounds for charity, and an awful lot of cancer charities benefit from it.
Baroness Merron (Lab)
My Lords, I congratulate the Minister and others in this House on their efforts yesterday and pay tribute to the tireless work of the Tessa Jowell Foundation. It deserves our support for how it presses home the need for urgent improvements in treatment research and training to combat the rising devastation of brain cancer. However, while survival rates for glioblastoma are shockingly poor, and the numbers are described as an epidemic, this still is not enough for a business case to encourage companies to test new drugs. How will the Government encourage longer-term investment and action to develop new drugs, and will the Minister act to increase the numbers in clinical trials?
Lord Evans of Rainow (Con)
I thank the noble Baroness, who is right to point out that the number of people surviving brain cancer has not moved in recent years. I assure her that the Government are doing all that we can. The money is there. Working with the charitable organisations, we must attract more projects and investigations on this very complicated and difficult disease.
Medical Devices and Equipment
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
I thank my noble friend for his question. The Government’s medtech strategy, published in February, will support medical device manufacturers by recognising the importance of domestic production to support resilience and identify practical support. The good news that was articulated in the Budget last week can only add to that.
Baroness Merron (Lab)
My Lords, rising cost pressures affect not only the supply of medical devices and equipment; spiralling costs are also threatening the supply of drugs in the UK, particularly generic medicines. What assessment have the Government made of how many drug companies they expect to exit this market altogether due to lack of profitability? What assessment have they made of the impact on patient care and NHS finances if the NHS has to pay an increasing amount for a smaller range of drug options?
Lord Evans of Rainow (Con)
When agreeing contracts with healthcare manufacturers that stipulate fixed pricing the manufacturers have full opportunity to account for the inflationary pressures of their tenders. NHS Supply Chain has established processes, where suppliers can apply for price increases due to exceptional circumstances. It has accepted price increases where they were justifiable, and it continues to consider such requests.
HIV Transmission
Debate between Baroness Merron and Lord Evans of Rainow
Lord Evans of Rainow (Con)
I thank my noble friend for that question. We know that the HIV prevention drug PrEP is extremely effective at preventing HIV transmission. We are developing a plan to improve access to PrEP for key groups and in settings outside of sexual health services, as part of our HIV action plan commitments.
Baroness Merron (Lab)
My Lords, I too pay tribute to the late Baroness Masham; she will be much missed for her work and effectiveness not just in this area but in many others too.
Following on from the Minister’s answer to the last question, I think we all acknowledge that the great game- changer in the prevention of HIV is the cheap and simple drug PrEP. However, there is a major problem with prescription, particularly for those trying to access it for the first time. What assessment have the Government made of the incidence of HIV because people cannot easily access PrEP? Will the Minister look at extending the prescribing of HIV prevention drugs beyond hard-pressed sexual health clinics to other sources, including GPs and community pharmacies?
Lord Evans of Rainow (Con)
The noble Baroness raises a very important point. PrEP is now being commissioned as a routine service, and PrEP funding has been fully included within the public health grant, which will benefit over 80,000 people at the highest risk of HIV. But I do agree that having access through GPs would be helpful.