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?

Smoking-Related Diseases

Baroness Walmsley Excerpts

Wednesday 14th September 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, last year, the Minister Jane Ellison confirmed that the Government were working on a new anti-smoking plan to be published this summer. I too hope that we are going to hear news about that from the Minister today. Jane Ellison stated that the Government would seek to,

“further empower local areas and support action within them, particularly where tobacco control strategies can be tailored to the unique needs of local populations”.—[Official Report, Commons, 17/12/15; col. 636WH.]

The Government, she said, would also seek to tackle the “stark differences” in health outcomes among smokers from different parts of the country. I strongly support those ambitions but fear that those words have not yet been translated into enough action. Indeed, the Government’s action in making cuts to public health funding for local authorities has flown in the face of those objectives.

The BMJ says that prescription medication and personal support are the best routes to quitting smoking. The Government agree, and yet up and down the country local authorities have reluctantly had to cut these services. The Government, therefore, are relying on the commercial supply of expensive aids to quit smoking, such as patches and electronic cigarettes, in order to achieve further reductions in smoking. I would like to know whether the Government support prescribing more of those aids to the people who really need them but cannot afford to buy them.

The Government have also said that although they believe that e-cigarettes can help smokers quit smoking, they are,

“not harmless and there is a lack of evidence on their effects in long term use”.

I would certainly agree with that. There is massive evidence that e-cigarettes are much safer than smoking, but there is also some evidence that they may have undesirable short and long-term effects, particularly on the heart. It was irresponsible for a national newspaper to claim that vaping is just as dangerous as smoking. There is no evidence for that claim. However, there is still a lot that we do not know. Therefore, I now repeat the call I made during the recent debate on the EU tobacco directive: we need more research. After all, we now have many thousands of users, and I am sure many would be happy to co-operate with research.

It is estimated that over 200,000 children take up smoking every year. I call on the Government to ensure that every child has good-quality PSHE lessons in which the dangers of smoking are emphasised. I welcome the proposed removal of packets of less than 20 cigarettes, which used to be so popular with children, and also the plain packaging and larger pictorial health warnings. I hope that Brexit does not get in the way of all that.

The BMA calls for more measures to protect others from second-hand smoke. This is particularly important for children. Since we cannot ban smoking in people’s own homes, it is really important to help all smokers voluntarily give up smoking or never to smoke when children are present. Those on these Benches fought for the legislation that banned smoking in cars with children present, but the ban is not being properly enforced. Will the Government carry out a public information campaign about this and encourage the police to enforce the law?

NHS: Health and Social Care Act 2012

Baroness Walmsley Excerpts

Thursday 8th September 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I thank the noble Viscount, Lord Hanworth, for initiating this debate, and the noble Lord, Lord Lipsey, for what he said at the beginning of his remarks. I think we all have a great deal to thank the NHS for and we should always remember that.

There is no doubt that the 2012 Act was the biggest reorganisation the NHS has ever seen. It was also probably the most controversial. It was opposed by the British Medical Association, the Royal College of Nursing, the Royal College of Midwives and the Royal College of General Practitioners. While accepting the principle that doctors should have a role in commissioning, the Royal College of Surgeons and the Royal College of Physicians were highly critical of the proposed mode of implementation.

I would judge the success of the Act by whether it minimised the health inequalities in this country, whether it treated physical and mental health equally, and whether it made health and social care sustainable for the foreseeable future. Whatever David Cameron and the noble Lord, Lord Lansley, had hoped would be the benefits, I suggest that we are yet to see them fully realised. Experts agree that none of the many reorganisations has really benefited patients in the end, and this was a particularly expensive one. One wonders how many treatments could have been paid for by the £1 billion redundancy bill alone.

The stated purpose was to “liberate” the health service. Well, it certainly liberated a lot of money which is now in the pockets of many private providers who have come into the health service since 2012. I am not saying that I believe any participation of private companies is in itself a bad thing—of course not—if they can provide better services at an equal or smaller cost to the public purse than that offered by NHS providers. The primary principle must always be that healthcare is, as far as possible, free at the point of need and cost effective to all of us taxpayers. The problem is that we are now seeing evidence that the criteria for whether we need the services or not, and therefore whether we get them, are being tightened in both health and, particularly, social care, as some services close down and the rest try to provide for a growing and ageing population, and pay for healthcare price inflation.

