Social Care

Baroness Walmsley Excerpts

Thursday 1st December 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been an excellent debate with many thought-provoking speeches, including, in particular, that of the noble Baroness, Lady Pitkeathley, in introducing the debate and that of the noble Baroness, Lady Cavendish.

Yesterday morning, there was a story on Radio 4’s “Today” programme that neatly illustrated how problems with social care affect the whole health and care system. The story was about ambulances and the fact that in the past year 500,000 extra hours were spent by ambulance crews waiting outside A&E departments, unable to discharge their patients, while other serious and urgent cases stacked up awaiting their arrival. The head of emergency medicine for the NHS gave an account of new ways of working that may help put a sticking plaster on the problem. However, the story illustrates very clearly the interaction between the various parts of the health and care system.

Of course, the reason ambulance crews have to wait so long is that A&E departments are full, unable to move their patients to beds in the wards because they are full too. One of the reasons that the wards are full is the delays in discharging patients to appropriate care in care homes or their own homes with a suitable package of help—and we know that people go to A&E, where the lights are on, because they cannot get an appointment with their GP. Nearly 570,000 bed days were lost in acute hospitals during the second quarter of 2016-17 as a result of delays in discharging patients, with problems in arranging social care now the main reason given by hospitals for these delays. This comes at a cost to the NHS of £820 million a year. The story illustrates why we need to sort out social care, apart from the need to ensure that elderly and disabled people get the care they need in a timely and dignified way.

The Care and Support Alliance of 90 charities points out that, as well as relying on help with everyday tasks such as washing, dressing and eating, social care plays a vital role in supporting recipients and their carers to move into, or stay in, employment, and in preventing avoidable expenditure, particularly in other parts of the health service. The charity Sense, which works for deafblind people, points out that in the past year alone 11.4% fewer people with sensory impairment were able to access services. This has greatly curtailed their community involvement and life chances.

The whole system is like a pack of dominoes that will fall with a great clatter unless something is done. That is why I, along with others who have spoken today, was shocked and horrified that, despite all the evidence that has come forward about the dreadful state of care funding, the Chancellor said not one word about it in the Autumn Statement and provided not one extra pound. The interoperability of all parts of the system of health and social care indicates strongly the need for a cross-party consensus on how we fund it in this country—I welcome the support on that from the noble Lord, Viscount Hanworth. While I look forward to the report of your Lordships’ ad hoc Select Committee on sustainability in the NHS, chaired by the noble Lord, Lord Patel, we need to go much further, as my right honourable friend Norman Lamb has so often proposed. We need to look at all the options: insurance schemes, the German scheme, the Japanese scheme, general taxation and national insurance.

The nearest thing we have to an independent commission is the King’s Fund and the Nuffield Trust, which work together and with others to inform the debate. Since the disaster of the Autumn Statement they have said that they now expect a funding gap of at least £2.4 billion in social care next year. That means that the intense pressure on services will continue to grow, increasing the burden on older and vulnerable people, their families and their carers, as the noble Baroness, Lady Farrington, has told us.

In its recent report on the sector, the CQC said that social care is at a tipping point. The CQC does not often use such language, but it should know, since it inspects all the services. However, it did report that 72% of settings were good or outstanding, and that is a credit to all those working in the sector who do their very best for the service users despite all the problems. The facts, however, are dismaying. Following multiple cuts to local authority funding over the past six years, 26% fewer older and vulnerable people are receiving services, while demographics mean that demand is rising. Because the potential for most local authorities to do any more within existing resources is limited, my colleagues in local government tell me that they will soon struggle to meet even basic statutory duties.

As we have heard, companies providing places in care homes are handing back contracts to local authorities because they cannot provide adequate care—the sort of care they want to give—with the funding that they get. Some are concentrating on self-funders. Indeed, self-funded service users are subsidising state-funded users in some places, and I agree with the noble Baroness, Lady Browning, that that is not fair. The national minimum wage—I still refuse to call it a national living wage because one cannot live on it—is putting enormous pressure on already small margins. Aside from the quantity of care available, good-quality care matters for many reasons, not least of which is that good care homes, working with their local GPs and community pharmacies, keep people out of A&E and other hospital departments.

Domiciliary care fares no better. Fifty-nine councils have had home care contracts terminated, affecting nearly 4,000 people. Three large national domiciliary care providers with multiple contracts have withdrawn from the market or are planning to do so. The critical condition of home care services threatens to undermine policies to support people at home, which, as we have heard, is where most people prefer to be, near their families and friends who can often help with care and are happy to do so within their capabilities. An estimated 1 million people now have unmet needs for care and support in England and research on disabled adults suggests that at least two in five are not having their basic needs catered for.

The new 2% precept increase that local authorities are allowed to raise does not help deprived areas where the majority of care users are state-funded and low council tax receipts from low-value properties will not raise anything like the amount of money needed. In those places, the potential for cross-subsidy from self-funders is minimal too. Besides, the precept, if fully applied overall, will raise only two-thirds of the cost of the increase in the national minimum wage in a sector where most employees are on that level of pay. At the same time, the Government have delayed until 2020 the implementation of Part 2 of the Care Act 2014, which introduces a cap on care costs and changes to means testing. These are reforms proposed by the Dilnot commission in 2011 and this breaches a Conservative Party manifesto commitment. So can the Minister say when it will happen, since many people are now doubtful as to whether these reforms will ever see the light of day?

