NHS: Healthcare Data

Baroness Walmsley Excerpts

Thursday 6th September 2018 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I thank the noble Lord, Lord Freyberg, for introducing this important debate and congratulate him on his masterful tour d’horizon in his speech. I support his demand for a national strategy on this issue—we must not be left behind. I also very much enjoyed the maiden speech by the noble Lord, Lord Bethell; as I sat here, I found myself musing on whether he would follow in the temperance footsteps of his grandfather or the non-temperance footsteps of his father. I look forward to hearing a lot more from him.

As we have heard, the NHS has the most enormous amount of valuable data that could be used for improving patient care in a large number of ways; to me, that is the most important objective. First, data can help healthcare providers to measure their performance against baseline standards and against best practice in other similar providers. It can alert us to problems with patient safety and emerging quality problems. Digging into the detail of data can often reveal where providers are failing and suggest solutions—I shall give an example of that later. Data can assist regulators and inspectors to reach their conclusions. It can inform clinical decisions, through what it reveals about efficacy and outcomes, and can influence commissioning decisions through what it reveals about cost-effectiveness and the effects of strategies on public health. It can be used to assist research and to plan and assess clinical trials, and can help agencies to plan and reconfigure services.

The noble Lord, Lord Kakkar, mentioned the importance of the quality of data. He told us about the massive amount of it, which made me wonder how accessible that data is to researchers—if it is not easily searchable, it will be like looking for a needle in a haystack, in the same way as the doctor, mentioned by the noble Lord, Lord Bethell, looks through his pile of paper files.

We have heard about many issues of concern. First there is patient consent and privacy, about which the noble Lord, Lord Hunt, was so eloquent. We have heard about the need to prevent exploitation and discrimination from the right reverend Prelate the Bishop of Southwark. We have heard concerns about how data is made available to commercial companies, how value can be realised and about the ownership of private data by a few large corporations. The noble Lord, Lord Mitchell, asked us to maximise that value and he is absolutely right, but there need to be enormous safeguards. I very much agree with him that the NHS, too, needs experts. Without them, the experts in the big data companies will, as he put it, “crawl all over us”.

A transparent public dialogue is needed about how data is currently used, the opportunities for the future and how risks can be managed. It is vital to balance the benefits of sharing data, which are enormous, with concerns about security and confidentiality, but these concerns should not be a barrier to progress. Many noble Lords have mentioned the crucial need to rebuild patient trust following the care.data problems and recent massive leaks—most recently, this was mentioned by the noble Lord, Lord Macpherson.

According to the Royal College of Physicians, patient-level data containing patient characteristics, as well as information about treatments, pathways and outcomes, are the most valuable. Indeed, such data can also reveal inequalities in access to care and the quality of care provided to different groups; it can also help to make comparisons of outcomes from different providers fairer, when we know something about the case mix they face. How fit the patient is at the point of diagnosis and how advanced the disease is at that point are important factors when comparing the outcomes achieved by different clinicians and healthcare settings. But such data should be anonymised or pseudonymised wherever possible to avoid identification of individual patients.

One can also get a lot more out of data if information about the patient can be linked to healthcare activity and outcome information; this requires different systems to talk to one another, which is particularly important in end-of-life care. But this is where the NHS currently falls down. However, I was pleased to learn from a recent briefing by the NHS Confederation, which represents private healthcare providers, that steps are being taken to integrate their datasets with those of the NHS; this will mean patients and the NHS can get a full set of information in one record. On a point made by the noble Baroness, Lady Rock, I was told recently by Simon Stevens that the NHS is no longer the world’s biggest purchaser of fax machines; he was rather indignant when I mentioned that.

There are many examples of where data can be used successfully to improve patient services. Some studies have also been able to motivate settings to improve their track record when linked to payment incentives—a sort of payment by results. This was done as a result of the National Hip Fracture Database. A number of notable national reviews have had tremendous effects on outcomes—such as the National Review of Asthma Deaths, which shockingly found that that a quarter of deaths resulted from inadequate care—which can then be addressed. The Sentinel Stroke National Audit Programme included patient input to help improve services resulting in the establishment of the very successful hyper-acute stroke units in London and Manchester, a model now being copied across the country.

One issue that concerns me is the amount of data available to the patient and how it could help patients to manage their own healthcare. We cannot expect patients to engage with doctors in taking steps to manage their own condition if we do not give them feedback about whether changes they make in their lifestyles result in better health. For example, I would like to know the exact readings for the good and bad types of cholesterol in my own blood tests, so that I can see whether my lifestyle changes are helping. When I asked the question, I was told, “It’s fine—keep on with the medication”. That is no help to me when I am trying hard to get to a position where I do not need the medication at all. I agree with the frustrations of the noble Baroness, Lady Neville-Rolfe, on this matter. Like her, I think we should be able to see our own medical records; we should be able to trust the patient with them.

I also look forward to the day when, living in Wales, I will be able to make appointments and ask for repeat prescriptions online, as my relatives in Scotland already can and my relatives in England will be able to next year. That, however, will require a major step forward in technology, which I do not see on the horizon.

This morning I came across a perfect example of how data can help to improve services. I hosted a round table at which we heard about research into the issues relating to local authorities missing targets for chlamydia screening. Chlamydia is an increasingly common sexually transmitted disease, which can cause major health problems including infertility. There have been several changes, and indeed reductions, in the funding for this screening. Initially the money went to local authorities, which are responsible for public health, as a dedicated grant, and then it became integrated with other funding. Finally, the funding has now dried up altogether and the National Chlamydia Screening Programme simply monitors how well targets are being met and supports local authorities. Unsurprisingly, the targets are not being met, following a year-on-year decline. In 2017, only 20% of commissioning councils achieved the Public Health England target of 2,300 annual diagnoses.