Of course, one cannot attribute all the cost inflation to the profits made by privatised services. Some of it is attributable to the increasing cost of the research that underpins the development of wonderful new drugs and treatments. That of course is something that I, like the noble Lord, Lord Kakkar, welcome, although there is always room for effective price negotiation at a national level. However, the fact remains that the NHS is struggling in a way that we have not seen before, and this is surely unsustainable. The NHS budget for this Parliament, as we heard from my noble friend Lady Tyler of Enfield, will be short of £22 billion by 2020, and the solutions outlined in the Five Year Forward View are not yet showing convincing results. It is right that all services are scrutinised as to their efficient use of money, and I understand that millions could be saved if the least efficient took several leaves out of the books of the most efficient. However, as with many other things, you need money up front in order to save costs down the line, especially if you are going to replace face-to-face consultations with digital communications and home testing kits.

On top of that, the Government promise £8 billion extra for the seven-day NHS, which even Simon Stevens says is not enough. A majority of acute hospital trusts are in deficit, and many GP practices are ceasing to take new patients because of unacceptable waiting times for appointments. Everyone knows how concerned the junior doctors are about all this. Although I believe that the planned series of five-day strikes should not go ahead without a further ballot of all BMA members, this historic reaction of the doctors to government policy does indicate that the dispute is not just about the detail of their weekend pay or training structures. They are worried about the survival of the NHS as we know it. Clearly, they have made their judgment about the effects of the 2012 Act.

Sustainability was a key word in the noble Viscount’s Motion for this debate, and it has to be one of the key criteria for judging the 2012 Act—apart, of course, from whether it improves services for patients. Nobody I have talked to believes that the current proposals for economies and efficiencies will deliver what is needed, especially given the continuing rising demand. There is evidence that the preparation of the sustainability and transformation plans is not going well. The STP process has been very top down and has become focused on short-term savings rather than longer-term sustainability. This could lead to fragmented care and wider inequalities. Neither has it been very transparent.

A current example of short-term savings is the recent closure for three months without consultation of the 12-bed ward at Rothbury Community Hospital in Northumberland. The hospital is only nine years old, purpose built to serve this very rural community, and is a valued resource. It serves a remote and ageing population, providing care to patients whose families would have enormous difficulty visiting them if they had to go to the nearest general hospital. There are serious concerns about whether due process has been followed. I am not sure, frankly, whether it is part of an STP, but it certainly does not sound like the result of a thoughtful, long-term review of local need, and is opposed by the local people and the local GP practice. Would the Minister care to comment?

Accountability is another issue which has not been well served by the 2012 Act. Even when the Bill was going through Parliament, there were concerns about this. Senior figures from the King’s Fund said at the time:

“At a national level, it is difficult to see who, if anyone, will be in charge of the NHS”.

It is still unclear how the five national bodies interact with each other, and where the Secretary of State comes into the picture. Does the buck stop with the DoH and Jeremy Hunt anymore, other than providing the money? It seems that when it is inconvenient for him to take responsibility Mr Hunt relies on the fact that powers have been delegated to these five agencies.

At local level, fragmentation, as we have heard from other speakers, makes accountability difficult. Although the principle of clinicians having a role in commissioning is one which most of us would support, there are concerns about the abilities of some of the clinical commissioning groups and about the fact that their very existence means a postcode lottery. Devolution to a local level has its advantages, but there are dangers, such as to patients with rare but expensive diseases which may not be funded by their local CCG. This is where national strategies come in, but they need money too.

Mental health, as we have heard from the noble Lord, Lord Lansley, is still a work in progress. Only today, my right honourable friend Norman Lamb has published evidence of the shambles in CCG provision for psychosis.