The King’s Fund believes that our starting point for reform should be the Barker commission recommendation of a new settlement for health and social care, based on ending the historical divide between the two and moving to a single budget and single local commissioning of services. I agree with that, but there is also a very large elephant in the room, and that is the looming Brexit. We spoke about this at length in last Thursday’s debate. A damaged economy, resulting in a lower tax take, and uncertainty about the future of the many thousands of care staff who come from other EU countries cast an enormous shadow across an already staggering system. When will the Government do the right thing and offer them certainty?

It cannot be right that the care and support received by older and disabled people increasingly depends on where they live and how much money they have—a postcode lottery—rather than on their real needs. Although additional funding is badly needed in the short term, in the long term reform is what is required. The only game in town on that front at the moment is the sustainability and transformation plans, funded by the Better Care Fund, but there is evidence that, first, the emphasis is on sustainability rather than transformation and, secondly, that local authorities, patients and care providers are the last ones to be consulted on the plans. How can services be integrated when crucial parts of the system are not being properly consulted and funds that should be used to develop and pilot new ways of working are just being used to prop up budgets in deficit?

As the King’s Fund said:

“England remains one of the few major developed countries that has not reformed the way it funds long-term care in response to the needs of an ageing population … A number of commissions and reviews have been set up over the years and made recommendations about how to place social care on a sustainable footing. However, successive governments have failed to grasp the nettle”.

I am a gardener and I know the value of nettles: they support wildlife and you can even make nourishing soup out of the small leaves at the top of the plant. So will the Government grasp the nettle, because they may find it good for them?

Health and Social Care

Baroness Walmsley Excerpts

Thursday 24th November 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I, too, thank the noble Baroness, Lady Finlay of Llandaff, for introducing this debate. I note with interest that not one speaker thinks Brexit will be good for health and social care. The tragedy of the vote on 23 June—by 37% of the electorate—is becoming more apparent every day, not least yesterday, following the Autumn Statement. The OBR has reacted to the statement by giving us an independent assessment of where we are now and where we are likely to be, as a nation, as a result of the actions of this disastrous Government, who cannot even stand up for their own judges, let alone stand up to their own right wing.

The Government say that we have a £220 billion Brexit black hole and will have rising unemployment, lower wages and higher inflation, resulting in lower living standards. The projected fall of £8.2 billion in tax receipts over the next two years will seriously impact on our public services. That fall is enough to fund more than 330,000 nurses.

It was shocking that there was not a single mention of social care in yesterday’s Statement from the Chancellor, despite the £1.3 billion hole in social care budgets needed by 2020 simply to stabilise the system, let alone deal with rising demand and reverse the fall in the number of people able to squeeze through the rising eligibility barriers for care. More than two-thirds of acute hospital trusts are in serious deficit and this figure is projected to rise. These are the real effects of Brexit on our national treasure. We cannot pay for the staff we need in the NHS and social care if tax receipts are falling unless the Government make different choices.

Our public sector workers have not had a decent pay rise in years and are promised in the coming year less than expected inflation—in other words, a real-terms pay cut. That is why we on these Benches called for the Chancellor to announce £4 billion extra for the NHS and social care yesterday and a decent pay rise for public sector workers—but he did not. Instead, we will be spending much more than that on additional civil servants charged with getting us out of the EU. You could not make it up.

In addition to that situation, since 23 June there has been enormous uncertainty, as we have heard from other speakers, among providers of health services and social care about whether they will be able to retain the staff from EU countries already here and recruit new ones in the future. The current staff from these countries are valued and essential to the operation of health and social care, and yet the Government refuse to give them any reassurance. Thirty thousand doctors, 55,000 nurses and others, 90,000 care workers and goodness knows how many medical researchers from the EU are currently working in the UK. Without them, the NHS and care services would fall over and our research efforts will be damaged. EU funding supports many of our medical research programmes and I am very concerned that without it, after Brexit, UK patients will no longer benefit from clinical trials and early adoption of the cutting-edge treatments that they bring.

Others have picked up their own areas of concern about the health and social care workforce but I should like to mention two groups: midwives and people supplying medical equipment. In April this year there were 1,192 full-time-equivalent midwives from other EU countries working in the NHS in England, according to figures from NHS Digital. In London alone, 16% of the NHS midwifery workforce was from elsewhere in the EU—674 full-time equivalent midwives. At University College London Hospitals NHS Foundation Trust, 32% of the midwifery workforce was from the EU. Outside London, in both Basildon and Thurrock, and in Walsall, more than 10% of midwives were from other EU countries.