The research that I heard about this morning was qualitative. It sought to collect data on various aspects of the difficulties that councils face with a view to proposing how things can be improved. It turns out that, although funding is a significant issue, public awareness is one of the greatest barriers that councils need help with. They would like more national resources to help them develop local marketing programmes to let people know about the dangers of chlamydia and about the screening and services available to them locally. They also need technical help with targeting the most at-risk groups. I thought it was a good example of where digging deep into the data can help to improve services. I am pleased to know that Public Health England is soon to publish a review on this and all other sexual health matters.

So my questions for the Minister are as follows. What progress is being made on integrating patient data from all health and care settings and making the records available to patients? What measures are being taken to give patients trust and confidence in their data being properly handled? How will applications for outside use of NHS data be handled and against what criteria? Finally, is funding being passed to the Welsh Government to enable patients in Wales to benefit from the technological advances that are already available in Scotland and are soon to be available in England?

Obesity

Baroness Walmsley Excerpts

Wednesday 18th July 2018 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I thank the noble Lord, Lord McColl, for bringing us back to this important subject, and I welcome the noble Baroness, Lady Boycott, to your Lordships’ House.

Travelling on the Tube yesterday in the middle of the afternoon, I sat opposite a gentleman who took up two seats. His stomach was protruding out of his shirt. He looked very uncomfortable, and he was eating a pasty. I thought, “Sir, this is not good for your health”. It took me back to an occasion soon after I entered your Lordships’ House when I sat down at the long table in the Home Room with a plate of salad. A former, very personable Member of the House sat next to me, looked at both our plates and started to laugh. She said, “Oh look! The slim lady is eating salad and the fat lady is eating sausage and chips”. I was too polite to say, “Well, yes, don’t you think there’s a connection?”. Of course, the noble Lord, Lord McColl, is right. What matters most is what we eat and drink.

Many clinicians now feel that it would help to regard obesity as a disease. We would then be less judgmental and recognise that many people suffering from it have been conditioned since childhood to respond to sugary or carbohydrate-rich foods, with those foods then becoming a need. The gentleman on the train is probably one of them. They need help and services, not judgment, and those must include mental health services. For some, one of the services needed is bariatric surgery, with a multidisciplinary team to help them return to a healthy body weight. I talked recently to an eminent paediatric bariatric surgeon. He told me that the service he provides is not widely available and yet it can save the lives of his patients and reduce the eventual costs to the NHS. Therefore, I ask the Minister what plans are in place to make this service available wherever it is needed. Of course, it is a last resort for very serious cases, and I want to emphasise that the surgeon I spoke to spends a great deal of time working with public health services to prevent people becoming obese in the first place. Prevention, I believe, is the key.

I was interested in two items on the news this morning which chimed exactly with what I wanted to say today. First, there was new guidance from Public Health England’s Scientific Advisory Committee on Nutrition about the number of calories that should be consumed by young babies. It was reported that many are consuming far too many calories and this is laying the foundation for obesity later in life. We were reminded that exclusive breast-feeding, at least for the first six months of life, lays the best foundation for health, not just because of the many antibodies and good micro-organisms passed on from mother to child but also because breast milk is perfectly balanced nutritionally and has just the right number of calories for healthy growth. Therefore, I call Public Health England in aid when I ask the Minister what is being done to encourage more mothers to breast-feed—we have a bad track record in this country—and to ensure that they can do so comfortably wherever they need to do it.

The second news item was about the Football Association saying that many days of play are prevented because of the state of the pitches. This is because of years of underfunding of local authorities, which cannot afford the necessary upkeep. As my noble friend Lord Addington told us, what we eat may be a major part of the obesity problem but keeping active is also vital. Incidentally, it is also important for mental health. A senior tutor at an Oxbridge college told me recently that, of all the students coming forward for counselling for mental health problems, not one took part in regular sport. She found that very significant and I am sure she is right.

However, my main concern is with young children. We have had the statistics from the Royal College of Paediatrics and Child Health, and I join its demand that there should be a 9 pm watershed ban on advertising on TV foods that are high in sugar, salt and fat. I am pleased that chapter 2 of the childhood obesity plan promises a consultation on this. I am quite sure that the evidence will show that the majority of TV watched by children is not children’s programmes, which already have a ban, but family viewing between 6 pm and 9 pm. If your Lordships are looking for evidence that advertising these foods influences people’s choices, they have only to look at how much the food companies spend on it. The noble Baroness, Lady Boycott, reminded us of that. They would not do that if it did not work. People are influenced by messages that tell them how delicious these foods are and how happy they will be if they eat them, so I hope the Minister will assure me that when the Government get this evidence in the consultation, they will act decisively.

NHS: Equitable Access

Baroness Walmsley Excerpts

Thursday 5th July 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Baroness for her Question and join the whole House in wishing many happy returns to the NHS on its 70th birthday. She asked an extremely good question: how do we make sure that the NHS is equipped for the future and that everybody can benefit from the technological advances we are seeing take place? I point her in the direction of three issues. First, the National Institute for Health Research has more than £1 billion of funding and supports the translation of research into new technology every day. It is based in the NHS and uses NHS staff. I have also recently commissioned the department to look at the money spent on innovation, which we think is around £750 million in total, to make sure that it supports the uptake of effective medicines and treatments better than it does today, and to make sure that staff have time. Finally, in response to her last question, as we set out during the passage of the withdrawal Act, we will align ourselves to the clinical trials regulation as much as possible, whatever the outcome of Brexit.