My greatest hope for the 2012 reorganisation was the local health and well-being boards. I hoped that they would bring together local services and resources and make the most appropriate provision for public health and social care in their areas with the involvement of the local authorities. Sadly, repeated cuts in public health funding have got in the way of local authorities’ realising their potential in making a difference to the health of their local communities. When public health funding is cut, and cannot be subsidised by cash-strapped local authorities, prevention suffers, leading to increased costs in the long term. We have seen preventive services being cut all over the country. In addition, local council representation on the boards is in the minority. The boards’ powers are not really broad enough for them to influence matters such as housing and air pollution, both of which have major consequences for health. Colleagues on health and well-being boards believe that the cultural divide between the self-determination of local government and the top-down NHS is a huge hurdle to these boards achieving better health and social care integration.

I strongly believe that the public do not want to be treated by more and more doctors on more and more days of the week. What they want are services to help them remain well for longer and for appropriate services towards the end of their lives, and they want that period of acute need to be as short as possible. Sadly, this country falls behind others in that respect. In the Scandinavian countries, the period of high-level need for health services at the end of life is, on average, much shorter than it is here. People remain well longer. Why is that? I would judge the 2012 Act on whether it promotes the Scandinavian standard. In order to do so, it would have supported more preventive services. I for one would have cheered. But it did not, so I have not.

What we need now, as has often been said by my right honourable friend Norman Lamb, is a genuine cross-party debate on how much we need to spend on health and social care and the fairest way of raising the money. I encourage all parties to consider this proposal seriously.

I would also propose that one of your Lordships’ excellent ad hoc Select Committees should do post-legislative scrutiny on the effects of the 2012 Act, along the lines of the very useful report of the committee chaired by the noble Baroness, Lady Deech, on the impact on disabled people of the Equality Act 2010, which was debated in your Lordships’ House on Tuesday and was a very useful exercise.

Will the Minister consider supporting proposals for such a committee on the impact of the Health and Social Care Act 2012? It would be able to take evidence in a way that has not been possible for noble Lords preparing for today’s debate. I think that we would learn a great deal from it.

Junior Doctors: Industrial Action

Baroness Walmsley Excerpts

Monday 5th September 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the noble Lord has raised many questions in his response to our Statement. He may well have read the article published earlier this week in the Times by Sir Simon Wessely, the president of the Royal College of Psychiatrists, which goes to the heart of what I would call the non-contractual issues that have bedevilled, coloured and provided the context for this dispute:

“Changes to the way that doctors are trained means that juniors face switching not just jobs but addresses every few months without much say about where they end up and when. Many seem condemned to spending years rootlessly shuffling from one place to another like lost luggage. Without any familiar faces, long hours are endured in relative isolation and managers who change all the time provide little or no recognition, let alone reward”.

This in a sense is what lies behind much of the dispute. The fact is that we had a contract that was wholeheartedly welcomed by Dr Ellen McCourt, now the president of the BMA, and by the association itself. The issues of difference in the contract were pretty small.

We have been discussing this contract for three years now and the Government have made 103 concessions. The Secretary of State’s door has been open throughout that time. The new contract is due to be introduced in October and at some point we really have to get on and introduce it. There is provision within it to review aspects as it goes forward. We have committed to looking at the gender pay issues that have been raised by the BMA and today HEE has published the work that it is doing on non-contractual issues with the BMA when the association is prepared to talk to it. The Government are bending over backwards to meet the BMA, but there comes a point where we just have to bite the bullet and go ahead with the contract that has been agreed, and that is the place we are in now.

The noble Lord referred to a lack of trust in local management and in the Secretary of State, but we now have the guardians of safe working hours built into the contract. They have a contractual commitment to report every quarter to the boards of trusts and to the GMC and the CQC every year. Plenty of independent safeguards have been built into the new contract. So while of course I understand many of the issues raised by the noble Lord, the Government have gone the extra yard every time they have been asked to do so and now we must get on and introduce this contract.

[Baroness Walmsley (LD)]

My Lords, I apologise to the Minister for not getting up quickly enough to add my questions from the opposition side before he gave his last response. We on these Benches welcome the fact that the strike planned for next week has been postponed. I think we have all taken very much to heart what was said by the GMC this morning. I hope the Minister can give an assurance that the Secretary of State will take this breathing space as an opportunity to get back around the table with the junior doctors not only to explore the details of the contract, which may not yet have been hammered out to everyone’s satisfaction, but to get to the core of the reasons why they are so up in arms.