On the latest calculation, the NHS in England is already short of around 3,500 full-time midwives. Without EU midwives, that shortage figure would be over 4,500. We need more midwives, not fewer. The Royal College of Midwives believes that any policy that could see EU midwives blocked from continuing to be able to work in the NHS post-Brexit would be very damaging for maternity services across the country and truly catastrophic for London. Can the Minister tell us what plans the Government have in their negotiations to protect our maternity services?

The information I have just mentioned concerns the proportion of the current midwifery workforce coming from the EU. It does not take account of how many join or leave in any one year. It is important to consider this churn because, even if existing EU midwives were able to stay, any who then returned to their home country might not be easily replaceable. The latest figures available on that churn, from September 2014-15, show that during that period 189 EU midwives left NHS employment and 248 started—a welcome increase. Simply allowing existing EU midwives to stay without taking any account of allowing new ones to come would lead to a fall in numbers. In summary, the NHS in England has been short of midwives for years. We need all the midwives we can get; currently well over 1,000 of those we have are from other EU member states. We need them.

Turning to my other concern, many people working in health and social care are involved in the provision and support of medical devices for their patients. Brexit will pose problems for them, too. At present the UK is closely involved with EU regulatory bodies in licensing about 150,000 medical devices. Licensing by these EU bodies ensures that patients receive safe and appropriate medical equipment. It also means that the businesses responsible for their research, development and sale can trade easily within the EU, and with other countries, based on EU-wide approval. There are thousands of jobs in these businesses and they affect millions of patients.

Many EU countries value UK expertise in the regulatory field and much of the approving of medical devices for use across the EU is done here in the UK. Casting us adrift from this EU-wide process and creating a wholly separate regulatory process will weaken the process of approving innovative medical devices and create barriers for businesses working to develop them.

Who knows what the results of negotiations will be, but it would make sense to continue the regulation of medical devices on an EU basis. However, that will not be possible if the EEA, EFTA or customs union models are rejected. What we do know is that creating a “bespoke” regulatory process as part of a hard Brexit will make it more difficult to develop and get approval for the kind of medical devices that will assist those working in health and social care to support patients properly, and in many cases to help them live their lives as independently as possible. That includes patients of all ages with chronic conditions, elderly people, people with disabilities and people with learning difficulties.

Creating our own bureaucracy for regulating medical devices will be costly and at the expense of direct support for people who may benefit from them. Why spend the money on new bureaucracy rather than on more prostheses, heart pacemakers, computerised blood sugar regulators, mobility aids and much more? In addition, failing to maintain EU-wide systems will threaten their future development here in the UK. If we are to leave the EU, the UK businesses that are researching, developing and promoting medical devices would clearly prefer a new arrangement in which the system remains EU-wide, even if that means a loss of sovereignty and the need to pay a share of the costs of EU-wide regulation. If the Government are determined on a hard Brexit to appease their right wing, however, this important UK industry will suffer, work will move to the EU, and those working in the health and care sector will find that the changes have been detrimental to their patients. There could be huge and unnecessary costs for the supplying of medical devices if there are not, at the very least, long transitional arrangements allowing issues such as labelling to be addressed. Will the Government’s industrial strategy take account of this important health-related industry?

The process and consequences of Brexit will cost this country millions and have already cost us trillions of pounds because of the fall in the value of the pound. What will the Government do to minimise the negative effect of Brexit on the health of the nation?

Mental Health: Children and Adolescents

Baroness Walmsley Excerpts

Wednesday 16th November 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, there is no doubt that whether it is housing for young people or loneliness for old people, many factors affect people’s mental well-being. The noble Lord may be interested to know, as I know that his particular interest is in looked-after children, that we have set up an expert working group to look particularly at that case. Interestingly, 85% of the local transformation plans that have been developed single out looked-after children as a group that requires special attention.

[Baroness Walmsley (LD)]

My Lords, I welcome the mental health dashboards, which allow people to hold their local clinical commissioning group to account for how much it spends on mental health, including on children, and on the quality of the services that it provides. However, can the Minister say how those dashboards are being publicised, and whether there is any way in which local people can benchmark the performance of their local CCG compared to others across the country?

[Lord Prior of Brampton]

My Lords, transparency is critical to this and every CCG will have its improvement assessment framework. Unless I am badly mistaken, they will all be in the public domain and it will be possible to look at the relative performance of each CCG. NHS England will also produce its own matrix and integrated dashboard, which will have all the key information about funding, the numbers of people accessing mental health provision and the improvements that those people achieve once they are in the system.

Hospitals: Unsafe Discharge

Baroness Walmsley Excerpts

Wednesday 9th November 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Baroness, Lady Wheeler, on submitting the same Question for Short Debate as the one that I submitted myself, but clearly she was in front of me in the queue.

This is a very important topic, impacting, as it does, both on the health of individual patients and their families and on the sustainability of the health and social care services. As usual, we see in the PHSO report evidence that we will never achieve sustainability in the health service until we address the shortfalls in budgets and provision in the social care service. Only recently we heard about more social care providers handing back local authority contracts because they are unable to make a reasonable profit while providing an adequate standard of care. One of my colleagues, who is a local councillor, told me that, in fulfilling its statutory duties relating to social care, her council now has to spend 33%—and rising—of its budget and that, if this carries on, the council will soon run out of money.