[Baroness Walmsley (LD)]

My Lords, as a member of the Parliament choir I am a bit tempted to start singing, but I will resist. Given the remarkable success of the various vaccination programmes during the 70-year history of the NHS, will the Minister say when preventive measures for two modern-day diseases will be made equitably and nationally available? I refer to pre-exposure prophylaxis for HIV, which has already been shown by the trials to be remarkably effective, and vaccination against human papillomavirus, which should be made available for teenage boys as well as teenage girls to ensure full protection.

[Lord O'Shaughnessy]

I am sorry that the noble Baroness has not started singing; I am sure that we would have all joined in. As she rightly said, the NHS carried out the first major public vaccination programme in the world. We have always led the world in vaccination programmes. As she said, prophylaxis has been deemed to be successful; I will need to write to her on the specifics of the rollout. On the HPV vaccine and its availability for boys, we are still waiting for the final recommendations of the joint committee on vaccinations. We will act on those as soon as we get them.

Cannabis-based Medicines

Baroness Walmsley Excerpts

Thursday 21st June 2018 Lords Chamber

[Lord O’Shaughnessy]

I will pass on my noble friend’s thanks to my right honourable colleagues. We agree with him that there is a very clear distinction: we know cannabis-based products can create harm but the question is whether they can also have therapeutic benefits. If they can, they need to be weighed in the balance and rescheduled appropriately. That does not diminish the negative impact that he has described that the recreational use of cannabis, particularly very strong strains, can have on young people.

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for showing that he quite clearly understands the distinction between recreational and medicinal use. Is he also aware that Epidiolex, which is medicine produced by GW Pharmaceuticals for epilepsy sufferers and which will soon be approved, will not help children like Alfie Dingley who have uncontrolled epilepsy seizures? I understand that the cannabinoid CBDV is very important to such sufferers, and there is none of it in Epidiolex. Will the Minister ensure that the review takes account of the special needs of the 200,000 patients with uncontrollable seizures? Will the panel be able to hear from patients as well as studying research?

[Lord O’Shaughnessy]

The noble Baroness makes excellent points. I know she has been deeply involved in the Alfie Dingley case and I thank her for her work on that. What we are discovering is that it is not the case that just one drug is going to fix this for the 200,000 people who are suffering. There is a need for variety. So it cannot be the case that just because one thing is licensed it is used for everyone; it needs to be specific to the needs of the patient, which is the noble Baroness’s main point. The interim panel is there precisely to make decisions on an individual basis. It is a patch to the system, if you like, not a long-term change, which is why the review is in place so that we can ensure that many other products derived from cannabis, if they are proven to have therapeutic benefits, can be developed into drugs for the range of needs that are out there.

Long-term Plan for the NHS

Baroness Walmsley Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord Hannay of Chiswick (CB)]

My Lords—

[Baroness Walmsley (LD)]

My Lords—

[Baroness Manzoor (Con)]

It is the turn of the Liberal Democrat Benches.

--- Later in debate ---

[Baroness Walmsley]

My Lords, first, the Statement mentions £1.25 billion cash to cope with specific pension pressures. Is that because so many doctors are retiring early, and therefore drawing their pensions early, because of the pressures of the job? I know three GPs who are retiring far too early because of those pressures, so will the NHS be able to spend some of that money to relieve those pressures? Secondly, the Statement mentions that the Government want to prioritise prevention and that the NHS should get better at managing demand effectively. There are two factors that limit its ability to do that: social care has been mentioned by many noble Lords but I would also mention prevention. Can the Minister assure us that, when we get the spending review, the amount of money that goes to local authorities co-operating with the NHS on the prevention of ill health will not just be enough to make up for the cuts they have suffered over recent years but enough to really go forward and transform prevention measures?

[Lord O'Shaughnessy]

To answer the noble Baroness’s first question, I believe that changes in actuarial calculations were the driver of that change. However, it is a technical issue and I will write to her and place a copy of the letter in the Library so that other noble Lords can see the rationale for it. Regarding her question about public health funding, obviously it is not for me to make predictions about exactly what will be in the spending review, save to say again that there was a clear commitment in the Statement that we would not create further pressures for the NHS through the settlements delivered for social care and public health.

Education (Student Support) (Amendment) (No. 2) Regulations 2018

Baroness Walmsley Excerpts

Monday 21st May 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, the huge pressure which the NHS is under is taking a massive toll on our nursing, midwifery and other health professionals. It has been estimated that the NHS in England has approximately 40,000 nursing vacancies, with a vacancy rate of over 10%. A similar rate applies to midwives, although the RCM estimates it to be higher, to reflect the number of babies being born. The other health professions covered by this regulation are similarly affected. More nurses and midwives are leaving the profession before retirement; one in three nurses is due to retire in the next 10 years. For various reasons, including Brexit, work pressures and the age profile of the nursing profession, the number of nurses and midwives on the NMC register at the end of March 2018 was less than that in March 2017 and significantly less than at the peak in March 2016.

The House of Commons Health and Social Care Committee inquiry found that the nursing workforce in England must be,

“expanded at scale and pace”,

and that,

“future projections of demand for nurses should be based on demographics and other demand factors, rather than on affordability”.

Given this, one would have thought that the Government would do all they could to support and encourage entry to these professions. Instead, they are doing the opposite, reflected in these regulations, by ploughing ahead with their plan to scrap bursaries for yet more students, despite knowing full well the disastrous consequences that will follow.

Two years ago, the Government scrapped the undergraduate bursary. The results were predictable. In 2016, before the abolition, there were more than 47,000 nursing applicants in England. In 2018, the figure fell to about 31,000—a fall of over 15,000. It is clear that this is the reason why we have seen the sharpest ever decline in nursing applications. I have no doubt that the Minister will say that the number of applications is less important than the number of acceptances. I disagree: I want nursing to be seen as a profession where there is hot competition for places because it is such an attractive profession to be in.