I am very impressed by the fact that when junior doctors are marching along the street, they are not shouting, “Save our weekend pay” or “Save our training structure”, they shout, “Save our NHS”. That is what every single doctor in this country is committed to. The reason why doctors are so concerned is not the Government’s intention to make tests or more frequent investigations available on Saturdays and Sundays for patients in hospital, it is the fact that there are gaps in the weekday rotas now. The Minister is saying that there will be extra money and extra doctors. Where are they going to come from? Does he know how many doctors have investigated the possibility of emigrating or have even actually emigrated since the beginning of this dispute? I ask this because I am hearing about it all the time. I wonder where the new doctors will come from in order first to fill the gaps in the weekday rotas and then to provide extra services at the weekend. The £10 billion mentioned in the Statement is clearly not enough when we already have a £22 billion black hole in the NHS.

Over the Summer Recess we had so many news stories about units being closed, not just to reconfigure the services and provide better service for patients, but to save money, because the system is desperate to do that in the short term. The sustainability and transformation plans clearly do not have the confidence of the doctors, partly because they are very opaque and partly because they are very short term. They are picking up on any short-term economies they can make, rather than looking at the very long-term savings that might be made and bring better provision for patients. Will the noble Lord say where the extra doctors are coming from and how the Government plan to convince existing doctors in this country that they will be fully supported if they are to implement the Government’s policy?

[Lord Prior of Brampton]

My Lords, the noble Baroness made a valid point when she said that when she meets junior doctors on their demonstrations or marches, they are concerned about the NHS—rightly so; it will be a sad day when doctors are not concerned about the future of the NHS—but that is no reason for going on strike over this contract. We are perfectly happy to have a debate with them. We will disagree and agree on some things, but to launch a wave of strikes over this cannot be right. As the noble Baroness indicated, it is not the contract that they are worried about at all; they are worried about much more general things than the state of the contract.

Staffing is a big issue. There is no question but that after the Mid Staffordshire tragedy, we saw a huge increase in agency staffing. We saw that increase because we did not train enough of our own doctors and nurses. That is a long-term issue about increasing training numbers, but, in the meantime, part of the £10 billion of extra money we agreed to put into the NHS, which the noble Baroness’s party agreed to do at the last general election, has to go towards increasing staffing in our hospitals.

Health: HIV

Baroness Walmsley Excerpts

Monday 5th September 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I too congratulate the noble Lord, Lord Black of Brentwood, on introducing this important debate, and at a particularly serendipitous moment—the very first day of the noble Lord, Lord Fowler, as Lord Speaker. I join with noble Lords who have expressed their admiration for his vision and energy. Not many of us in this House can say that we have saved hundreds, if not thousands of lives; the Lord Speaker did.

One of the subsidiary UN sustainable development goals is to end the epidemic of AIDS—by which is meant HIV—by 2030. UNAIDS has set interim targets for 2020 which have been agreed by UN members, including the UK. Individual nations are expected to develop a national strategy for HIV. However, England has not had one since 2010, which is what we have been exploring in this evening’s debate. Therefore, my first question for the Minister is: why not? We have the tools now. How sad it is to think, as we heard from the noble Lord, Lord Maude, who lost his dear brother many years ago in the early days of HIV infection, that if the tools we have today had been available then, many of us would not have lost close family members and close friends. I too lost a dear friend years ago, in the early days, and I still mourn and remember what a lovely person he was and feel so sad that it happened at a time when research was in its early stages. As we have heard, part of the problem is that although we do quite well on treatment, we are falling behind on diagnosis. Thousands of people have undiagnosed HIV, which means they will pass it on without knowing it. They will also develop associated conditions for which proper treatment will be difficult because of the undiagnosed HIV.