Care providers are not fat cats who do not think that they are making enough money; on the whole they are caring companies which have reluctantly had to admit that they cannot go on as they have recently been forced to do and deliver the standard of care they want to give. We have also had media stories about the fact that those who are self-funding in care homes are paying a premium of up to £400 per week to subsidise the home’s budget and compensate for the shortfall in local authority payments for publicly funded patients in the setting. From every point of view, this is an unsatisfactory state of affairs, which threatens to get worse, and it backs up the call by my right honourable friend Norman Lamb MP for an independent or cross-party commission on how the health and care systems can be sustainably funded.

I turn to the detail of the report. When I asked an Oral Question about this on 15 June, the Minister’s first Answer was to the effect that the sustainability and transformation plans would integrate health and social care, fill the black hole in funding and solve all our problems. So my first question to him today is to ask him to follow up on that Answer. We have heard in the news recently that STP boards must delay making their draft plans public for two weeks because of the concerns of some Conservative MPs that the plans may involve controversial hospital closures. Is that the case?

That is not the only concern I have heard. I am told that the development of the plans has been very top down and has been led by the acute hospitals, despite the fact that one of their main purposes is to plan how patients can be treated in primary and community care rather than in expensive hospitals. I have also heard that local authorities and community groups have not been involved in developing the plans but have been told that they can comment after the plans are complete. Once the ink is dry on the paper, people can do no more than tweak the plans. Given that these plans need to fundamentally reform the way that care is delivered, and given that the most successful change is bottom up, this is no way to go about it. It will produce the “not invented here” syndrome. I have found that health and care professionals will engage enthusiastically with change that they know will work because they have recommended it, but not when change is imposed on them. Every manager knows that the best changes, and those that are easiest to implement, come from the staff suggestion box.

Also, I have heard that “sustainability”, not “transformation”, has become the over-riding objective. In other words, boards have been told that the books must be balanced, and this has resulted in outrageously unrealistic plans. The Government were wise to call these plans “sustainability and transformation” because, through transforming how services are delivered, we might achieve savings. However, it cannot be the other way round. I also heard a health economist make the very valid point last week that in mental health there has been a transformation from in-patient care to care in the community, but this has taken 20 years. The point he was making was that the timescale for the Government’s STPs is quite unrealistic.

If ever there was a demonstration that this process needs to be carried out properly, it is to be found in the PHSO report on unsafe discharge. The point that I made in my supplementary Oral Question in June, quoting examples from the report, was that there are problems on both sides of the discharge cliff edge: problems in the hospital and problems with the care to which the patient should be discharged. The Minister answered:

“My Lords, there are millions of interactions between patients and consultants and doctors every day of the year, and there will be some mistakes. We cannot draw conclusions from one or two desperate situations. In so far as they reveal systemic problems, it is valid to draw attention to individual cases of this kind, and there are some systemic issues lying behind the PHSO's report. In particular, it states:

‘We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight. …health and social care ... have historically operated in silos’”.—[Official Report, 15/6/16; col. 1216.]

I agree with the Minister that there are millions of satisfactory—nay, exemplary—interactions every day, but the report quoted specific examples only where the ombudsman felt that they did demonstrate systemic issues. That was made very clear in the report. But common sense tells us that mistakes are more liable to be made when people are under great pressure. The Minister also acknowledged that these historic barriers to safe discharge cannot be fixed overnight. So why are the STPs expected to fix them in the health service equivalent of overnight, which is in three or four years?

No doctor or nurse wishes to discharge a patient into unsafe circumstances, but mistakes will be made when the pressure on the service is so great and there is such a shortage of hospital beds, according to the briefing from the BMA. In its submission to the Public Accounts Committee inquiry on this very same subject, the Royal College of Physicians revealed that 40% of advertised consultant vacancies remain unfilled, mostly due to the lack of suitably qualified candidates. At the same time, the Government are telling us that they do not want to bring in doctors from abroad. This is quite unrealistic in the timescale quoted. The RCP says that the,

“staffing crisis is impacting on physicians’ ability to swiftly assess patients… to tailor their care plans and to work across disciplines to achieve safe and timely transfers of care”.

The RCP also emphasises that more needs to be done to prevent unnecessary admissions, and quotes examples where early access to multidisciplinary assessment led to a reduction of up to 24% in hospital admissions. Patients were given care in more appropriate settings and pressure on hospitals was reduced. That is what we should be seeing across the board.

It also makes the point that better integration between hospital and community settings is fundamental in preventing patient readmission to hospital. That was one of the regrettable consequences of unsafe discharge, according to the report. To be fair, this integration is one of the major objectives of the STPs. Why, therefore, in too many cases, is one partner producing the plan and then showing it to the other for comment?

The Royal College of Nursing, in its briefing for this debate, accepts that poor care is unacceptable, and agrees with many of the findings of the report. It mentions the problems with recruiting and retaining nurses in the NHS and shows a link between shortages and poor patient experience. Can the Minister tell us what impact the Government expect the change in funding for student nurses to have on this situation and what effect this will have on the availability of nursing homes?