No doubt the Government will say that they have committed to create more training places for nurses. They certainly promised an extra 5,000 nursing places and said that nursing bursaries had to be scrapped to make that possible. What has been delivered is a mere 700 fewer students training to be nurses. It is worrying, too, that there has been such a huge drop-off in mature students applying—the extraordinary figure of 42%. The very people we need to apply, who have often brought up a family, are now being denied an opportunity to make a career in nursing or face the consequences of being forced into huge debt.

We know that postgraduate students in particular are more vulnerable to the introduction of fee loans: 64% of postgraduate healthcare students are aged over 25 compared to only 18% of students generally. Women are largely attracted to the healthcare postgraduate route and represent 80% of the course places. There is a higher percentage of ethnic minority students on postgraduate healthcare courses compared to the general population, and the Department for Education equality analysis clearly states that these groups are known to be more debt averse. So introducing loans is likely to undermine recruitment of this cohort and represents yet another missed opportunity to grow the nursing workforce at a time of severe shortage.

The Government claimed in the other place that raising the cap will unlock additional places, but it was the Government themselves who set the cap through their funding of Health Education England. They also say that they can fill some of the gap with nursing apprenticeships. They have promised 1,000 of them, yet only a handful have started the course. This shortfall is not the only problem with overreliance on apprenticeships. A nursing apprentice will take four years to become a registered nurse. Even if there were a miraculous surge in apprenticeships starting this summer, we would not see any qualified nurses on our wards until 2022. Contrast that with an undergraduate nursing course, which can take three years, or postgrad courses referred to in the regulations, which can take two years, which makes them the quickest way to tackle the shortfall in numbers.

Another solution the Government have come up with is nursing associates. But there is clear evidence that using support workers or trainees as replacements for qualified nurses has potentially disastrous consequences for care. I hope that the Minister will confirm that that is not the Government’s intention. The nursing associate is a support role and must not be used as a substitute for registered nurses. Research is clear that diluting and substituting the registered nursing workforce with nursing support workers has ill consequences for many patients.

In pushing ahead with this regulation, Ministers ignore their department’s impact assessment. The DfE’s assessment of the changes to the bursary said that it would disproportionately affect women and ethnic minority students, yet Ministers have pressed ahead. Then the department found that the change could make women, older students and students with lower incomes less likely to participate. Again, Ministers pressed ahead.

This is not just a matter of fairness or even just about the benefit of having a diverse working population. In fact, older nursing graduates, to take the nursing profession in particular, are more likely to stay longer in the NHS and are more likely to choose areas such as mental health or learning disability nursing, which are facing such severe staff shortages. Nearly two-thirds of postgraduate nursing students are over 25, more than a quarter are from minority ethnic groups and 80% are women, so the impact of today’s regulations will surely be even worse than the previous cuts.

I welcome the golden hellos to postgrad students in specific hard-to-recruit disciplines, but the Government need to do much more to financially support postgraduate students.

Even if the Government are determined to make the change, there are good reasons not to make it now. This policy would move postgraduate nursing students over to the main student finance system, which means dealing with the Student Loans Company. There is every reason to believe that that company may not be ready. In recent weeks, the Government have been dealing with an error made by the company that has led to 793 nurses being hit with unexpected demands to repay accidental overpayments they were unaware of. I do not know whether the Minister has seen the recent NAO report on the company, but that also gives great pause for thought about whether it is able to accept this new responsibility. It strikes me that, before embarking on these regulations, we have the flagship review of higher education. The Government could have allowed that review to take account of this matter, rather than going ahead with the change today.

My final point is about student finances in general, and the impact on the Government. How many postgraduate students affected by this policy will repay any or all of their additional loan? How is this financially sustainable? Or is it just another example of what the Treasury Select Committee called a “fiscal illusion”—in this case, a student financial system that allows the Government to pretend that they have made a saving when all they are doing is passing the Bill to the next generation?

It is little wonder that the devolved nations have retained the NHS bursary system. We in England should do the same. I beg to move.

[Baroness Walmsley (LD)]

My Lords, like the noble Lord, Lord Hunt of Kings Heath, we, too, oppose the introduction of these regulations—and for very similar reasons. It always makes sense to make policy based on evidence and on the advice of experts. This is what the Government have failed to do in relation to the funding of student nurses. The removal of the bursaries for undergraduate nurses has already considerably reduced the number of applicants, and the number of those taking up a place was 705 lower last year than the year before. Given the 40,000 nurse vacancies that the noble Lord mentioned, this is a serious matter for patient safety, as pointed out by the Care Quality Commission. I accept that these are only one year’s figures, but I believe that, before upsetting the apple cart even further, the Government should postpone removing bursaries from postgraduate nurse trainees and other important groups until we have clear evidence of the effect on the number of undergraduate student nurses.

If we want to increase the number of registered nurses quickly, which we need to do, it makes more sense to support the two-year postgraduate route, not put it at risk by removing those bursaries, too—because this is the quickest way to get more nurses. Most suppliers of the two-year courses indicate that capacity could be increased by 50% given the right financial support, yet the Government are planning to deter applicants by removing the bursary. This does not make sense. Instead, the Government are focusing on the two four-year routes into nursing, yet the apprenticeship route is not providing the expected 1,000 extra nurses per year. The most recent data tells us that there are only 30 apprentice nurses—hardly a success. Will the Government look into the barriers that are preventing NHS employers taking on apprentices? It could be the 60% cut in funding for further professional development, which has affected the number of those who would like to become training assessors and mentors for student nurses and apprentices.

