National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) Regulations 2019

Baroness Thornton Excerpts

Monday 10th June 2019 Lords Chamber

Moved by

[Baroness Thornton]

That this House regrets that the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) Regulations 2019, in the rate increase that the National Health Service pays to care homes to cover the costs of services, include an unrealistic “efficiency expectation” of 3.1 per cent that may lead to further shortfalls in social care funding; and further regrets that Her Majesty's Government still do not have a long-term funding package for social care, which is urgently needed to alleviate financial instability in the care home sector (SI 2019/789).

Relevant document: 47th Report from the Secondary Legislation Scrutiny Committee

[Baroness Thornton (Lab)]

My Lords, first, I declare my interests as outlined in the register.

If ever a statutory instrument were crying out to be discussed on the Floor of the House, this one must rate pretty highly for a number of reasons, not least the instability in this sector and the lack of, and disgraceful delay in bringing forward, a long-term strategy for the social care sector. I might do the parliamentary equivalent of a scream if the Minister uses the words “soon” or “imminent” with regard to the strategy.

The somewhat dry words of a statutory instrument, particularly this one, conceal a reality—the lives and security of people for whom we have a responsibility as a society, as family members and in our communities, and this is the reason for my Motion to Regret. Each threat to a care home that houses the oldest and most vulnerable people in our community means, literally, that people will die. They will die when they are moved or they will become ill from the stress of not knowing what the future holds for them or where they might end up living. They wonder whether the people who look after them will be kind and caring.

At the beginning of Carers Week, this seems an appropriate debate. Carers care for their loved ones in their home, but there are also many carers who support their loved ones in residential care when caring at home becomes impossible and too demanding, particularly for older carers.

This instrument increases the rates that the NHS pays to care homes to cover the costs of services that must be carried out by a registered nurse, called the FNC rate. As noble Lords know, accommodation and social care costs are the responsibility of either the local authority and/or the individual, subject to the outcome of a needs assessment and financial assessment.

The 4.7% increase this year is influenced by the outcome of a Supreme Court case on the Welsh FNC rate and by a subsequent review by LaingBuisson. Information about this is helpfully included in appendix 1 of the Secondary Legislation Scrutiny Committee report that goes with this statutory instrument. The rate that has been set includes a 3.1% “efficiency expectation” of nursing home providers. Given the recent reports in the press about financial instability in the care home sector, it begs the question of how realistic that assumption is. These changes took effect on 26 April 2019, rather than 1 April as is usual, and the Department of Health and Social Care published a statement on 5 April saying:

“The findings of the study were delayed, following requests to improve the robustness of the data collected and an increase to the sample size of surveyed nursing homes. With an overall budget of approximately £675m for NHS-funded Nursing Care in 2018-19, any changes to the NHS-funded Nursing Care rates have significant financial consequences for both the NHS and nursing home providers”.


The background to the additional information that the Department of Health and Social Care has provided is that in August 2017 the Supreme Court ruled against the Welsh local health boards on how they had set the FNC rate in Wales. The administration and operation of the Welsh FNC rate is separate from the rate in England. However, the basis for FNC in legislation is very similar in Wales and England, and the judgment of the Supreme Court also impacts on how the Secretary of State for Health and Social Care must set the FNC rate in England.

The Supreme Court judgment set out an expanded definition of what constitutes nursing care by a registered nurse and stated that the FNC rate should pay for the costs of everything within that definition—that is, direct and indirect time on nursing care; paid breaks; time receiving supervision; stand-by time; and time spent on providing, planning, supervising or delegating the provision of other types of care which in all the circumstances ought to be provided by a registered nurse because they are ancillary to, closely connected with, or part and parcel of the nursing care which the nurse has to provide.

That definition is being applied to the FNC rate in the context of the LaingBuisson study, which has shown that FNC costs have continued to increase at a sustained and above-inflation rate since the last full study of FNC in 2016. Since 2016, the pay component of the national tariff has been used to apply inflationary uplifts to the FNC rate, so it is believed to be appropriate to accompany this with an efficiency factor. I fail to see how that is justified.

I thank the department for that explanation. However, I looked in vain for a sign of any upgrading for the care staff who work in care homes. Of course, there is none. Why is that? When do the care staff who carry out such important and personal work get the pay, training and recognition that they deserve? When will the funding for residential care be resolved? How can the NHS long-term plan possibly be delivered if the funding of social care is not also resolved?

The truth is that the UK is running out of care home places and care home operators are collapsing. The Guardian published an article on 6 June detailing concerns about care homes collapsing under financial pressure and the impact that this is having on vulnerable people. The British Geriatrics Society has warned that,

“soon there will not be enough”,

care homes,

“to look after the growing number of vulnerable older people needing specialist care”.

More than 100 care home operators collapsed in 2018, taking the total over five years to more than 400 and sparking warnings that patients in homes that close down could be left with nowhere to go but hospitals, and we know what that means in terms of costs and bed blocking.

Three out of five MPs say that people in their constituencies are suffering because of cuts to social care, with three-quarters saying that there is a crisis in care in England. That is according to a recent poll by the NHS Confederation, which leads Health for Care, a coalition of 15 organisations. In other words, there is a rising demand for social care but the cost of care is rising far more quickly than the money that local authorities pay for it. In some cases that money is being cut and in many others it is not rising at all.

The Association of Directors of Adult Social Services has shown that councils had £700 million of social care cuts planned in 2018-19, despite growing demand. I do not see how that is consistent with the regulations before us today. Major operators to suffer financial difficulty include Four Seasons Health Care, which was put up for sale after rescue talks failed, seven years on from the high-profile collapse of Southern Cross Healthcare. It was reported that a care home which was part of Four Seasons Health Care had left a patient without medication for two days.

These are our most vulnerable members of society and we have a duty to care for and protect them. However, they are being let down by an underfunded sector that is under constant and growing strain. Care England has called for the Government to put more money into social care to avoid a shortage of beds in a sector that provides care and accommodation for more than 400,000 residents. The future of funding for the sector is due to be laid out this year in a much delayed government Green Paper intended to address a £3.5 billion shortfall expected by 2025.

So, with care homes already crumbling under the pressure of an underfunded sector, it becomes a greater concern that the increase in charges may exacerbate the existing situation. There is concern that these charges will leader to further shortfalls in social care funding. Furthermore, these regulations come at a time when there is a lack of clarity surrounding the long-term care plan, which is needed to alleviate financial instability in the care home sector. Can the Minister confirm the impacts that these regulations may have on an already struggling care home sector? How do the Government plan to keep people in appropriate care settings with the recent care home closures, and when will we see an appropriate care plan? I beg to move.

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, I open with an apology for the state of my voice. I shall do my utmost to make myself heard and make it to the end of my speech. If I do not manage to answer all the points made, I shall write not only to the two noble Baronesses who have raised questions but to all those present in the debate, and will place a copy of that letter in the Library.

I would also like to identify myself with the points raised by the noble Baroness, Lady Thornton, regarding Carers Week, and to pay tribute to all those carers in this country who make tremendous sacrifices for those they care for. We should all thank them for the work they do. Our system would not cope without them; we should all be very grateful.

I turn to the questions that have been raised. NHS funded nursing care is of course an incredibly important part of the health and care system, supporting the provision of nursing care in nursing homes. The NHS funded nursing care rate plays the important role of ensuring that neither individuals nor local authorities have to pay for nursing care, which is the responsibility of the NHS. My department is seeking to ensure that nursing home providers are paid a fair rate for employing registered nurses, so that nursing care can be provided to all who need it. On the point that was just raised, it is helpful to know that the average pay for registered nurses in the independent sector has now risen from £23,400 to £29,400, so that is the benchmark we are talking about.

The noble Baroness, Lady Thornton, raised the issue of the nursing care rate for 2019-20, which my department set in regulations in April. This was done, as she said, following the LaingBuisson report into the costs of providing NHS funded nursing care to nursing home providers, after further consideration by my department. Following this work, the rate has increased by 4.7%, which is a significant increase above inflation, as has been recognised. The efficiency expectation, which is regretted in tonight’s Motion, should be seen in the context not only of this above-inflation increase but in the context of the significant increase of 40% which came in 2016-17; that is part of the picture that the efficiency expectation was put in place to address.