The RCN also points out that discharge targets mean little if the resources in social care are not there to meet them. What do the Government plan to do about this? They must surely accept that the small precept for social care which has been allowed to local councils to cover the cost of the increase in the national minimum wage will not do so—and by the way, I refuse to call it the national living wage because no one could live on it. We also know that in the areas where most is needed for social care, because of the predominance of publicly funded patients, the ability to raise extra cash from the precept is the lowest. This is a topsy-turvy policy that the Government are labelling a legitimate solution to the problem.

I ask the Minister what plans the Government have to address the shortfall in funding for social care and the shortage of doctors and nurses, the main causes of unsafe discharge? There are problems with communications and poor interoperability of IT systems, but—although they should be addressed—they are not the great big elephant in the room. We all know what that is. When will the Government address it and stop burying their head in the sand? Even Simon Stevens and a Select Committee in another place have questioned the Government’s claim that they have given the NHS all it asked for. They have not, and the five-year forward view remains an aspiration and not a plan.

Without a properly funded plan, the crisis in health and social care, of which unsafe discharge is very sad evidence, will continue as demand continues to rise. Instead of picking fights with junior doctors and community pharmacists, the Secretary of State would be better advised to tackle this with his usual energy. If he did so, his name would go down in history as the best Secretary of State for Health we have ever had. I await that day with bated breath.

NHS Funding

Baroness Walmsley Excerpts

Monday 31st October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I will try to respond to those last three points. First, the noble Lord is right: the NHS is—and I would regard it still as—the highest-value healthcare system in the world. It does have fewer doctors and MRI machines—however you want to measure it—compared to many other OECD countries, but its outcomes, on the whole, are very good. I can, therefore, certainly confirm that the NHS is a very high-value healthcare system. As far as the involvement of the NHS in the plan is concerned, it was very much put together by the NHS and signed by all of the arm’s-length bodies at the time. This is a quote from Simon Stevens about the spending round settlement:

“This settlement is a clear and highly welcome acceptance of our argument for frontloaded NHS investment. It will help stabilise current pressures on hospitals, GPs, and mental health services, and kick-start the NHS Five Year Forward View’s fundamental redesign of care”.

This brings me to my last point, the fundamental redesign of care. That was possibly not really recognised at the time of the NHS review, because it is a fundamental redesign of care. As the noble Lord said, it means moving resources away from acute settings into community settings, very much as mental health care was restructured 20 or 25 years ago.

[Baroness Walmsley (LD)]

My Lords, the Secretary of State said that there were going to be another million over-75 year-olds in five years’ time, and I very much hope that I am going to be one of them. May I give the noble Lord a couple of other statistics? The King’s Fund quarterly monitoring report found that, for each month in the first quarter of this year, there were an additional 54,000 attendances at A&E departments and 14,200 emergency hospital admissions compared to the same time last year. All these emergencies are no way to run a health service.

The noble Lord and the Secretary of State pray in aid the five-year forward view as if it were a statement of fact. It is a plan; it is an aspiration, and at the time it was written, the hole in the funding of the NHS was not £4.5 billion, as the Select Committee says has been given to the health service; it was not £8 billion or £10 billion: it was £30 billion. The Government gave about a third of it and suggested, through the five-year forward aspirational plan, that the rest could be done by efficiencies. We have the STPs, which are supposed to find those efficiencies. We have heard many times in this House over the last few weeks about the shortcomings of those, so when will the Government respond to my right honourable friend Norman Lamb when he calls for a cross-party commission on proper funding of social care and the health service?

[Lord Prior of Brampton]

My Lords, I am sure that the noble Baroness will be here well past the age of 75, and that there are many years to come before she reaches that age.

The noble Baroness is absolutely right: for many elderly people, the worst way to be treated, frankly, is to be blue-lighted in an ambulance into an A&E department of a very busy acute hospital. The whole purpose of the five-year forward view is to deliver care to many more such people outside. I think we all agree with that. The noble Baroness’s party, like ours, agreed with the £8 billion of extra government spending over the course of this Parliament, and accepted the fact that very significant efficiencies could be generated from the NHS. We still subscribe to that view, and the STPs will be the right vehicle for delivering many of them.

Mesothelioma

Baroness Walmsley Excerpts

Thursday 27th October 2016 Grand Committee

[Baroness Walmsley (LD)]

My Lords, I, too, would like to focus on the patients—the 2,500 British people who are expected to die each year of mesothelioma, most of whom have contracted the disease as a result of exposure to asbestos. The use of asbestos in industry and construction, although now banned, was a practice that has had a detrimental effect on many lives, and it is our duty now to offer sufficient aid to those it has affected.