Nursing associates have a role both as assistants to registered nurses and as users of an alternative four-year route into nursing—but, again, it takes a long time and these associates, as the noble Lord, Lord Hunt, said, should not while training ever be seen as substitutes for fully qualified nurses. So why are the Government planning to deter applicants for the rapid postgraduate route, where 64% are over 25, where they are predominantly women and where they are more diverse than the general student population? In a career such as nursing it would be advantageous to attract people with a little more life experience than the average 18 year-old.

Also, we know that older women and ethnic minority students are more debt averse, as well as already having a student debt of up to £50,000 from their first degree. Therefore, it is vital to look at how this fast route into nursing could be supported. The RCN tells us that, if the fees were paid and a modest bursary towards living costs provided, the total would be less than the average annual premium paid by trusts over a single year for a full-time agency nurse. This is short-termism of the worst kind.

While the Government carry out their review of post-18 education, they might benefit from looking at the measures introduced in Wales by Kirsty Williams AM, the Liberal Democrat Minister in the Welsh Government responsible for medical education. Her conversations with students revealed that the main concern and deterrent was not fees but living costs. Therefore, she has introduced the equivalent of the minimum wage for students during their course. This method of student funding should be carefully considered by the Government while carrying out their review, particularly for nursing students, who have more contact time than other students because of their clinical placement and therefore less time to get a part-time job to support themselves. Will the Government please consider this sensible idea?

The House of Commons Select Committee on Health and Social Care stated that the nursing workforce should be expanded at scale and pace to avoid dangerous levels of vacancies. It should be based on need and demand rather than affordability. It is up to the Government to say how the money will be raised, but from these Benches we recommend some sort of hypothecated taxation or a reformed national insurance scheme which is truly progressive and demonstrates intergenerational fairness. The Liberal Democrats are also in favour of restoring the bursaries for undergraduate student nurses and we are against these new regulations, which would remove the bursary from postgraduate nursing students and other important health professional courses.

--- Later in debate ---

[Lord O'Shaughnessy]

I do not want to get into an argument about funny money and magic money trees, but it is worth pointing out that the proposal to treble student fees came from the Browne review, which was instigated by a Labour Government, and indeed the 2010 Labour manifesto committed a future Labour Government to implementing the findings of that review.

[Baroness Walmsley]

I would add that the Browne recommendations had no cap at all.

[Lord Hunt of Kings Heath]

My Lords, I would pray in aid my noble friend Lord Adonis, who sadly is not here tonight, and take the Minister back to the original intent of the loans that we introduced.

The Minister does not seem to have responded at all to the issue that, essentially, we are transferring this debt to future generations. At some point, the fact that so little of the loans is being paid back will have to be confronted. The Minister justifies increasing the number of places now on the basis that at some time in the future some Government are going to be faced with a massive problem. So not only are we discouraging some of the most important people that we want from coming into the profession, but we are also engaging in the most extraordinary financial trickery to justify current expenditure.

The Minister mentioned apprenticeships and associates. Of course we should welcome apprenticeships, and I welcome the associate profession, which is a good thing. However, the problem is that we know what the health service gets up to. We know that directors of nurses do not have as much influence on boards as they need, and that NHS trusts up and down the country will substitute associates for qualified general nurses whenever they can. Given the debacle of the whole apprenticeship approach, in putting all our eggs into that basket we are very much risking the future of this profession.

My noble friend Lord Puttnam talked about the problem that it takes a long time to recover from a situation of drastic shortage, and my noble friend Lord Clark talked about some of the implications. When you see a car crash about to happen, you usually attempt to stop it. I see this policy as putting the foot on the accelerator, leading to an inevitable crisis.

However, this was debated in the other place. I see no purpose in prolonging the debate. I hope that, under the auspices of the review of student finance, the Government will start to think again. I beg leave to withdraw the Motion.

Children: Obesity

Baroness Walmsley Excerpts

Thursday 10th May 2018 Lords Chamber

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for her acknowledgement of that important step forward in recruiting nurses to hard-to-recruit areas. That is important because we want more mental health, learning disability and district nurses in the future. They have an important role to play in schools. If I may say so, the noble Baroness is slightly underplaying the work that schools are already doing in this area. We have talked about the Daily Mile programme, which is going very well, with 900 schools in England adopting it. Learning about food, healthy eating and nutrition is a compulsory part of the curriculum in key stages 1, 2 and 3. However, I agree that there is always a need to do more.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that when you cook your meals from scratch, you know what is in them and are more likely to stay healthy? Can he assure me that children learn to cook in schools, not just the theory of nutrition? Will he also join me in encouraging the BBC to produce a cookery programme aimed at children?

[Lord O'Shaughnessy]

I am turning into the commissioner of children’s programming. I am trying to remember—I think that there is actually a CBBC programme that encourages children to cook. Its name has gone completely out of my mind but it was popular with my children. The noble Baroness raises an important point. Children learn to cook in primary schools, most of which have some sort of kit that allows them to do that. It is critical for them to understand that food does not just come from packets or shops but can be created by hand—and enjoyably, too.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Walmsley Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, as the brilliant Select Committee report makes clear, sustainability of health and social care is mainly achieved by a match between demand and available resources. Whatever funding solution the Government eventually propose, there is always likely to be pressure on money, so two approaches are necessary—to reduce demand and to work more cost-effectively. As my noble friend Lord Willis said, healthcare costs cannot be considered in isolation. Social care and the wider determinants of health, from public health, prevention, education and housing must be factored in. So the issue is much wider than the NHS, although its role in helping to reduce demand by prevention of ill health and developing new models of care is crucial.