It is only right at a time of continued and much-needed investment into nursing home providers—ensuring they are able to employ and retain registered nurses—that the Government and the NHS also expect those providers to deliver as efficient a service as possible and value for money to the taxpayer. The 4.7% increase in the nursing care rate for 2019-20 is a far larger increase than that being seen in the vast majority of prices across the wider public sector and NHS; this is because of the priority that we have set on that rate. For example, the NHS national tariff is increasing the majority of prices in the NHS by 2.7% for 2019-20. The national tariff has also asked most NHS providers to make efficiencies of 3.1% across 2018-19 and 2019-20, and the Government believe that while still getting an above-inflation increase, nursing home providers should be able to do the same.

The LaingBuisson report provided evidence showing that many nursing home providers are already delivering nursing care more efficiently than others, so there is variability in the system. The study shows wide variation in the cost of delivering nursing care, even when factors such as region or provider size are taken into account. Efficient providers surveyed were shown to deliver an hour of NHS funded nursing care for 18% less than others. Additionally, the study showed that nursing home providers are increasing their use of agency nurses, as has been discussed. An hour of agency nursing costs 47% more to providers, and so, obviously, to the NHS. We believe that providers can work to reduce the proportion of their workload covered by agency nurses, as we have required other parts of the NHS to do, in a sustainable way.

There is a need to ensure value for money in important NHS services and to maintain their sustainability. The Government believe that efficiencies can be made in relation to the rate this year—for example, in the use of agency nurses. However, this is still within the context of a significant and above-inflation increase to the nursing care rate. That is why we think that the rate set is achievable.

The noble Baroness, Lady Thornton, also raised the important issue of the need for a long-term funding settlement for social care and financial sustainability for the sector, as she has on more than one occasion in this Chamber. The Government have already given councils access to around £10 billion of additional dedicated funding for social care over this spending review period. This includes a £240 million adult social care winter fund for 2018-19, and again for 2019-20, to help local authorities. It is the biggest injection of funding for winter pressures that councils have ever received. As a result of the measures the Government have taken, funding available for adult social care is increasing by 8% in real terms from 2015-16 to 2019-20. Councils have responded by increasing their spending on social care, so the money has gone where it was supposed to, which is always encouraging.

Local authorities were also able to increase the average fees paid for older people’s residential and nursing care by 6.4% in 2017-18, which we believe brought more stability to the market. When we look into the detail of the figures we see that, while there has been a reduction in the number of care homes, the overall number of social care beds has remained broadly constant over the last nine years, with an increase in nursing beds and care home agencies. As in any market, there will be inevitable entries and exits of care organisations, but we feel that there is some consistency. It is more reassuring than it may appear on the surface.

As we have also discussed, social care funding for future years will be settled in the spending review, where the overall approach to funding of local government will be considered in the round. We are also looking ahead to ensure that the social care system is sustainable in the longer term so that we can continue to deliver as our society ages. This is why the Government have committed to publishing a Green Paper at the earliest opportunity, setting out proposals for reform.

I hope I have answered the majority of the questions raised by the noble Baronesses. If I have failed to respond to anything, I hope they will allow me to write.

[Baroness Thornton]

I thank the Minister for that answer. I am not completely convinced about the stability of the care home sector. I think we have some major problems coming down the line. Of course, like the noble Baroness, Lady Jolly, I welcome an increase in payment for nursing staff, because that is absolutely essential. However, we have to take seriously the issue of social care staff who work in homes or a domiciliary setting. They do not get the attention or esteem they deserve, or the training they need, and they are certainly not paid sufficiently, yet we still expect them to deliver the best possible service. This statutory instrument is not the place where that can be solved, but it amplifies the challenges we face here.

On that basis, I thank the Minister for getting through that answer without completely losing her voice. We heard everything she had to say. I beg leave to withdraw the Motion.

Motion withdrawn.

People with Learning Disabilities

Baroness Thornton Excerpts

Thursday 6th June 2019 Lords Chamber

Asked by

[Baroness Thornton]

To ask Her Majesty’s Government what action they are taking to address the treatment of people with learning disabilities and complex needs in in-patient units; and what plans they have to provide adequate, alternative community support.

[Baroness Thornton (Lab)]

My Lords, the Minister will be aware that this Question was prompted by the BBC “Panorama” programme shown immediately before the Recess and the statement made by the CQC at the same time. I thank the Library, Mencap, YoungMinds, the Royal College of Speech and Language Therapists, and others for their briefings. I also thank the noble Lords taking part in this short debate.

The “Panorama” programme was shocking. You have to wonder what the owners of Whorlton Hall, Cygnet Health Care and the CQC were doing in previous years; they were certainly not looking in the direction of, or carefully enough at, the care of some of the most vulnerable people in our society. The programme revealed conduct and attitudes almost medieval in their cruelty and ignorance. The fact that it took place somewhere that should have been safe and caring is shaming for all of us. The BBC’s undercover filming appeared to show patients with learning disabilities being mocked, intimidated and restrained. We know that 10 workers have since been arrested and that the health watchdog—the CQC—has launched a review, led by David Noble, into how it handled a 2015 report raising concerns about Whorlton Hall hospital. It beggars belief that although the former Care Quality Commission inspector Barry Stanley-Wilkinson flagged up the potential abuse of patients four years earlier in an as yet unpublished report, it took an undercover programme to reveal what was going on in the home. It is even more unbelievable given that the site had at least 100 visits by official agencies in the year before the abuse was discovered.

Of course, this is not for the first time. Since the 2011 Winterbourne View abuse scandal—also revealed by a BBC “Panorama” programme—Ministers have promised repeatedly to move such people out of unsuitable secure units and into community care, yet the number of adults with autism and learning difficulties locked up in ATUs fell only slightly over the past three years, while the number of children in them has more than doubled. Last year, there were 28,880 restraint incidents in England alone.

The Transforming Care programme has taken many forms since 2012: the initial two-year targets were missed and a new lead was appointed but resigned. After two critical National Audit Office reports, two Public Accounts Committee hearings and various other reports, NHS England and partners wrote Building the Right Support. Eventually, a three-year programme for 2016-19 was announced, with three aims: to develop new community support and services; to improve the quality of care in in-patient settings; and to reduce the number of people with learning disabilities and/or autism in in-patient settings by between 35% and 50% by March 2019. The programme failed to deliver these aims. By March, at the end of the programme, bed numbers had decreased by only 19%. What is the Government’s response so far? It is true that NHS England included that target in its long-term plan. However, that has simply moved the delivery date, with NHSE now aiming to meet the target in five years’ time. That is not good enough.

It is also true that, in the meantime, the Secretary of State commissioned a CQC review of seclusion and restrictive practices in response to numerous media exposures of poor practice. The recent interim report reveals the widespread use of restraint and restrictive practices in in-patient units for people with learning disabilities and/or autism. In May 2019, a damning report from the Children’s Commissioner highlighted the shocking treatment of children in these places and the lack of community support leading to their admission. This very sorry tale reveals a lack of leadership, ability or preparedness on the part of the Government to effect real change for this most vulnerable cohort of our fellow citizens.

The truth is that, seven years on from Winterbourne View, the system continues to sanction an outdated and wrong model of care. If people are contained in institutions a long way from home, awful things seem to happen behind closed doors. Can the Minister tell the House whether the Secretary of State now takes personal responsibility for closing down institutions that provide the wrong model of care? Why does the CQC continue to register new institutions that offer inappropriate institutional care? Does the CQC need new powers? What lessons must we learn from the fact that the CQC rated this place “good”? Is this another case of whistleblowers not being listened to? How much was Cygnet Health Care charging the NHS per week for this awful abuse and neglect?

This horror came in the same week as the damning CQC report on segregation, an equally scathing report by the Children’s Commissioner and the LeDeR—the learning disabilities mortality review—report confirming the extent to which people with learning disabilities and autism are fatally failed by our system. Does the Minister accept that we are tolerating widespread human rights abuses? Surely families want not another review but action to protect their loved ones. Many of the people abused at Whorlton Hall were hundreds of miles from their families. Does the Minister recognise, and will she commit to the fact, that cutting people off from their support networks allows such abuse to carry on without anyone noticing?

The Government’s inadequate response to this matter is deeply shocking. There is agreement among experts in this field, including many health and social care professionals, that robust community support and leadership across government is needed to ensure transformation. Most recently, but still six months ago, Sir Simon Wessely’s report— Modernising the Mental Health Act: Increasing Choice, Reducing Compulsion—was published. It included a number of positive proposals meaning that children and young people would be treated in hospital only when absolutely necessary and clarifying their rights to be involved in—and challenge—decisions about their care. I agree with YoungMinds when it says that it is,

“concerned that essential reforms to improve the quality and type of support for young people with complex needs and mental health conditions could be further delayed or put at risk”.