Asbestos lurks in many strange places, including, as we have heard from the noble Lord, Lord Alton, this very building. My husband and I recently demolished an old cottage on our property, and we discovered that there was asbestos in the floor tiles with which my late mother-in-law had been living for 40 years. We had to have them removed by specialists. In the 1970s, when I lived in an old farmhouse, I used an asbestos product to fill the rather irregular holes that I used to drill in the walls to hang pictures and bookshelves, having no idea that there may be a problem with it. Concerns about the dangers of asbestos were first raised early in the 20th century, but its use was not outlawed until 1999. For the thousands of cases now arising 40 or 50 years after first exposure, it is our responsibility to ensure that they are given the compensation and support they require. Unfortunately, the median survival time for pleural mesothelioma, once it has taken hold, is 12 months from diagnosis, but this time, and beyond for the dependents of those affected, must be made as comfortable as possible for those who need help.

Over the years, there have been many shortcomings in the handling of asbestos-related cases across the globe, one such case being the fire at the central ordnance depot in Donnington, Shropshire, in 1983. The blaze which released a huge cloud of asbestos into the air has had a huge repercussion which is still being felt today. Paula Ann Nunn, Ellen Paddock, Susan Maughan, Richard George and Marion Groves are just five local people who contracted mesothelioma and unfortunately passed away as a direct result. Mrs Maughan died only last October. Her daughter told the inquest that it took the local authority five days before they told the community so they were exposed to asbestos for all that time. The ash cloud which spread over an area of 15 square miles attracted many small children who played in it as if it were snow which fell in local gardens for days before people were told it was unsafe. We have heard from the noble Baroness, Lady Finlay, how very harmful that could be to those children. My colleague and noble friend Lady Pinnock has told me about many cases in her area of Kirklees, resulting from working for a brake linings factory, long since closed down.

Mesothelioma is generally resistant to conventional cancer treatment. Long-term survival and cures are extremely difficult, but that does not mean that the mistakes of government and industry alike over the past century should not be paid for by compensation to those affected. The current range of available benefits, both lump sums and long-term allowances, must get to the right people at the right time. The Mesothelioma Act 2014, for which we have to congratulate several noble Lords present today, went a long way to help those who had been unable to access compensation because of the passage of time or a lack of effective record-keeping identifying those responsible. Since 2014, a total of £62.2 million has been awarded. However, of those who were unhappy with the result and requested a review of what they were awarded, 25% had their compensation rate altered—I presume upwards. Given that this illness is still an issue affecting thousands of British people every year and that the nature of mesothelioma’s progress means that time is literally of the essence, it is essential that the correct support is awarded without delay in all cases. Given the significant number of cases reviewed since the launch of the scheme, how do the Government intend to learn from those cases and improve the process so that the right decision is made the first time in as many cases as possible?

Can the Minister also outline the ways in which the Government are promoting the compensation scheme, so that those most in need are fully aware of the support available? Given the vital work done by the charitable organisation, Mesothelioma UK, and its invaluable lung nurse specialists, do the Government intend to follow its lead and introduce more specialist nurses into hospitals to support patients?

Finally, to safeguard against mesothelioma cases slipping under radar given the disease’s lengthy latency, are the Government willing to begin actively seeking out those involved in previous incidents, such as the Donnington fire, so as to promote early identification of their disease and to get immediate support to them?

Medical Students

Baroness Walmsley Excerpts

Wednesday 26th October 2016 Lords Chamber

[Lord Prior of Brampton]

I respect the views of the noble Lord but I have looked very carefully at the number of applications coming into medical schools in 2016 compared with the previous year. In 2016, there were 20,100 applications for all medical schools, including in Scotland. The previous year the figure was 20,390, so there is no firm evidence to support the view that the noble Lord expresses. There were some rumours that St George’s was having trouble filling its places. I have investigated that and understand that it was a result not of any lack of demand but of the fact that it wanted to wait until A-level results had come through so that it could choose the best candidates based on those results. So I do not think there is any evidence to substantiate the noble Lord’s point.

[Baroness Walmsley (LD)]

My Lords, one of the objectives in Health Education England’s mandate is to reduce our dependency on temporary staff. However, the National Audit Office tells us that we are short of 50,000 clinicians, and that HEE is failing to be sufficiently proactive in addressing the,

“variations in workforce pressures in different parts of the country”.

Is the noble Lord’s department monitoring how well HEE is responding to these challenges?

[Lord Prior of Brampton]

My Lords, predicting the future requirement for doctors is extremely difficult. It is more a matter of prophesy than science. The fact that we are now going to fund an extra 1,500 doctor places a year, which is a 25% increase, should make a huge difference.

Breast Cancer: Innovative Drugs

Baroness Walmsley Excerpts

Monday 24th October 2016 Lords Chamber

[Lord Prior of Brampton]

We received the report today. We warmly welcome its principles and believe that by combining the great depth of our research base in this country with the NHS, which is the largest single integrated provider of health services in the world, we can create a world-leading life sciences base in this country. The detailed response to the report and the costs attached to it will come in due course.

[Baroness Walmsley (LD)]

My Lords, repurposed off-patent drugs often fall in the cracks between the processes of NICE and the processes of NHS England, both of which organisations take the role of approving these drugs. The Accelerated Access Review recognises this problem and recommends that the new streamlined process involve both organisations talking to each other to make quite sure that that does not happen. What will the Minister’s department do to ensure that under this new streamlined process these drugs do not fall between the cracks, because many of them are very useful to patients?