Since April 2013, prevention of ill health generally has been funded from the ring-fenced public health budgets of local authorities. But while NHS funding has been protected, public health has been subject, as we have heard, to repeated government cuts—£200 million in one year—which I and others have lamented in the House many times. We are also told that there will be further cuts of 3.9% a year over the next five years. Government proposals to abandon the ring fence or even fund public health through business rates could further lessen the funds available for this work.

HIV prevention funding is already inadequate to meet changing needs and behaviours and is a fraction of what it was 15 years ago. It is also 55 times less than the amount spent on HIV treatment. In this situation a more effective and widely available prevention strategy is needed. If we can have a strategy on hepatitis C, why can we not have one on HIV? HIV prevention needs a strategy because it requires a combination approach, including traditional forms of outreach, sexual health counselling, condom schemes, harm reduction and of course—I say this particularly because the noble Baroness, Lady Gould of Potternewton, is not able to be with us this evening, and she and I share an interest in this—good sex education in schools, with frank discussion of the risks and of how young people can protect themselves. That is what is needed. Information is power when it comes to health, as the noble Lord, Lord Fowler, proved in his campaign many years ago.

Most HIV sufferers are very responsible about their condition. However, the majority of onward transmissions occur when the transmitter is not aware that he or she has AIDS. The majority of those already diagnosed are in treatment and, since treatment reduces viral load to the point where transmission is almost impossible, new cases are not coming from there; they are coming from people who do not know that they have the disease. Therefore, better diagnosis is essential in defeating the epidemic.

Why, then, when the number of diagnoses is rising, does the NHS refuse to make use of or fund PrEP—the most effective preventive treatment yet devised, as we have heard very clearly—and then appeal the decision of the High Court? I find it very difficult to understand why the NHS wants to spend its money on lawyers instead of treatments. We have to balance the cost of treating a patient pre-infection against the cost of treating the disease if it happens, as well as against the loss to the public purse of the talents of that person and the taxes that would be paid if he or she was fit and healthy and not suffering from HIV.

Prevention has long been at the heart of our NHS. Vaccination was one of the most beneficial discoveries of medical science and has been used over the years to save lives and to save the NHS many billions of pounds. Those of us who were war babies will remember that we had orange juice to increase our vitamin C level when we could not get citrus fruits, as well as cod liver oil to give us vitamins A and D to ensure that we did not get rickets. Programmes such as those prevented a lot of ill health and saved the NHS billions of pounds. Surely, pre-infection prophylaxis of such a dangerous disease corresponds to many of the vaccination and supplement programmes that have saved the lives of babies and children over the years.

For diagnosis to be improved, we need an effective programme of testing, as we have heard, but in 2014-15, contrary to national guidelines, 60% of high-prevalence local authorities did not commission any HIV testing outside the sexual health clinic setting. That is probably because they are so cash-strapped. Putting the financial burden of PrEP on them will not help the diagnosis rate; nor will it help them provide the support that many patients need to take their medication. On the whole, HIV medication requires a high level of adherence and some patients need support and help with that.

So we need a proper strategy, including PrEP being made available on the NHS for people in risk groups, not just for the sake of those at risk but for the sake of the many people to whom those patients might transmit the disease in the future. We must be realistic: risky behaviours happen and we have to live with that fact. Unless we protect from infection those who take part in those behaviours, we fail to protect the whole population. If the international community can help very poor African countries to eliminate a highly infectious disease such as Ebola, why cannot a wealthy country like ours eliminate HIV? We should get on and do it. We know how to do it but, as others have said, it needs leadership.

Bread and Flour Regulations (Folic Acid) Bill [HL]

Baroness Walmsley Excerpts

Friday 8th July 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I strongly support the noble Lord, Lord Rooker, in putting forward the proposal that the UK mandates fortification of white flour with folic acid or vitamin B9, and I congratulate him on his Private Member’s Bill and his persistence in promoting this measure. Twenty-five years ago when I first stood for Parliament, I was given the advice by my noble friend Lord Maclennan of Rogart to never take no for an answer. The noble Lord, Lord Rooker, is doing exactly that. It is good advice.