On its behalf and that of thousands of young people and their families, I have some questions for the Minister. When will we see the Government’s response to the Wessely review recommendations? When will we see a new mental health Bill? When will the Secretary of State for Health and Social Care grasp the nettle and drive forward cross-departmental work and joined-up NHS and social care support? Only proactive and strong leadership from the top will unlock the systemic blockages stopping people from moving out of in-patient settings and back into their communities.

Mencap proposes four actions that should inform the Government’s action programme. First, it proposes increasing cross-departmental leadership, accountability and oversight through a commitment from the Secretary of State for Health and Social Care to convene and lead a new, cross-departmental ministerial group with the Minister for Children and Families and the Minister for Housing, Communities and Local Government. It states that referring the Transforming Care programme to the inter-ministerial group on disability, as the Government previously suggested, is wholly inadequate given the attention that the programme requires, so it will not be effective. Secondly, it proposes a commitment from the Secretary of State to ensure that learning takes place from the independent evaluation of the Transforming Care programme, and that this leads to new and credible implementation plans across health, social care, housing and education. Thirdly, it proposes pooled and ring-fenced funding to build high-quality, specialist support in the community. The buck-passing between health, education and social care has to end, with budgets pooled and focused on getting the right outcome for the person by intervening early so that children get the right support and adults have the right adapted housing and specialist staff support they need. Finally, it proposes co-production with families and individuals with lived experience. The regulator, specialist practitioners and commissioners should drive forward workable solutions, but not without the lived experience of children and adults with a learning disability, as well as of their families.

Finally, I have to raise the question of who owns, runs and profits from these homes. Julie Newcombe, a mother who—as she puts it—“rescued” her son and set up Rightful Lives, said:

“There is a huge conflict of interest within the private sector because heads on beds equals money in the bank, which means profit becomes the ultimate barrier to discharge”.


Last November the Mail on Sunday published an article, “Profiteers of Misery”, lifting the lid on the profits made by private companies that run establishments such as Whorlton Hall. We need to discuss and raise the issue of the conflicts of interest—with which, of course, we are very familiar through our recent consideration of the MCA Act.

Universal Health Services—whose former CEO, I think, is Simon Stevens, now the head of NHS England—is a huge US healthcare firm snapping up British psychiatric services. Its British operations are run by Cygnet Health Care, the owners of Whorlton Hall. Cygnet Health Care boasted in recent accounts of earning revenues from 220 NHS purchasing bodies and almost doubling its profits to £40.4 million in the last year. Will the David Noble inquiry look at the issues this raises—underpaid and inexperienced staff—and ascertain what the occupancy rates were and whether patients were being kept longer than was needed, ultimately to boost the profits of Cygnet and its US parent company, Universal Health Services?

Food and Feed Hygiene and Safety (Miscellaneous Amendments) (EU Exit) Regulations 2019

Baroness Thornton Excerpts

Tuesday 4th June 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I congratulate the Minister on her explanation of this statutory instrument. We are of course back in the territory of whether there will a deal or no deal. Even more bizarrely, this will depend on the machinations of her party over the coming weeks and on who ends up as our Prime Minister. It is a bit surreal really, much like the parliamentary world we inhabit at the moment.

Earlier this year, as we approached the Brexit deadline of 29 March, we were regularly rushing through statutory instruments. It is just as well that the Prime Minister was able to secure a Brexit extension because, if we had left on 29 March, some of the so-called minor deficiencies that emerged with regard to food and feed safeguarding, which we are discussing today, might have turned out to be major quite quickly.

Crashing out of the EU means that the regulatory framework for food and feed, which has protected us in the UK for so many years, will cease to exist. I can see that the proposed amendments are critical to ensuring minimal disruption of food controls in the event that we leave the EU without a deal, and we on these Benches will support them. The changes seek to ensure a robust system of control which will underpin UK businesses’ ability to trade both domestically and internationally.

The first question I have concerns trichinella, a parasitic nematode worm which can be extremely serious and can cause disease in people who eat raw or undercooked meat from trichinella-infected domestic animals or game. I appreciate that this instrument provides assurance that testing requirements that ensure protection will continue after EU exit. However, is the Minister confident that we have enough capacity in this country to continue testing for that worm and its associated health risk? How quickly can the government put in place our own testing facilities? I would be grateful if the Minister could tell the House how much extra resource her department has allocated to make sure that we do not allow a loss of control in this area. I am aware that extra funding has been made available to the FSA to deal with Brexit, but the Minister could help the House by being specific about the amount of extra resource that would be available to ensure that those particular nematodes do not infect meat that might be imported into this country and eaten by people here. I am aware that the Minister in the Commons, Seema Kennedy, offered to write to my honourable friend Angela Eagle about this matter. Did she do so and can the letter be made available here?

The instrument states that facilities approved by EU member states would in future no longer be automatically approved for food imported from the UK. I repeat the question that my honourable friend Sharon Hodgson MP asked in the Commons: does the Minister know what impact that will have on supply and businesses? How long will the process be to approve facilities for food imported from the UK, and when will a list of approved facilities be available?

The instrument also includes provisions to set minimum charging rates for hygiene controls for fishery products by amending, as the noble Baroness said, the Fishery Products (Official Controls Charges) (England) Regulations 2007. Will the Minister outline what the charges will be and what impact any new set rates could have?

The Explanatory Memorandum for the statutory instrument states that functions currently undertaken by the European Commission in adopting some implementing regulations rendering applicable the controls on imported food will in future be the responsibility of the Secretary of State. Can the Minister provide information on how decisions on those controls will be made and managed? What will the arrangements be for collecting data monitoring the effectiveness of the regulations and for regularly reporting the findings? What bodies will be able to scrutinise performance and delivery? What assessment has been made of their capacity to take on that work, as my honourable friend Angela Eagle mentioned in the Commons?

Finally, what conversations has the Minister had with the devolved nations regarding this statutory instrument? Although the issues seem fairly technical, and potentially innocuous, they raise a few worries. This is about food safety, safety for consumers, consumer protection and food supply in general. Should we leave the EU European Union, a range of duties will transfer from where they have been carried out in the past for many years, in the EU, not just back to the UK but to four different bodies due to devolution, one of which is not even sitting at the moment because of what has been happening in Northern Ireland. So will the resources be available in the devolved authorities to cover these issues?

My honourable friend Angela Eagle said in the Commons:

“Despite the Minister’s attempts to engage with some of my questions, I am still not entirely sure whether this is irradiation of things such as collagen, which in specific instances is derived from animals for human consumption, or whether it is about more general irradiation of meat and vegetables that are for public consumption, which happens in the US”.—[Official Report, Commons, Third Delegated Legislation Committee, 13/5/19; col. 9.]


I agree that the answer the Minister in the Commons gave begged more questions, so let us have another go. That is probably appropriate today, when the President of the United States of America has made it clear that all our regulatory regimes will be on the table and up for negotiation, along, of course, with the NHS.

It is important to remember that the horsemeat scandal was not discovered by the enforcement processes in this country, but by testing in the Irish Republic. So we are right to be concerned that, post Brexit, things could go wrong due to weaknesses that have been created in our own enforcement system. I am looking for further reassurance from the Minister that the system we have, weakened by austerity and divided by devolution, will be robust enough to take on the extra duties that the Minister is adding through this statutory instrument.

[Baroness Walmsley (LD)]

My Lords, I too thank the Minister for outlining all the technical details of this SI. Of course, this instrument has been withdrawn from the Order Paper twice before. Some of the changes made since we originally saw it are small but crucial. We are lucky that they have been spotted, but that raises concerns for the industry that there may be others. Now that the leaving date has changed, are the Government planning on conducting additional scrutiny on the other SIs that are being rushed through this House to make sure that they are up to scratch? How do the Government intend to convey these changes to the relevant individuals and companies on whom they will impact?

I add my support to the question asked by the noble Baroness, Lady Thornton, about the capacity of the FSA. This is probably about the 16th time that we have asked the same question and we are still concerned about the capacity to replace all of the other measures.

Some of these changes reflect very recent EU law that has come into force, as the Minister mentioned, so what do the Government intend to do about any new EU law that might come into force between now and 31 October or whenever we happen to leave? Will these SI and the ones that preceded them have to be further amended if there are other changes to EU law?