[Lord Prior of Brampton]

My Lords, I need to consider the report in detail. I do not believe that repurposed generic drugs naturally fall within the AAR streamlined procedures, although it is very important that they do not fall between the cracks. The AAR is largely designed for new products rather than for repurposing old products.

Mental Health: Young People

Baroness Walmsley Excerpts

Tuesday 11th October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, in his recent national confidential inquiry, Louis Appleby reported that in 36% of all suicides of people aged under 20, family breakdown or family circumstances were part of the cause. My noble friend is absolutely right that families are critically important. That is very much part of the strategy in our Future in Mind paper. I was horrified by the figure that 43% of all people who took their own lives under the age of 20 had had no prior contact with any agency—no contact with GPs, no contact with CAMH units, no contact with schools—about their condition. Nearly half the people who took their own lives were completely below the radar. That is a shocking figure.

[Baroness Walmsley (LD)]

My Lords, I ask the Minister about young people with mental health problems in the criminal justice system, where they are particularly vulnerable to self-harm and suicide attempts. Recent draft NICE guidelines recommend that all staff working in the criminal justice receive training to recognise and respond to mental health problems. Although the NHS is not responsible for the physical or mental health of those in custody, the guidelines recommend co-operation between healthcare and the criminal justice system on mental health, so how will his department respond to them, and who will fund the training?

[Lord Prior of Brampton]

My Lords, I do not think I can answer the question about who will fund the training; I will write to the noble Baroness to answer it. She is absolutely right that a huge proportion of people who are in the criminal justice system, in prison, also suffer from mental health problems. Tackling the mental health problems of people in prison is just as important as tackling them outside. If I may, I shall write to the noble Baroness on this matter.

Drug-Resistant Infections

Baroness Walmsley Excerpts

Thursday 15th September 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I too congratulate the noble Lord, Lord Lansley, on initiating this debate. Antimicrobial resistance is a global health disaster waiting to happen, so it could not be more important and it cannot be understated. The report we are debating today is extremely comprehensive and makes a large number of very important recommendations, most of which are practicable and very cost effective. I was glad to see that they focus mainly on reduction and prevention.

Developing new antimicrobial products is important, but it is a bit like closing the door after the horse has bolted. We must shut the stable door and stop the horse bolting in the first place. Global co-operation and a massive awareness campaign about the problem of drug-resistant infections will be essential to tackling it. I have my doubts about whether this could ever really work, but it must if we are to defeat this terrible threat. Given the difficulties and cash shortages of some of the countries that would need to be involved, we would do well concentrate on two things: what we can control within our own shores, and co-operating where we can with international initiatives and funding projects in poorer countries, perhaps with the DfID funding for the Department of Health referred to in yesterday’s debate on smoking.

If we are to be able to reduce the prescribing of antimicrobials to humans, we need to reduce the pressure on doctors from patients who do not really need them. That will take public education and a culture change—and of course we know that a lot of them do not work anyway, so it will save money as well. But we also need to improve rapid diagnosis, as has been said, and develop the use of vaccines and other alternatives to the use of antibiotics.

Vaccine programmes have been very cost effective over the decades, often saving society more than 10 times the cost of their development. But, as the report points out, new vaccines relevant to AMR are more complex and therefore more costly to develop. The report’s authors therefore recommend a greater level of investment in this area with funding from government, charities and international organisations. I do not go back in your Lordships’ House as far as 1998, but this recommendation cast my mind back to the House of Lords Select Committee on Science and Technology report in 2002-3, entitled Fighting Infection. I was a member of that committee. In our report we said:

“We were particularly impressed, when we visited the National Institutes of Allergy and Infectious Disease in the US, to hear about their Small Business Initiatives. Small companies willing to take financial risks inherent in developing a vaccine could apply for up to $100,000 to cover initial development costs. If the company then patented the vaccine they were obliged to make every effort to bring it to market … Pharmaceutical companies invest ten or twenty times less money in vaccine R&D than in therapeutics. They regard the public expectation that vaccines should not have any side-effects as a particular burden. Such public anxiety requires vaccines to be more thoroughly tested than other pharmaceutical products in order to reveal any potential side-effect. This informs companies’ risk-analysis of products to decide whether or not to further develop or to market … Pharmaceutical companies desire clearer guidance from Government about levels of demand”.

We recommended that,

“vaccine development should be facilitated and … that the Government should develop and maintain clear evidence-based guidelines about vaccine requirements and should create financial incentives to enable early research, development and commercialisation of vaccines”.

That was in 2003, and I fear that the same needs still exist today. What are the Government doing to encourage and enable the development of new vaccines? Do they have a similar scheme to assist smaller research companies to mitigate the risks associated with the development of vaccines and other treatments, such as the company producing reactive oxygen, mentioned by the noble Lord, Lord Colwyn? We have to accept that development will have to be done in the richer countries, of which we are one—and, of course, happily we also have the skills here.