There have been mountains of scientific evidence that this fortification works in preventing foetal neural tube defects, prevents a great deal of disability and distress and causes no harm, as we have heard. When will the Government stop stalling and take action? I do wonder whether they would have taken the same attitude if it was a matter of men’s health rather than that of women and babies. I wonder whether a woman Prime Minister would have a bit more understanding of the level of distress that is caused to women affected by this issue. Perhaps we should start a petition of all the thousands of women who over the years have had to have terminations for this reason, or given birth to children with terrible disabilities. Perhaps that might have some effect.

To my mind, five facts make the case. First, currently the folate levels in the blood of women in the UK of child-bearing age are below WHO recommended levels and risk NTDs.

Secondly, supplementing the diet with vitamin B9 can protect against neural tube defects that can be caused by a shortage of this vitamin. Thirdly, there are 1,000 cases—that is a lot of people—of NTDs in the UK every year, of which 800 are terminated and 200 are live births. The terminations and the live births cause parents great distress and cost the NHS a great deal of money, both for the terminations and for the lifelong services needed by the children. Fourthly, supplementation needs to take place, as we have heard, before the 27th day of gestation—long before most women know that they are pregnant. It really is nonsense to rely on the suggestion that women planning a pregnancy should take supplements when we know that half of all pregnancies are unplanned and so, if followed 100%, that would prevent, at most, only half the cases. You cannot rely on women taking supplements, because only 28% of women of childbearing age take vitamin supplements and, for women under 20—the age group least likely to plan their pregnancies—it is even lower, at 6%. Fifthly, the UK has the second-highest rate of unplanned pregnancies, behind only the USA. However, as we have of course heard, there they fortify their flour and have half the relative incidence of NTDs compared to us.

The problem is getting worse. The number of abortions due to NTDs has risen 40% in England and Wales in the four years to 2013, which is the latest figure that I have seen. The availability of terminations free on the NHS is not a cost-free option. Termination is not in the best interests of women, because it can cause great distress and present dangers to the woman’s health. It is also a very bad strategy for the NHS, because terminations cost money and, of course, there are some women who would never choose a termination, no matter what. It is like controlling conception with the morning-after pill. It is even worse than closing the stable door after the horse has bolted; it is closing the stable door after the horse has bolted, broken down hundreds of fences and broken all four of its legs.

On the other hand, it would cost the Government nothing to insist that, along with calcium, iron, niacin and thiamine, manufacturers must fortify flour with folic acid. As we have heard, the principle of fortification has been established since World War II. I think that the case is made. At a time when prevention of disease is more important than ever before to ensure the sustainability of the health service because of the growing demand and rising costs, it is perverse to resist the call of the BMA and all the other medical and scientific experts, as well as the noble Lord, Lord Rooker, to agree to this small but important measure. I hope that the Government will stop procrastinating and will act by supporting and giving time to this Bill.

--- Later in debate ---

[Baroness Flather]

What amazes me is that we are talking about nudging and not doing this or that, but we often have research on issues which are of great importance not only to the individual—as we have been talking about—but to the family and to the country. When a child needs lifelong care, surely it is not a good idea to not do anything about that. We seem to be going round and round, saying that we cannot be led by research, while the Government must have their policy. But what is the policy based on?

[Baroness Walmsley]

The noble Lord has just read out a list of the functions of government. Would he not add protection to that? We chlorinate all our water to protect people from water-borne diseases. Why not put folic acid in flour?

[Lord Prior of Brampton]

I will continue with the example that the noble Lord, Lord Hunt, gave, of alcohol. Clearly, the Government have the responsibility to put the science into the public domain. But should they ban people from drinking more than 14 units of alcohol a week or should they leave it to people to make that choice themselves, on the basis of the information that they have? That is the philosophy that lies behind the Government’s position on folic acid. It is also our thinking on how we address the scourge of obesity and lies behind the way we deal with our smoking and alcohol problems and behind all our prevention strategies. It is about doing all we can to help people make the right choice, but ultimately accepting, outside of extreme circumstances, that the final choice has to be made by them and not by the Government.