The Minister mentioned that the system for minimum charging rates for hygiene controls of fishery products is somewhat out of date. Will the Government confirm whether they aim to change the pound-euro exchange rate from the 2008 level at which it is currently set? Although these charges, as we know, are rarely levied by local authorities, any change in the exchange rate, which could happen after Brexit, could have a big impact on the ability to pay of those against whom the charge is levied. We saw a big difference in the rate of the pound against the euro after the 2016 referendum, and the way in which we might, unfortunately, leave the EU, could have a similar serious effect on the exchange rate. What are the Government planning to do about those charges if there is such a big change in the exchange rate? Are they planning to bring it up to date from 10 or 11 years ago?

Mental Health of Children and Young Adults

Baroness Thornton Excerpts

Thursday 16th May 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I congratulate my noble friend on bringing this important debate to your Lordships’ House. It is of course appropriate that we are having it during Mental Health Week, as my noble friend Lord Haskel said at the beginning of his remarks. Indeed, he is quite right: we have been on a mental health journey in this country over the past 10 to 20 years. My noble friend described most eloquently the issues facing students and others with mental health problems. I should like to address the scale of the challenge we face.

I start with a shaming aspect of this challenge. Some 22 children have died suspected self-inflicted deaths while admitted to mental health hospitals and in-patient units in the past five years. My noble friend Lord Giddens spoke more widely about the tragic issue of suicide and related behaviour. Figures released by the Department of Health and Social Care show that four patients aged under 18 have died already in 2019, matching the highest number of fatalities in any previous year.

A Sky News investigation reveals that poor care in privately run child and adolescent mental health services units is putting vulnerable young people at risk. Patients, parents and whistleblowers have shared their experiences of privately run facilities paid directly by the NHS to care for some of the most challenging mental health patients, including those with serious eating disorders and those engaged in persistent self-harm and suicidal behaviour. One former patient told a story of the brutal physical restraint she had experienced, and of how she had been able to inflict life-threatening self-harm while in a privately-run unit. She said, “I would rather have been dead than alive in that place”. Former staff at another facility run by the same company until it was closed last month, described the culture of self-harm as “out of control”, and alleged that employees were directed to downplay serious incidents. Sky News revealed that a former member of staff at a third unit, also now closed, is subject to a police investigation.

These children are often placed in units many miles from home and family because of a shortage of appropriate services in their area. In 2017-18, NHS England paid private providers £156.5 million for specialist mental health services, which is 44% of its specialist budget. Inspection reports compiled since 2016 for 60 CAMHS units show that 88% of the NHS units were rated good or outstanding, while just 58% of those run by the largest private recipients of NHS funding were rated good. No privately run unit was rated outstanding, five were rated inadequate, and, since 2017, five have been closed.

First, how acceptable does the Minister think this is? Does she think that the NHS is getting value for money from these units? What is the incentive to make these young people well, given that the duty of the private units is to their shareholders, which must mean keeping full occupancy? There is a potential conflict of interest here. Those of us who have recently been engaged on the Mental Capacity (Amendment) Bill will be familiar with this issue. I would like to know from the Minister what the safeguards are.

A recent FoI request by the Labour Party found that 1,039 children and adolescents in England were admitted to non-local beds in 2017-18 for NHS mental health treatment, in many cases more than 100 miles from home. Is it acceptable that patients from Canterbury in Kent were sent 285 miles for in-patient mental health care, those from Cornwall and the Isles of Scilly 258 miles, and those from Bristol 243 miles? What effect does the Minister think this has on the youngster and their family? If that family are on a low income, it might prove impossible to visit on a regular basis, or for them to know what treatment their youngster is receiving.

Let us look further at the scale of this challenge. As my noble friend Lady Royall said, three in four children with a diagnosable mental health condition do not get access to the support they need. Three in four: that is graphically illustrated by the narrative from my noble friend Lady Massey. CAMHS turn away 26%—more than a quarter—of children referred to them for treatment by concerned parents, GPs, teachers and others. The average waiting time is more than 26 weeks. In a YoungMinds survey, 76% of parents said that their children’s mental health had deteriorated while waiting for CAMHS treatment.

Therefore, is it surprising that the number of A&E attendances by people aged 18 or under with a recorded diagnosis of a psychiatric condition has almost tripled since 2010? This translates, for example, to a severely depressed or anxious young person being at home for several months, unable to go to school because they feel so ill, with all the strain that puts on them and their family, to say nothing of the education they might be missing. They may become even more severely ill, which could have been avoided had treatment been readily available.

As many noble Lords have said, this means a huge cost to our NHS. Can the Minister provide assurance that the Government’s forthcoming Green Paper on prevention will include measures to improve the promotion of positive mental health for children and young people? Given that one in six young people aged 16 to 24 have symptoms of a common mental health disorder such as depression or anxiety, how does the Minister’s department aim to address the specific needs of that age group?

My noble friend Lord Bradley and the noble Baroness, Lady Tyler, have approached the workforce issues more than adequately. It is concerning that the number of doctors working in child and adolescent psychiatry has fallen every month since the beginning of 2018. There are serious societal problems that need addressing because of our children’s growing mental health issues. My noble friend Lady Morris gave us a great message of hope, but children who have had the most difficult and complex starts in life, experiencing abuse, neglect, bereavement, discrimination or poverty, are more likely to have mental health problems as they grow up. A study by SafeLives showed that 52% of children who witness domestic abuse experience behavioural problems in later life.

At a time of austerity, rising personal debt and precarious work, we are all encouraged to be individuals and not rely on anybody. Society perceives us to have failed in life and look weak if we do. There is a narrative that many people choose to be on zero-hours contracts. Then there is the gig economy. All these things put stresses on families, which puts stresses on our children. It is not only a well-funded NHS that we need. It is no accident that countries with stable welfare systems and school systems that do not focus on endless testing have good records on workers’ rights. That, surely, is where we must aim to be.

I thank my noble friend Lady McIntosh for her brave and honest speech. I too watched Nadiya Hussain yesterday, and was very moved by her story. I also thank my noble friend Lord Bragg for reminding us of the change we have seen and the reducing of stigmatisation, and my noble friend Lord Layard for asking very pointed questions about money, which is where I wish to end my remarks.

One of the key targets in the Five Year Forward View for Mental Health is to go from 25% of CYP to 35%. That still leaves 65% not receiving access, which is not good. I am so pleased that my noble friend Lord Bradley shared his huge experience with the House. He got to the nub of it. Research by YoungMinds demonstrated that only 14% of STP plans at local level showed evidence of engagement with children and young people. Can the Minister provide assurances that integrated care systems will be required to consult young people about the services that affect them, as part of the implementation of the NHS long-term plan?

[Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, I thank the noble Baroness, Lady Royall, for introducing this debate and giving us the opportunity to discuss such an important issue during Mental Health Awareness Week. She spoke movingly and importantly. We have had an extraordinary debate today, with many personal reflections; it is an incredibly valuable contribution to this week. I also thank those who have asked the huge range of questions which I am now tasked with trying to respond to in less than 20 minutes. I hope your Lordships will forgive me if I do not cover each one; I will write on those points I am not able to cover today.

The noble Baroness, Lady Royall, is absolutely right when she says that, unfortunately, it remains true that many young people who seek help for their mental health find it difficult to access the right support at the right time. This is wrong, and we need to work harder and faster to get it right.

I would like to start by responding to a point about data, made by the noble Lord, Lord Storey. We have recently improved the available data in two key areas, with a significant prevalence survey on mental health in young people that was done in 2018 with 9,117 children and young people aged between 2 and 19. It showed that the prevalence of mental health diagnosis has increased by 1.1% since the previous survey, and that 25.2% of young people with a diagnosable disorder report having been in contact with NHS mental health specialist services in the last year. This is important, because the previous prevalence survey was 10 years old, and during that period social media has intervened, which we expected to have had a significant effect. The CMO then did a review which created evidence-based guidelines on screen time—an important intervention. In addition, we have brought in the dashboard to track data at a local level and the implementation of various standards which we have brought in.

This is a huge improvement on the level of data and tracking that we have on mental health within the community and the performance of our mental health trusts compared to the last time I was in the post. Therefore, I would like to reassure the noble Lord on the point about data. It is not where we would like it to be, but it is still a significant step forward. I wanted to start on that, because you cannot talk about policy and where we are if you do not have the data to know about it. That is why I want to talk about where we have come to before I talk about where we need to go.