The committee was quite right in its recommendation 19: it is essential that social care and health are properly integrated from top to bottom as they are interdependent —and Salford has proved that that works. Social care thresholds are rising but the need remains and is often displaced to the more expensive NHS. That is not clever. As the population ages, and as technology and infrastructure develop and appreciate, funding levels need to be adjusted accordingly. However, it is vital that we get a grip on rising demand, which is not caused just by our ageing population but by our failure to prevent preventable diseases. An eight year-old child wrote to me the other day about the link between child obesity and junk food; he said that we were not preventing preventable diseases, that it was not hard to prevent them and yet we were not doing so, and it was very sad. Well, indeed, it is very sad. The Select Committee was forced to write:

“We are of the firm opinion that continued cuts to the public health budget are not only short-sighted but counter-productive”.


Hear, hear. I strongly support its recommendation 30 that these funds should be restored.

Unless we put more effort into prevention of ill health, the burden of disease and demand for services will continue to rise. The committee pointed out that 89% of deaths in the UK are caused by cardiovascular disease, cancer, respiratory disease and diabetes. Many of these diseases are caused by lifestyle choices, such as poor diet and sedentary lifestyles, alcohol abuse and smoking. In recommendation 29, the committee proposes a nationwide campaign to highlight the problems caused by obesity, particularly among children. I hope that my speech on child obesity last week indicated how much I support that. I welcome the fact that the chef, Hugh Fearnley-Whittingstall, has already started that nationwide campaign with one city, Newcastle-upon-Tyne, as the noble Lord, Lord Rea, pointed out.

Many diseases are also caused by the social determinants of health, poverty, poor housing and poor air quality, which can shorten life in poor areas by as much as seven years, according to Professor Michael Marmot. This shocking health inequality is not social justice and must be addressed.

The five-year forward view called for a radical upgrade in prevention and public health and yet, in recent years, as many have said, we have seen a 30% cut in spending on these areas. Hard-pressed local authorities cannot subsidise public health. The Select Committee makes it very clear that this must change. What are the Government going to do about it?

People must take some responsibility for their own lifestyle choices, but we must not continue to rely on the NHS to fix it when we make the wrong choices. To make the right choices, we need information and help from public services that have now gone. However, people are not responsible for finding themselves in poverty or for living in areas with terrible air quality and poor access to healthy foods, as Hugh Fearnley-Whittingstall discovered.

The Government cannot rely on food retailers to take responsibility for this, but they do have a role to play. I welcome the recent initiative by Waitrose to introduce healthy eating specialist advisers in some stores—although it must be pointed out that Waitrose stores are not usually to be found in the poorest areas of the country. I congratulate those food manufacturers which have already reformulated their products to reduce sugar, salt and saturated fat and to reduce portion sizes but, as the noble Lord, Lord Rea, said, there is still a very long way to go. What plans do the Government have to learn from the response of sugary drink manufacturers to the threat of the mandatory sugar tax?

There is also enormous potential for technology and innovative treatments. The committee’s recommendations 24 to 28 encourage this, which I support. Where I live in Wales, we do not have access to some of the new tests and treatments available to noble Lords who live elsewhere in the country. It is a postcode lottery, which is the responsibility of the Welsh Labour Government. I say to the noble Baroness, Lady Meacher, that we are also about to lose the only GP practice in our large village of 4,000 people. Although I have often had to dial 50 times before getting through to make an appointment, I will miss it. I hope that my husband and I will not find ourselves sitting for over four hours in the A&E department of our local hospital as a result of the withdrawal of our valued primary care, so I agree with the committee’s recommendation for a review of the business model of primary care.

Children and Young People: Obesity

Baroness Walmsley Excerpts

Tuesday 17th April 2018 Lords Chamber

Asked by

[Baroness Walmsley]

To ask Her Majesty’s Government what steps they are taking to address obesity among children and young people.

[Baroness Walmsley (LD)]

My Lords, we have a childhood obesity epidemic in this country, with disadvantaged children significantly more likely to be affected. Nearly one in four children is overweight or obese in their first year of primary school, rising to more than one in three by the time they leave. Overweight children are more likely to become overweight adults, leading to heart disease, cancer, diabetes and stroke. Issues related to diabetes are a strain on the economy and on the NHS, so we need to address this at the earliest possible opportunity, while people are young—hence this debate.

Out of the mouths of babes and sucklings come truth and wisdom, so I thought that perhaps we should hear from the children themselves. It so happens that I recently received 30 letters from children at St Joseph’s Catholic Primary School in Burnham-on-Sea. These eight and nine year-olds are very aware of the dangers of obesity, such as heart disease and diabetes—although they did not mention cancer, even though 5% of cancers are thought to have a dietary link. They are not alone, since 85% of the population is also unaware of that link.

The children have been looking into the advertising of junk food on TV and wrote to ask me to do something about it. They said that 23 children out of their class of 30 had seen more junk food adverts than healthy food adverts. Here is what William had to say:

“As everyone knows fat is bad for you and surely our kids are being poisoned by too much. Firstly we should get good foods on our plates. Secondly we need to get bad foods off our plates. Thirdly fatty foods can block your arteries. I would draw your attention to the fact that 28 out of 30 children said adverts make us want to buy garbage. Therefore we must not let unwholesome adverts on TV every day, just on Mondays and Saturdays and moreover we must show more Fit4Life adverts. My evidence to support this is only 10 out of 30 kids have seen Fit4Life adverts which is not good. In summary we must stop this advertising problem. My final point is that you are responsible”.