This is why the Government agree with the statement made by my honourable friend in the other place, Jane Ellison, when she said that the Government consider that a broad approach to the promotion of good pre-conception health needs to be taken to make sure every child gets the best start in life. On balance, the Government have decided that mandatory fortification is not the right way forward and therefore have no plans to introduce it in England.

We know that good pre-conception health, of both future mothers and fathers, can lead to healthier pregnancies and good infant health. By contrast, poor pre-conception health—for example due to diabetes, poor diet, obesity or smoking—can lead to poor pregnancy outcomes, including gestational diabetes, NTDs, premature births, and poor perinatal and infant mental health.

Many parents make few preparations to improve their health before pregnancy. That is why a more proactive approach which promotes good pre-conception health to reduce the risk of poor pregnancy outcomes for women and their families should be adopted. This is why my colleague Jane Ellison has set up a ministerial round table. She held her first meeting with interest groups on 13 June to help identify additional measures to promote good pre-conception health.

I recognise the tragedy of neural tube defects. I recognise the urgency and passion that lies behind this Private Member’s Bill but, at this time, the Government have decided that, on balance, we are against mandatory fortification of white bread with folic acid and therefore have no plans to introduce it in England. Instead, all our efforts will be directed at promoting good pre-conception health. I realise that that is a disappointing but probably not unexpected reply to the noble Lord, Lord Rooker, and to his colleagues who support the Bill. Of course, that balance may change over time. As the noble Baroness, Lady Hayman, said, he is a formidable opponent and I have no doubt that he will carry on pushing the case for fortifying with folic acid. In time, who knows where that argument will go but, for the time being, the Government’s position is that we will not support the Bill.

NHS: Junior Doctors’ Contract

Baroness Walmsley Excerpts

Wednesday 6th July 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, it is certainly a matter of regret on all sides that this dispute has not been resolved in an amicable, satisfactory way; I agree with the noble Lord on that. The Secretary of State plans to introduce the new contract with NHS employers in a phased way beginning in November. He has said that in terms of how the contract is implemented and any extra-contractual issues that arise, his door is always open; he is willing to talk to the BMA and junior doctors.

[Baroness Walmsley (LD)]

My Lords, is it not entirely inappropriate for the Secretary of State for Health to claim that a 16% majority on a 68% turnout is undemocratic, especially when he represents a Government who are in power with the votes of less than one in four of the electorate? Has he now become a supporter of proportional representation? Is it not entirely irresponsible to try to impose on junior doctors this contract, which they are so against, at a time of great danger to the NHS because of the referendum result?

[Lord Prior of Brampton]

My Lords, 40% of junior doctors voted against this contract. That is a fact, but it does not alter the fact that it is disappointing and sad that so many junior doctors feel obliged to vote against. I am not downgrading that at all. I have not heard it said that it is not democratic. A significant minority of junior doctors have voted against the contract. We have a huge need to rebuild trust between the Government and the junior doctors. The vast majority of junior doctors are committed to their profession and the NHS and we want to rebuild with them the level of trust that always existed in the past.

Health: HIV

Baroness Walmsley Excerpts

Monday 4th July 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the judicial review is being held next Wednesday, which is only 10 days from now, at which point we will know the exact legal position. I really cannot comment further on it today. As far as this drug being widely available as a prophylaxis, it is widely available only in some countries for very specific groups of people. If we commission it in the future, it is important that we are clear about where we can get the most benefit from it.

[Baroness Walmsley (LD)]

My Lords, the PROUD study reported in the Lancet last year showed that the PrEP use of Truvada in high-risk groups reached nearly 100%. Are there any other preventive treatments for life-threatening diseases which are 100% effective but for which NHS England is refusing to take responsibility?

[Lord Prior of Brampton]

It is true that in the control group used in the PROUD trial there was a very high level of success—85% or 87%, I think—but it is critical to identify the right group of people. That is why NHS England is providing £2 million to test Truvada as a prophylactic among a wider group of people to see whether it is equally efficient.

Tobacco and Related Products Regulations 2016

Baroness Walmsley Excerpts

Monday 4th July 2016 Lords Chamber

[Lord Hunt of Kings Heath]

No doubt we will of course be able to see in the future what a Government would do in the event of Brexit. However, to be fair, at the moment we are debating these regulations, which have come into force. I have attempted to signal some of my concerns that this would have a negative impact on the use of e-cigarettes without detracting from the overall regulations. I beg to move.