We are on track to meet the commitment to improving access that we made in the five-year forward view, and to have 70,000 more children and young people accessing treatment each year by 2020-21 compared to the 2014-15 baseline. We have introduced the first-ever access and waiting time standards for mental health services. For young people experiencing their first episode of psychosis, we have a target for early intervention to ensure that treatment begins within two weeks for more than 50%. Nationally, the NHS is exceeding this: over 75% of patients started treatment within two weeks in March 2019. We have also set a target for 95% of children and young people with eating disorders—which have been on the increase—to access treatment, with a one-week referral for urgent cases and four weeks for routine cases by next year. Nationally, we are on track to meet this, with the most recent data showing that over 82% of patients started routine treatment within four weeks. We need to pay tribute to those who work incredibly hard within the mental health system and are making some very difficult changes to achieve this, coming from what was a very low base. It is important to pay tribute to them for their achievements.

I would like to move on to some questions put to me by the noble Baroness, Lady Royall, about crisis care, before moving on to those from the noble Baroness, Lady Thornton, about out-of-area placements and the private sector. The noble Baroness, Lady Royall, is absolutely right that we need to improve access to crisis care for those young people who need it most. A commitment has been made that we will invest £400 million in 24/7 crisis resolution home treatment teams in every local area by next year, and £249 million in mental health teams in A&E departments to improve the system. The long-term plan makes a commitment to ensure timely, universal mental health crisis care for everyone, including young people, and to drive out the variability which we recognise exists for them.

We also recognise the concerns raised by the noble Baroness, Lady Thornton, about out-of-area placements. We have made a commitment that inappropriate out-of-area placements must come to an end. Where there are specialist cases, a young person will need to travel, but we want in-patient stays to be as close to home as possible and to avoid inappropriate stays. For that reason, we have introduced the accelerated bed scheme, which has already created 117 new beds, with 69 new beds on the way. This is being done to reduce variability of access to in-patient care, but we also want to reduce that care by bringing in more prevention and earlier access to lower-level care, such as that pointed out by the noble Lord, Lord Layard. I shall return to the point that he made.

We are very concerned about the recent reports of failings within mental health care, which the noble Baroness raised. She is absolutely right that all providers of NHS services, whether NHS or private, must abide by the same high standards. Where this is not the case, we are ensuring that the NHS looks into the circumstances and considers what action should be taken. Private providers play an important role in the provision of children’s mental health services, but these must be safe and of high quality. We have tough regulators to ensure that that happens.

I will move on now to the points made on early intervention by the noble Baroness, Lady Royall, and the noble Earl, Lord Listowel, who is not in place.

[Baroness Thornton]

He is there.

[Baroness Blackwood of North Oxford]

I apologise—perhaps the noble Earl is sitting low in his seat.

They are absolutely right that prevention and early intervention are crucial. We prioritised improving perinatal mental health when I was previously the Mental Health Minister for exactly that reason. The noble Earl put it so eloquently: it is vital for newborns to form that early attachment with their mother and father. We must also consider the role played by the wider family, as those on our own Benches have put it. From 2020-21, we have put in place increased access to perinatal mental health services in all areas for at least 30,000 women, backed by £365 million in funding, as part of the five-year forward view for mental health. The long-term plan will also go further, with a commitment to increase evidence-based care for women with severe perinatal mental health difficulties and a personality disorder diagnosis, to benefit an initial 24,000 women per year by 2020-21. That is reassuring, but we also need to ensure that it carries on beyond the early years and into the school years—a point made by a number of your Lordships.

I recognise the impatience surrounding the Green Paper, but I would like to clarify a few points. The commitment within the Green Paper is to have a pilot, for 25 schools in the first instance, but it is then to incentivise every school and college to identify and train a designated senior lead for mental health to create new mental health support teams in and near schools and colleges. We are starting by piloting so that we can work out what the best design is and then move it across to all schools. The idea is not to have variability but to drive it through the whole system. While I recognise the frustration with rolling out these proposals in a phased way, it is a very ambitious commitment. We need to recruit and retain a workforce numbering in the thousands for the mental health support teams alone. We cannot do that overnight, given that there are over 20,000 schools and colleges. To roll out a fifth to a quarter of these by 2022-23 is already a challenging target. We must ensure that we train that workforce in an appropriate way to meet the challenges they will face.

I will also respond to the eloquent words of the noble Baroness, Lady McIntosh, and the moving experience which she spoke of. She is right that I do not speak for the Department for Education, but the thing about being at the Dispatch Box is that I can say whatever I like; once I am up here, they cannot pull me down. As she said, I speak as a former music graduate of Somerville, and I believe strongly in the importance of the arts, and in particular music, for education and mental health. I back her entirely on its importance for social prescribing as well. I will advocate strongly for that in this role. I agree with the noble Baroness that it is extremely important that young people’s experience should be safe, inspiring and nurturing. We should all be pushing in our roles for more joy within our society.

I know that I will run out of time quite quickly, so I will move on. I would like to talk a little about the work we have been delivering for university students. This key aspect has arisen on a number of occasions, and I know that the mental health of young people in universities is vital. Noble Lords will be pleased to hear that NHS England and Universities UK are working together on a programme to support and improve mental health at universities through Universities UK’s StepChange programme, which calls on higher education leaders to adopt mental health as a strategic priority and to take a whole-institution approach to mental health. As part of this programme, the Government are actively backing the introduction of a sector-led university mental health charter, which will drive up standards in promoting student and staff mental health and well-being.

NHS England is also working closely with Universities UK through its mental health in higher education programme to improve welfare services and access to mental health services for the student population, including focusing on suicide reduction while improving access to psychological therapies. There is funding attached to this and I am happy to meet with the noble Baroness if she would like to discuss that further, as it is a vital part of the picture.

I will move on to the questions raised regarding stigma and social media, which are crucial if we are to have a preventive approach to the situation we find ourselves in. The noble Baroness, Lady Massey, and the noble Lord, Lord Bragg, spoke incisively on this issue. We are committed to eliminating the stigma around mental health and are providing £20 million in funding to the Time to Change national anti-stigma campaign, which has been hugely successful. As the noble Baroness rightly said, it involved high-profile individuals who cut through the noise that often comes at young people every day. The campaign aims to improve social attitudes towards mental health, including promoting the importance of well-being in all areas.

However, we should also think about one area that did not get aired within the debate, and that is those who face double stigma when they have a chronic condition. As I think was raised by the noble Baroness, Lady Tyler, there are those have learning disabilities and mental ill-health. It is challenging for them to navigate their way through the system. Public Health England is delivering a £15 million national health campaign called Every Mind Matters, with the aim to equip 1 million people to be better informed to look after their own mental health. This will be of huge benefit going forward.

It is important that we do not imply, in this place, that everybody who suffers from mental ill-health will end up in the criminal justice system. I do not believe that is the case.

I also point out that this Government have been committed to addressing the agenda of social media and the harms it can produce, even though it is beneficial in other areas when it is used as an effective tool. That is why the Secretary of State has not only taken this on as a personal commitment in the round tables he has held with internet companies, but we are also bringing forward the online harms White Paper. The noble Lord, Lord Haskel, was right when he said that we have to make sure this has teeth. That is why there are commitments to bring forward a new regulator under it and why the CMO brought forward recommendations on screen time.

None of this is relevant if we do not have the workforce and funding that we need. I am pleased that NHS funding for young people has increased. I was concerned to hear the noble Lord, Lord Bradley, and his comments about reduced funding. The information I have is that children’s mental health funding is increasing. It has gone up from £516 million in 2015-16 to £687.2 million in 2017-18. Planned spend next year is £727.3 million, an increase of 5.8% compared to the previous year. This will be monitored with the investment standard and dashboard. I am happy to follow this up with the noble Lord, but I believe that NHS funding for mental health is increasing and at a faster rate than overall NHS funding. We are tracking this and ensuring that local CCGs stick to that commitment. This transformative investment will ensure that more young people receive the mental health support they need.

I finally turn to the questions about suicide prevention, which was movingly spoken about by the noble Lord, Lord Giddens, and others. The noble Lord is right that we have an excellent suicide prevention strategy. It must be based on accurate data. It is challenging to ensure we have that data, but I have a great deal of confidence in Public Health England working with local authorities to ensure we raise the standards of that work. Understanding the reasons for suicide is complex. Suicides among children are relatively rare, but each is an appalling tragedy, so we must work with every ounce of our abilities to move forward and make that better.

I am proud that we recently increased the amount of research funding for mental health, by a record amount, to £74.8 million. This will play an important role in helping us understand the sources of all forms of mental ill-health, including those that drive individuals to suicide.