George agreed, but he let out a little secret:

“Isn’t it the case that people like the taste of fat and if you keep eating junk you will get heart disease? Some eat a midnight snack under the bed, not often but it is probably junk food”.


Jared was concerned about the NHS. He said:

“Surely we can help the NHS. They are having too many customers”.


He must have read the 2016 report from the Food Foundation, which claimed that the current diet-driven crisis is crippling the NHS. The report said that NHS costs associated with being overweight or obese are £6.1 billion every year and £27 billion for the wider economy.

Ryan thinks you should have a balanced diet. He said:

“My view is balance. Get rid of some junk food but not all junk food because some people like it, including me”.


The new soft drinks industry levy, commonly known as the sugar tax, came into force recently, and that is a very good thing—although the children are not fooled. They have noticed that it is limited to sugary drinks. For example, Brac said:

“I would draw your attention to hidden sugars which are found in cereal, yoghurt, bread, smoothies and pizza”.


No fool, Brac.

So, on the children’s behalf, can I ask the Minister whether the Government plan to do anything about all the other hidden sugars in our food? I must say it is very heartening to hear that so many popular drinks have been reformulated, although I am sure they would not have done it without the levy. So it is important to monitor the effects of the sugar tax, and I hope the Minister will say how they intend to do that. Will he also tell us where the money is to be spent and whether local authorities, which now have the responsibility for public health, will have a say in the matter?

The Advertising Standards Authority’s Committee of Advertising Practice is about to carry out a review of whether the rules on advertising junk food during children’s TV programmes and on non-broadcast media are right. The children and I think the rules need changing, so I hope the reviewers will take notice of their opinion. For example, Emma said:

“In my opinion adverts about junk food are taking over and I can’t help noticing that they mostly do it when children are around. Clearly people are falling for things like, if you eat these delicious golden chicken nuggets it will make you happy and if you drink this Cola, you and your brother will get along forever”.


But Lillia was not taken in. She said:

“Bad food makes you fat and ill and in the end you just die”.


Manley agreed. He said:

“Don’t eat junk. It could give you a very bad tummy ache”.


Joshua had a solution. He said:

“Isn’t it clear preventable diseases aren’t being prevented? It’s not hard to prevent them yet we don’t. It’s quite sad don’t you think?”.


He wants cheaper fruit and vegetables. The Food Foundation agrees. It recommends:

“Subsidies that favour healthy food over unhealthy food”.


The ASA said in its briefing to us at half past two this afternoon:

“Currently, the evidence shows that advertising has only a modest effect on children’s food preferences and that there are multiple and complex factors, beyond advertising, that are instrumental in childhood obesity.”


The causes are indeed complex but the children of St Joseph’s and many other experts do not agree that advertising has only a modest effect on children’s food preferences. Their letters refer to the large number of junk food adverts on TV programmes—in “family time”, not just children’s programmes—but they do agree that there are other factors. Holly says:

“Surely the Government can make a law saying there should be a limit of junk food adverts”.


But she realises that it is not just about what you eat; keeping fit is also part of the solution, and it is fun. Tommy agreed. He wants more PE lessons.

Finbar described children’s sedentary lifestyles. He said:

“It seems to me that people are starting to get more lazier by the day. As I see it people finish school or work, go home then walk to their TV or games console. And might even have their dinner there”.


Ukactive, chaired by our noble friend Lady Grey-Thompson, promotes physical activity for children. It told me that half of all seven year-olds are failing to achieve the recommended 60 minutes of physical activity per day. NHS research in 2015 found that one in five children did no sport or physical activity at school. It would help schools to plan if the Government were clearer about their long-term plans for the primary PE and sport premium. This might be the responsibility of the Department for Education, but could the Minister from the health department enlighten us? As Finbar said, physical inactivity is a major cause of childhood obesity.

The children want to know what we are going to do about it. Cancer Research UK proposes a 9 pm watershed on TV advertising of junk food. This does not require legislation; Ofcom could be instructed to act. Will the Minister comment on that? It is a decade since Ofcom’s restrictions came into effect, and in that time viewing habits have drastically changed. Evening and family programmes, shown between 7 pm and 9 pm, are now most frequently watched by children and young people, yet they are not covered by existing regulations unless the advertisement is directly aimed at children. It seems that current rules are no longer fit for purpose. The Obesity Health Alliance found that more than half of food and drink adverts shown during family viewing would be banned on children’s TV under current rules.

Your Lordships might wonder whether there is any evidence that restricting the marketing of junk food could help in the fight against childhood obesity. Well, I have good news. There is evidence from Quebec that a ban on advertising junk food to children can work. Its strict rules since 1980 have resulted in a much lower level of child obesity there than in any other part of Canada. Will the Minister look at this evidence and act on it? Given that Public Health England advised the Government to include further advertising restrictions in the 2016 child obesity plan, perhaps the Minister will explain why the Government did not take its advice. Could he now tell the House whether they have seen the error of their ways? If so, I will be delighted to tell the children of St Joseph’s.

Brexit: Health and Welfare

Baroness Walmsley Excerpts

Thursday 29th March 2018 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been a very well-informed debate, led by my noble friend Lady Brinton with her excellent and wide-ranging speech, on which I congratulate her heartily. There have been some excellent and moving speeches from across the House. I hope others will forgive me if I say how much I support the passionate and robust comments of the noble Lord, Lord Balfe.