I was glad to see the warnings about the prophylactic use of antibiotics in agriculture because excrement from livestock is subject to even looser waste management practices than human waste. So not only are we taking in those chemicals in the meat that we eat but they are also being flushed away into our rivers, streams, soils and also the sea, where they are picked up by fish. So even careful usage and hygiene on one continent can be neutralised by poor practice on another—hence the need for global action. Of course, this is in addition to the effect of the mass movement of people, referred to by the noble Lord, Lord Trees.

Clearly, the consumer needs more information about the antibiotics used in meat production. If we had that, I am convinced public pressure would reduce their use in food production. I absolutely agree with the comments of the noble Lord, Lord Lansley, and the noble Earl, Lord Selborne, about this. I hope that our departure from the EU will not stop us from banning more categories of use than we have already. But hygiene measures to prevent these products getting into the water we drink and the fish that we eat are also essential. That should include antimicrobials in development, which should be disposed of by pharmaceutical researchers in a way that does not pollute our water. I use the word “pollute” deliberately, because these products can be just as dangerous as the microbeads which have recently been brought to our attention as a great danger to marine life.

There is another danger which I did not notice mentioned in the report. That is the fact that bacteria can swap bits of their DNA with other bacteria—and this is very significant. A drug-resistant bacterium that passes through the intestines of any animal into the local waterway may not in itself be a pathogen that normally threatens human health, but that benign bug can share its drug-tolerating secrets with others. David Cummings, a biologist at Point Loma Nazarene University in San Diego explains in his paper on the subject:

“It’s not necessarily important what species is holding on to the DNA as long as the DNA is held on to and propagated. Then it can later be released to cause disease in an animal, plant or human”.

Of course, course, drug-resistant strains of bacteria—to go back to what the noble Earl, Lord Selborne, said about Darwinism—tend to be the fittest, and therefore survive. Cummings’s research has identified dangerous DNA in the river sediments around San Diego and across the Mexican border. He says:

“These coastal wetland habitats are becoming sinks and ultimately sources for drug-resistant bacteria—more importantly, sinks for the DNA that provide resistance”,

and he points his finger at very common things, such as pet waste, bird faeces, leaky sewer pipes and hospital waste effluent as the likely culprits.

Bacteria are very biologically clever and flexible. Not only are they able to develop resistance to our antibiotics and thrive but they can then pass that resistance on to other bacteria that can harm us. So our focus needs to be not only on pathogens and developing ways of killing them but on reducing the use of antimicrobials as a whole. In relation to that, I was very interested in the section of the report covering the provision of clean water and proper sanitation in four middle-income countries. These simple, fundamental basics of public health, which we take for granted here, can break the chain of infection and reduce the need for antibiotics by up to 60%. This in turn reduces the development of drug-resistant strains.

I saw for myself the practical benefits of improvements in these areas when I visited an area near Calcutta with UNICEF a few years ago. I have never seen more brand new toilets in a few short days in my whole life—and, of course, people were very proud of them, as well they might be. The benefits of clean water to the schoolchildren, with whom I washed my hands with soap before a meal, showed in their smiling healthy faces and their growth charts on the wall of the school. The benefits of proper toilets to the mothers, who earned money by manufacturing them, and then of having them available in their homes, were enormous and obvious. I have mentioned before the UNICEF project in a village where clean water was being pumped up from a well by a pump which was serviced regularly by the women. They may not have realised it, but they were not only saving their children from diarrhoea but were contributing to limiting the global development of antibiotic resistance.

The report also recommends the development of more rapid diagnostics and early recognition of human disease. Obviously, early treatment will require smaller quantities of antimicrobials. The Royal College of Nursing agrees. One key recommendation in its briefing was implementation of rapid diagnostic testing for suspected cases of pneumonia and investment in systems that capture the rationale for prescribing antibiotics to improve practice, reduce unnecessary prescribing and cut the cost to the NHS. The RCN also calls for a national strategy for infection prevention and control, but rightly points out that AMR is not exclusively a hospital or even a healthcare-related issue, and multisector engagement is necessary.

For so long, we have had so many very effective treatments for infectious diseases that we are in danger of being casual about infection control. After all, if we get an infection, the antimicrobials will deal with it, will they not? Well, perhaps not any more. The many factors that we have heard about in this debate that make it easy for micro-organisms to develop drug resistance, all put together, make me feel that the human race has become very cavalier about infection—we have in the West at least. For example, all hospital wards and departments that I have been in now have little machines at the entrance with antimicrobial stuff that you can rub on your hands. But do we always use them? I must admit that I do not always. When hospitals look superficially very clean, as most do, it is tempting to forget the millions of invisible but potentially dangerous microbes lurking in every corner. Of course we do not want to live in a completely sterile environment, because that would not allow our immune systems to develop strongly, and we need that. The human immune system is a wonderful thing but it cannot cope with overwhelming odds. We need to take all the recommendations of this excellent report to heart. As the report says, it will save money as well as lives. Can the Minister tell us how the Government plan to respond?