While I am sure that noble Lords feel there are other areas I could have covered, and would like answers to other aspects, I hope that, by pointing out the areas of rising investment today and that we are improving access and waiting times, I have communicated to you that the Government are genuinely working across all departments to ensure that we see this as a priority agenda. I have demonstrated that we understand that we still face significant challenges. While we are impatient for faster improvement, there can be no question of our commitment to a brighter, healthier and more joyful future for our children and young people.

I was deeply moved to hear the words of the noble Lord, Lord Bragg, his testimony of his own experience some years ago and how different he feels things are today. Each of us still feels frustrated by how far we still have to come and how many things we still have to deliver to give our children the services that they deserve. I cannot think of a better way to close than by repeating some of the comments that he gave in his speech. We are only as good as the way we treat the weakest among us. There is a long way to go, but we are now on the road. If we can make as much progress in the next 20 years as we have in the last 20 years, we can give young people the stigma-free lives that they deserve.

Learning Disabilities Mortality Review

Baroness Thornton Excerpts

Wednesday 15th May 2019 Lords Chamber

[Baroness Thornton (Lab)]

I thank the Minister for repeating the Statement. I just make the obvious point that the Government have had the draft report since 1 March, and if they had published it in a reasonable time it might not have leaked.

I am sure that we can all agree that people with a learning disability have worse physical and mental health than people without a learning disability, and that the Confidential Inquiry into Premature Deaths of People with Learning Disabilities found that the average age of death from different levels of impairment was between 46 and 67 years, which is massively below the average lifespan for those without a learning disability. I look forward to the report, which the Government have told us that we will soon see.

Will the Minister now say that it is always unacceptable for learning disability to be given as a reason for not resuscitating someone? For this programme to work properly, does she agree that it needs to be resourced so that it can consider all reported cases in a timely manner? I suggest to her that many families feel that the review is the NHS marking its own homework, and that what is required here is a truly independent national body to review the premature deaths of people with learning disabilities.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her important questions. On her first point, which is that the Government have had the report since March, I should like to be very clear that this is not a government report; it is an independent report from the University of Bristol. It is free to publish it when it is ready, although it was commissioned by NHS England, so the Government are not in control of the timetable for publishing it.

The noble Baroness is 100% right, however, on her point about “do not resuscitate” orders. The reports that we have heard that disabilities such as Down’s syndrome are being used by some doctors as a reason not to resuscitate are entirely unacceptable. We are taking immediate action and a letter will be sent to health professionals to make clear that that is not an acceptable reason to put in place a “do not resuscitate” order. On her last point about resourcing and the effectiveness of the LeDeR programme, progress has been made in implementing it: 15 out of 24 of the recommendations have already been completed, and in others we are making real progress. NHS England has trained more than 2,100 experts to carry out reviews, 1,500 reviews have been completed and a further 1,500 are in progress, but I have no doubt that given the situation in which we find ourselves, questions will be taken into account by NHS England and the department.

Tessa Jowell Brain Cancer Mission

Baroness Thornton Excerpts

Monday 13th May 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for repeating the Statement. Of course, it is a matter close to the hearts of many noble Lords here, particularly those of us who took part in the debate when Tessa Jowell spoke in this House for the last time. Who could forget Tessa’s determination to fight for change, so that in the future people would not die of brain tumours but that research would lead to prevention, early detection and more effective cures, and that these would be available to everyone throughout the NHS, without being dependent on where you live? I pay tribute to Jess Mills, Tessa’s daughter, and her family for their continuing commitment to fulfilling the challenge that Tessa set all of us, as the noble Baroness quite rightly said.

We know that brain tumours are indiscriminate; they can affect anyone at any age. What is more, they kill more children and adults under the age of 40 than any other cancer, yet historically just 1% of the national spend on cancer research was allocated to this devastating disease. We all welcome the progress made so far by the Government; we congratulate them and support the fact that treatments are now available across the country that were not available when Tessa spoke to us in this House. However, we also know that the NHS faces a cancer diagnostics crisis. Cancer Research UK has pointed to chronic shortages in the diagnostic workforce, with more than one in 10 positions unfilled nationally. Hospitals are reliant on outdated equipment and some of the lowest numbers of MRI and CT scanners in the world. The UK is fourth from bottom in a league table of OECD countries with the lowest number of CT scanners per million inhabitants.

As the Minister rightly said, this is a question of both resourcing and staffing. In today’s Statement, we have been given sight of the key points that have been touched on and we are pleased that it references the upcoming workforce plan. However, it would be useful if she could expand on this point, specifically around the need for a global scientific workforce and the plans for immigration in relation to the research community. Because without the right skills and technical staff in place, a lot of the research funding and momentum achieved in the past year will not amount to very much. She will be aware that a mix of domestic and international scientific talent underpins the UK’s position as a world leader in life sciences. The 2018 immigration White Paper was not fit for purpose, in the view of those on this side of the House. The £30,000 a year salary threshold would have had a devastating impact on the recruitment of junior research capacity and the increased cost and bureaucracy requirements of the visa system. Indeed, the British public recognise the importance of an international research workforce to the UK. Ninety per cent of the public think scientists make a valuable contribution to society and 86% want to increase or maintain the level of immigration of scientists.

While I absolutely accept that progress is being made in the noble Baroness’s department, this question applies across government and I should like some reassurance that that is understood and action is being taken. Neurosurgery is no exception when it comes to the problems of cancer targets. In March 2019, the 18-week completion target for referral to treatment pathways stood at 81.3% for neurosurgery, 5% lower than the average for all specialties. This made neurosurgery the worst-performing specialty, almost certainly because of staffing shortages in these areas. Therefore, while I absolutely welcome the Statement and the progress being made, we all have to accept that we have some way still to go to fulfil the ambition and the targets that Tessa Jowell set us.

[Baroness Jolly (LD)]

My Lords, I thank the Minister for repeating the Statement. I had the honour of responding to Baroness Jowell’s maiden speech on 23 May 2016. I looked it up in Hansard this morning. She recalled Seamus Heaney’s injunction to his wife:

“‘Noli timere’—‘Do not be afraid’”.—[Official Report, 23/5/16; col. 167.]

As it turned out, we did not have long to wait for her to show how fearless she could be. I responded to her maiden speech by saying that I felt sure she would make her mark very soon. Sadly, she did not have as huge an amount of time to make her mark as I had expected—but nobody who was in the Chamber for her valedictory speech in January 2018 will ever forget her demonstration of total fearlessness.

5-ALA received FDA approval for use in the USA on 3 July 2017, just over a year after Baroness Jowell joined your Lordships’ House. Use in the UK was given NICE approval on 10 July 2018, just two months after she died. I clearly welcome today’s announcement, but I have some questions for the Minister about 5-ALA and its rollout. What weight does NICE give to treatments that have received approval by the FDA? Is it usual for a treatment that is so obviously effective to wait nearly a year before being used routinely? Will it be universally available to all those who stand to benefit from it?

NHS: Shortage of GPs and Nurses

Baroness Thornton Excerpts

Wednesday 8th May 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

My noble friend is absolutely right, and he has his own expertise in this area. I am pleased to be able to report that we have had an increase in recruitment of nurses and NHS workers from abroad. Compared with June 2016, we have over 5,200 more EU health and care staff working in the NHS, and we have had a 126% increase in the number of non-EU NHS workers, which shows the attractiveness of working within the NHS. But he is also right that we need to make sure that those who work in the NHS have access to the most innovative and effective tools possible, which is why, particularly within GP practice, we are launching the GP IT Futures programme. That will provide GPs with the best tools possible so that we can make their job more efficient while also allowing them to provide the best-quality care to patients.

[Baroness Thornton (Lab)]

My Lords, I think I need to declare an interest as a member of a CCG; I spend some of my time surrounded by GPs, who are utterly wonderful, and who tell me that morale is not good. The problem is that a lot of GPs are leaving because they are completely fed up with the way that they have been treated by the NHS. That has to be taken account of by the noble Baroness, Lady Harding, as part of her work in bringing forward the plan, and I know it will be.

I am afraid that it does not say much about the current lack of a workforce strategy that we are having to trawl the world to get GPs and nurses to come and work in the UK. I know that other Members of your Lordships’ House have been worried that we are taking nurses, GPs and doctors from countries where they are very much needed. Will the Minister address how to deal with the morale of GPs, as well as the ethics of the UK recruiting nurses and doctors from countries where they are needed?