As ever in your Lordships’ House, we have covered the ground very thoroughly. My noble friend Lady Brinton started us off by expressing her concerns about procurement and the need to protect our NHS from United States predation. We heard worries about the levels of staffing in both health and social care, and particularly the effects on some of our most vulnerable citizens of the loss of care workers from the EU. We heard about the loss of the EMA and its consequences for medicines regulation and for the access of UK patients to cutting-edge medicines. We heard concerns about clinical trials and the availability of clinical isotopes if we leave Euratom. We heard concerns about the recognition of qualifications; about research; about medical treatment across the Irish border; about data sharing; about health inequality; about reciprocal parking for disabled drivers; and about mental health. Lastly, from my noble friend Lady Tyler we heard a welcome, which I endorse, for the Prime Minister’s recognition at last that we need a long-term funding settlement for the NHS.

For myself, I would like to mention two issues that have been mentioned but not dwelt upon. The first is my concern that, if we leave the EU, we will no longer be part of the European Centre for Disease Prevention and Control, the ECDC, and have a seat at its table, currently occupied by Professor Dame Sally Davies, the Chief Medical Officer. The ECDC is an EU agency aimed at strengthening Europe’s defences against infectious diseases. It works in partnership with national health protection bodies across Europe to strengthen and develop continent-wide disease surveillance and early-warning systems. The ECDC pools Europe’s health knowledge to develop authoritative scientific opinion about the risks posed by current and emerging infectious diseases. It provides the NHS with evidence for effective decision-making, helps to strengthen our public health system and supports our response to public health threats. It does so through surveillance, epidemic intelligence, scientific advice, microbiology, preparedness, public health training, international relations and health communication. Its programmes cover a number of important issues that have been debated in your Lordships’ House over the past couple of years, including: antimicrobial resistance and healthcare-associated infections; emerging and vector-borne diseases; HIV; influenza; TB; and vaccine-preventable diseases. All in all, the ECDC monitors 52 communicable diseases.

If we no longer have access to these services after Brexit, we will suffer when, for example, there is a flu epidemic or pandemic and vaccines or other specific treatment need to be rationed across the EU. This is almost inevitable, as it is not possible with current technology for vaccine production to be scaled up fast enough since we need to know the specific flu mutation that we are dealing with before we can start manufacture. The ECDC will be driving who gets what, as it will be the conduit to the World Health Organization for the EU; the UK will be a single nation at the back of the queue, as we will be with new medicines licensing and access. What action have the UK Government taken to ensure that UK patients do not suffer because of our exit from the ECDC?

My second issue is that of food safety. I am sure that all noble Lords agree that the safety of our food is an important element in enabling our citizens to be healthy. In order to ensure safe food, our food producers need to practise the highest possible standards of hygiene, which most of them do, and our consumers need the best possible information. It is because of this that scandals such as 2 Sisters, Muscle Foods, DB Foods and Fairfax Meadow are relatively rare. It is also because of this that British food producers are currently able to sell their goods in large quantities across Europe and the rest of the world. Indeed, one claim the Government make about the potential benefits of Brexit is that British food producers will be able to sell more, thus benefiting our economy. We shall see.

There does not seem to be much emphasis on food and health in current government thinking. The agriculture Command Paper Health and Harmony, which came from the Environment Secretary, makes little reference to food apart from the issue of pesticide residues. The fisheries paper focuses on maximum sustainable yields—again, nothing about health. The focus seems to be more on cheap food than on food standards. But the British people want decent, affordable, sustainable healthy food, not a race to the bottom. I am concerned that this is not the direction in which we are going. I certainly do not think we should be opening our doors to a lot of foods from the United States, where its need to export large amounts of corn syrup means that sugars are found in the most surprising foods. For example, breast milk substitute in the United States can contain any kind of sugar in any amounts. We do not want that here.

Let us look at how our food industry standards are currently maintained. Currently, they must be up to the standards of the European Food Safety Authority, controlled by the European Commission. In the UK, the regulator is the Food Standards Agency, but it relies heavily on local authority environmental health officers and trading standards officers. I expect that the Government will say that the UK food supply is safe and that we are currently aligned with EU standards and that that will continue, so what is the problem? The problem is this. Between 2012 and 2017, the FSA’s budget was cut by 23% and the number of samples taken for testing by EHOs fell by 22%, so resources, including local authority funding of EHOs, are already stretched.

On top of that, Ministers have insisted that the FSA makes even greater savings, as a result of which last year it obligingly published a document entitled Regulating Our Future: Why Food Regulation Needs to Change and How We Are Going to Do It. I have just read a critique of this document by a collaboration of academics from the University of Sussex and City, University of London. I have scarcely ever read such a scathing academic study. The authors have the grace to support the proposal for mandatory registration of food business operators. They also support demands by environmental health officers that they should have the power to refuse registration to,

“FBOs that cannot demonstrate they can produce food that is safe and honestly labelled”.

However, the rest of the report is strongly critical, in particular of the proposal that inspection of FBOs should in future be outsourced—and not just outsourced. The proposal is that the food producer itself should contract a third party to inspect it on a basis it thinks is right at an agreed frequency and decide whether the inspection is notified—talk about marking your own homework. The fear is that the food producer will go for the cheapest option, which is unlikely to be the most rigorous, and our food safety will be affected. The other worry is about access to information—and the list goes on.

I do not think that this proposal from the FSA will give confidence to the European Commission or the European Food Standards Agency, in which case UK FBOs will have great difficulty selling their produce to either the EU or other countries, given that all over the world countries are moving to EU standards so that they have only one set to deal with. Add to all that the fact that the majority of vets contracted to supervise abattoirs and meat-cutting plants were recruited by the FSA’s outsourcing contractor from non-UK EU countries and you have a recipe for disaster in UK food safety.

This is one of the issues that the Government need to take extremely seriously when they are negotiating our exit from the EU. We need some confidence that the safety of our food, which has such a big effect on our health, will be taken into account by the Government.