[Baroness Blackwood of North Oxford]

I slightly question the premise of the noble Baroness’s question, given that I am the daughter of an English doctor and a South African nurse. This has always happened in the NHS, and it is an absolutely acceptable process. Recruitments go back and forth between nations, and that has always been the case.

To move on to the noble Baroness’s question about morale in the NHS, particularly within general practice, it is essential that that is addressed, and she is right that GPs are the bedrock of the NHS now and in the future. That is why we have announced in the long-term plan not only that we are investing an extra £4.5 billion in primary and community care, which is at a faster rate than the rest of investment within the NHS, but the new contract to develop partnerships to provide greater certainty for GPs to plan ahead and to give them the extra 20,000 support workers who can make the job within GP practice more effective and sustainable. That is also why we have announced the GP IT Futures programme to give them the tools that they need to deliver more effective services and to deliver better-quality care, and why we have announced targeted and enhanced recruitment schemes to support and retain GPs within practices, not only in hard-to-reach areas but within the pipeline. That demonstrates that the Government are completely committed to general practice and will retain that commitment as long as we are able to do so.

Antimicrobial Resistance

Baroness Thornton Excerpts

Thursday 2nd May 2019 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, this has been a fascinating debate and revealed again the depth and breadth of the knowledge and passion your Lordships’ House has on this issue. I thank the noble Lord, Lord Lansley, for initiating the debate and the Library and many other organisations for their helpful briefings. I feel I should declare that I am a member of a CCG. I say that because it is rare to see a subject that is the victim of as many acronyms as the NHS, but this field certainly challenges that, combining as it does health, farming and the environment, the research and science communities, pharma businesses and international organisations. I was very grateful for the list of acronyms at the front of the Government’s five-year paper.

As noble Lords have said, we know that AMR currently results in 700,000 deaths globally every year, that by 2050 that could be 10 million, and that it threatens to turn back the clock on a century of medicine, rendering modern surgery, organ transplantation and chemotherapy too dangerous to use. Preventive treatment is needed, as the report says, to curb the spread of bacterial diseases requiring antibiotics. As the noble Baroness, Lady Walmsley, said, vaccines are the most effective preventive health tool in human history. We therefore need to expand the use of existing vaccines to have a better impact.

One of the most serious issues in the fight against AMR, which almost every noble Lord mentioned, is that no new class of antibiotics has been introduced for more than 30 years. Antibiotics are quite unlike any other category of drug, because every dose of antibiotics poses the risk of encouraging bacteria to adapt and develop resistance. That was illustrated by the noble Baroness, Lady Masham, in her description of the fight she has been having, which we have discussed on several occasions over the past year.

The Government’s five-year action plan is indeed an impressive document and a step along the road. I join the noble Lord, Lord Lansley, in saying that we may not be moving as quickly as we should. That has been echoed across the Chamber. Of course, it is not the complete solution, and serious questions have been asked in the debate. I join the noble Baroness, Lady Miller of Chilthorne Domer, in saying that the plan is disappointing in that it fails to give a clear commitment to incorporate into domestic law the European Union’s recently agreed legislation that bans routine preventive use of antimicrobials. It is a pertinent question at this point. Article 107.1 provides:

“Antimicrobial medicinal products shall not be applied routinely nor used to compensate for poor hygiene, inadequate animal husbandry or lack of care or to compensate for poor farm management”.


That is not being incorporated into UK law, as far as we can tell. I agree with the noble Baroness that the answers given to questions in the Commons were ambiguous, to put it mildly. Perhaps the Minister could take this opportunity to clarify the issue.

When I discussed the five-year plan with my noble friend Lord Winston, who regrets that he cannot join us this afternoon, he said two things to me. The first was that meeting this challenge will be well-nigh impossible given the dearth of lab, technical and science staff in the NHS at this moment. Secondly, he said that investment in research needs to be much greater and the follow-through more effective. My noble friend would have put those points more eloquently and, probably, more forcefully than I have, but neither of those issues is new; they have been articulated in your Lordships’ House over a long period.

Part of the NHS long-term plan talks about the delivery of the five-year plan we are discussing today. Will the staffing review address technical staff, of which there is a terrible shortage? They are essential for the delivery of both the NHS long-term plan and this plan. We know that the issue of research is not just about funding to deliver ground-breaking research. The UK does a great job in training PhD students, but loses a lot of talented people because the post-doctoral period is so unstable. We need continued support for interdisciplinary networks to strengthen research and develop capacity. Does the strategy address that issue as robustly as the emergency that we are facing requires?

Many noble Lords mentioned market failure, which the noble Lord, Lord Lansley, dwelled on in his opening remarks. According to Professor Dame Sally Davies, the reason for that is in part that the easy wins have been made and there is now a fundamental failure of the market for new antibiotics. Given the growing threat of AMR and the need to conserve and use current and future antibiotics carefully to preserve their effectiveness for as long as possible, it is clear that pharmaceutical companies are aware that any new antibiotic they bring to market will be prescribed only very sparingly rather than as a first-line treatment during its patent life, thereby reducing its profitability. I found that idea very dispiriting because it seems that we must address market failure. The report of the noble Lord, Lord O’Neill of Gatley, also recognised and addressed this issue.

That is even more discouraging when one realises that, over the past five years, we have seen pharmaceutical companies withdraw further and further from the development of antibiotics. In June last year, the latest company, Novartis, exited the market, bringing the total number of companies involved in antimicrobial drug development to six. The issues of market failure and disinvestment are incredibly important; therefore, the Government’s scheme to delink the price paid for antimicrobials from the volume sold is also crucial.

Even more depressingly, Professor Dame Sally Davies argued that the industry needed to step up and act in a socially responsible way, pointing out that tackling AMR was also in its interest. In her evidence to the Commons Select Committee, whose report I found extremely useful, she said:

“I am disappointed by the number of them”—


pharmaceutical companies—

“who have said quietly over a drink, ‘Well, Sally, we know you’re going to solve this. The Government will have to pay, so we’re waiting until you pay’”.

Where is the social responsibility? What terrible short-sightedness. To go back to the point about losing modern medicine, what is the point of developing the world’s greatest cancer portfolio if there are no antibiotics to rescue the patients? Yet industry expects us in government and the public sector to fund this, or that it will happen through somebody else being corporately responsible.

This market failure might lead to catastrophic consequences, as referred to on pages 74 and 76 of the five-year plan. It rightly states:

“The UK cannot solve such market failures alone”.


I question that because I should not like to think that the idea that we cannot solve this alone because we are 3% of the world market means that we do not try to do things in this country to turn this round. Our NHS has huge purchasing power: it pays billions of pounds to pharma, which makes billions in profit from these sales, for the drugs and treatments we need. We must have some leverage here. I ask the Minister: if a UK university or small pharma company found a new antibiotic, surely our Government would find a way to make sure that it was developed and brought to market. They would not wait for this to happen on the world stage, would they? I really want to hear that we will not have a repeat in the UK of the situation described in the MRC report, as referred to by the noble Lord, Lord Lansley. I received that report; the story of Achaogen was a graphic one of market failure in developing a new antibiotic. However, the noble Lord did not ask something that I wish to ask: what will happen to that drug? Achaogen developed a drug that can treat the most serious superbugs; therefore, it is not much needed so the company did not make enough money and went bankrupt. Where has that drug gone? What has happened to it? That is an important question.

[Lord Lansley]

As I understand it, the company is up for sale so, effectively, people would buy the patent and the drug.

[Baroness Thornton]

Let us hope that the people who buy it are public-spirited enough to know that they need to develop it and that that can be done. That puzzled me when I read the fascinating article, which I recommend to noble Lords. I thought, “A new antibiotic is out there and it is not available to us, for goodness’ sake”.

I congratulate the Government on the five-year plan. It is important, however, that the impetus behind it works, that the incentivisation schemes unlock investment in AMR, that we do not face the same issues being faced in America, and that implementation of the plan is speeded up.

NHS Funding: Mental Health Services

Baroness Thornton Excerpts

Wednesday 1st May 2019 Lords Chamber

[Lord Bradley]

To ask Her Majesty’s Government what proportion of the additional money allocated to the National Health Service budget over each of the next five years will be ring-fenced for the development of mental health services.

[Baroness Thornton (Lab)]

With his consent, I beg leave to ask the Question standing on the Order Paper in the name of my noble friend Lord Bradley. Noble Lords will know why he cannot be with us today, and the House will wish to know how much he and his family appreciate the sympathy that has been expressed.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, NHS England and NHS Improvement have set out their commitment to increase mental health spending by at least £2.3 billion in real terms between 2018-19 and 2023-24. In five years, this will represent over 10% of NHS England’s additional settlement. More details of how the long-term plan will be resourced will appear in the implementation framework, which is due to be published soon.

[Baroness Thornton]

I thank the noble Baroness for that Answer. Given that mental health illnesses account for 28% of the burden of illness in the NHS but receive only 13% of its funding, I find her Answer very confusing. Can she be more precise? This is not just about the number of staff required but about how much will be required to achieve parity of esteem and over what period.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness, Lady Thornton, for her question on behalf of the noble Lord, Lord Bradley. I am sure that the whole House will want to join me in sending him and his family our support at this difficult time.

The noble Baroness has asked a very important question. The mental health budget will increase by £2.3 billion by 2023-24, growing faster than the wider budget. We are using transparency to drive improvements. The mental health dashboard shows that last year, for the first time, all CCGs met the mental health investment standard, which is an encouraging sign. This builds on the work done in the five-year forward view, which delivered real improvements for patients. It delivered £247 million for liaison psychiatry, £290 million for perinatal services and £400 million for crisis resolution and home treatment teams. However, we will not rest there. The long-term plan will deliver much more for patients, including 345,000 more children and young patients to receive specialist support services. This is the ambition that we have and the ambition that we will deliver.

National Institute for Health and Care Excellence (Miscellaneous Amendments) Regulations 2018

Baroness Thornton Excerpts

Wednesday 1st May 2019 Lords Chamber

[Baroness Thornton (Lab)]

I thank my noble friend for bringing this matter to the Floor of the House and for leading this short discussion. I too have many questions for the Minister but many of the questions that I would have asked have already been asked by my noble friend and the noble Baroness, Lady Jolly. It seems that our concerns are very similar. I agree with the noble Baroness, Lady Jolly, that when I read through the notes accompanying this regulation, it seemed puzzling that the consultation had produced a majority against this process, and I too was not completely convinced by the Government’s justification. That must lead to something which we can probably call cuts and wanting to save money. To want to save money with an organisation which is so integral to our NHS infrastructure and so important to ensuring the efficacy and cost benefit of and access to medicines and procedures is not a sensible way to proceed.

Some of my other questions centre around a concern about the impact that these charges will have on the jewel in the crown that is the UK-based science industry, particularly at a time when there is already such uncertainty with the dual impact of Brexit and these charges. It seems that the additional costs for a market may diminish the UK’s attractiveness for life science businesses, which has already been mentioned, and may also mean that NHS patients get access to new therapies later than those in other countries across Europe, which my noble friend also alluded to. Has there been an assessment of the impact of these charges on the UK bioindustry and its attractiveness to the international life science community, and of the UK as a location to research, develop and launch innovative medicines?

What will be the impact on patients? The UK BioIndustry Association has stated its concerns that the charges for technology appraisals could either prohibit or delay patient access to medicines in England. This could result in inequalities across the UK, as medicines may be available in Wales and Scotland, where charges for technology appraisals have not been introduced, before receiving approval for use on the NHS in England. That might disproportionately affect patients with very rare conditions, and therefore might also undermine the UK rare disease strategy to ensure equity of access across all four nations of the UK. Have the Government considered not only the financial impact but the potential impact on patient health? Do the Government have a strategy in place to mitigate delays in patient access to medicines that may come from these charges?

I join the noble Baroness, Lady Jolly, in asking whether there will be a review of the impact of this proposal, when that will take place, and when we will learn about the impact of this proposal on NICE and the NHS infrastructure. That will be important. We need to review this, because I fear that it may be a wrong decision.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

I thank all noble Lords who have contributed and congratulate the noble Lord, Lord Hunt, on securing this debate. It is an important subject and it is right that we take time to consider it. I know that he takes a keen interest in NICE’s work from his previous role as the first Minister with responsibility for NICE, and it is a privilege to have taken on his mantle some years later.

This year marks a significant milestone for NICE, as it celebrates its 20th anniversary, during which time it has transformed the way in which decisions are made in the health and care system. I echo the comments made by the noble Baroness, Lady Thornton, who referred to NICE as a jewel in the crown of the UK life sciences ecosystem. She is absolutely right that we must ensure that we not only protect it but promote its success. Since its inception, NICE has played a vital role, not only in securing maximum value from health spending but in ensuring that patients are able to benefit from rapid access to effective new drugs and other treatments. The noble Lord, Lord Hunt, hit the nail on the head when he said that that balancing act in the health system is so challenging.

Of course, the NHS is required to fund the treatments recommended through NICE’s technology appraisals and HST evaluation programmes, so that they can be provided if a patient’s doctor says that they are clinically appropriate for the patient. Over the past 20 years, more than 80% of NICE’s recommendations have supported use of the technology assessed, meaning that many thousands of patients have benefited from rapid access to effective new treatments. A less-frequently reported statistic is that 75% of HST applications have also gone through, which is encouraging.

Recent IQVIA research has just been published which showed that, despite some of the frustrations we have with update and access—which is something we are working hard on—the UK is in fact one of the fastest countries in Europe to get products through its regulatory system. We can be very proud of that, and must protect it.

I know that your Lordships will agree not only that it is extremely important that we have a system such as NICE in place to ensure the NHS spends its money in the most effective way possible, but also that it is critical that NICE operates on a sustainable footing so that it continues to be responsive to developments in the life sciences sector, to which noble Lords all referred.

To date, as has been mentioned, NICE’s TA and HST programmes have been funded through government resources but, as is common with government bodies, it is right that NICE considers how to operate to the utmost efficiency, and that those who stand to benefit from services contribute.

This is standard procedure and a standard model for many organisations and ALBs such as NICE. It is standard for the MHRA, the HTA, the CQC and for HTAs in other countries, so we are not operating an unusual procedure here, as the noble Lord, Lord Hunt, mentioned. I was grateful for his support for the charging model.

However, recognising the need for sustainability must be balanced with the imperative to encourage innovation, and the Government and NICE believe that the most appropriate and sustainable model for NICE’s TA programmes in future is for it to levy a proportionate charge on companies that benefit directly from its recommendations. This goes right back to a recommendation of the triennial review of NICE in 2015, so long-term work has been going on in this area. Recognising the importance of getting it right, the Government consulted on the draft regulations. That consultation has been referred to by noble Lords. At that point, as part of those proposals, the Government proposed the 25% discount for small companies. The consultation also sought views on a proposal to enable NICE to recruit appeal panel members engaged in the provision of healthcare in the health services across the UK instead of just England. This has not been mentioned and I know is widely supported, but I just wanted to point out that fact, which we are very pleased about.

As was raised by the noble Baronesses, Lady Thornton and Lady Jolly, there were 78 responses to the consultation, around half of which represented views from the life sciences industry, including pharma companies, industry representatives, consultancies and medtech companies. Other responses came from patient groups, NHS organisations and individuals. Although, as has been said, the majority of respondents—62%—disagreed with the specifics of the proposal to charge companies for making recommendations, the analysis showed that just over half of respondents agreed that life sciences companies should contribute to the cost of developing NICE recommendations, which is why further work was done to develop the charging proposal but refine it.

Respondents also supported, by 59%, a mechanism for reducing the impact on small companies, but felt that the proposed 25% discount did not go far enough. Other more specific concerns were raised about the potential impact on patient access to new treatments, in particular for rare diseases, the impact on NICE’s independence, and the analysis contained in the impact assessment.

The SLSC also picked up on issues in its report, and I will address some of those in response to points raised by the noble Baronesses, Lady Thornton and Lady Jolly. The Government considered the issues raised in the consultation very carefully and carried out further analysis to feed into the final impact assessment. We concluded that it was appropriate to make two main changes to the policy in light of the consultation responses. These particularly dealt with concerns about the design of the charging with respect to SMEs. I know that noble Lords are well aware of those concerns.

There is an increased discount for small companies of 75%, to minimise barriers to the participation of small companies wishing to bring forward new products. I realise that many feel that that did not go far enough but, to address that concern, it also included the new power to enable the Secretary of State to direct NICE in specific cases to calculate charges on what it considers to be the appropriate commercial basis. This provides more flexibility for amending charges, should that be required in future, subject to consultation with stakeholders. For example, we may see different types of innovation, including devices or digital products going through TA programmes, and this provides flexibility for the Secretary of State to direct NICE to propose charges at a level appropriate to those markets. I think that responds to the point raised by the noble Lord, Lord Hunt.