[Baroness Walmsley (LD)]

My Lords, I was most interested in the speech made by the noble Lord, Lord Callanan, and in particular his gallant admiration of his colleague the Public Health Minister, who in my experience has usually been quite on top of her brief. I venture to warn the noble Lord never to make a mistake in your Lordships’ House, because I suspect that Facebook might be watching. I was also very moved by his defence—in fact it was quite tear-jerking—of the discrimination against the multi billion pound tobacco companies compared with the multi billion pound pharmaceutical companies.

I agree with much of what was said by the noble Lords, Lord Callanan and Lord Hunt of Kings Heath, about the desirability of encouraging smokers to give up smoking. There is no doubt that vaping devices have an enormous role to play in this campaign, as many former smokers have managed to give up through using them. However, the regulations are not just about vaping devices but include, as the noble Lord, Lord Hunt, pointed out, standardised packaging regulations, which are essential for ensuring the effectiveness of the health information and warnings on cigarette packs. They also help to enable the UK to meet its obligations as a party to the World Health Organization’s Framework Convention on Tobacco Control with respect to tobacco packaging and labelling, and product regulation.

There is no doubt that vaping devices have already been an enormous benefit to public health—although I fail to see why we need 25,000 different kinds of them—and have saved the NHS a great deal of money. When the directive to which these regulations give effect was first discussed in the European Parliament, as has been said, the Liberal group, which contained at that time several Liberal Democrat MEPs, worked hard to ensure that while the regulation of tobacco packaging continued to be robust, the regulations about vaping devices would be proportionate. Given that the original proposals followed the World Health Organization’s recommendation that these products should be licensed as medicines and would therefore be extremely tightly regulated, the Liberal group had some considerable success in making them a bit more proportionate, resulting in the directive as it is now. However, one of the things on which the group was not successful was the prohibition of commercial advertising of vaping products. This is the major item contained in my regret Motion.

According to the Royal College of Physicians, vaping is 95% less harmful than smoking and half of all smokers die from diseases that result from smoking. That is why it is vital that smokers can get information about these products and their benefits, and I regret very much that publicity about them is to be restricted. However, I support the noble Lord, Lord Hunt, in his call for a new public information programme to inform smokers of the benefits of switching to e-cigarettes. It may surprise your Lordships to know that half of smokers are not aware of how much safer for their health e-cigarettes are. I also agree with the noble Lord, Lord Hunt, in regretting the cutting of smoking cessation services—one of the many results of the public health funding cuts which I have condemned many times in your Lordships’ House.

I suppose that one of the reasons for the advertising ban is the fear that advertising will attract young people to vaping even though they have never smoked. This is of course undesirable, because nicotine vapour is very addictive, and I would not want to see children being attracted to spending their money on something so addictive and with no known benefits to their health. Indeed, more research needs to be done on the effect of nicotine inhalation combined with the various flavouring chemicals used in e-cigarettes. Some evidence is emerging that if inhaled, some of the flavourings may be harmful to the delicate cells lining the lungs. But although e-cigarettes have been around for years, there is no significant evidence that they are attracting non-smokers to take them up. On the other hand, we now have a large and growing cohort of people who use vaping devices, which is why I call on the Government to fund research on the benefits and—if there are any—the dangers of vaping.

Everything should be done to encourage smokers to switch to vaping, which is why my Motion also regrets that little attention has been paid to those vapers who claim that they need the higher-end concentration of nicotine products, which would be banned by some of these regulations, to help them give up smoking. Only time will tell whether that is the case. That is why the Government need to monitor and report on the implementation of these regulations and their impact on public health. While the further regulations on cigarette packaging are likely to be good, those on vaping devices could turn out to be bad.

Therefore, like the noble Lord, Lord Hunt, I do not support the Motion in the name of the noble Lord, Lord Callanan—that the Government should withdraw these regulations—because we need the ones that affect tobacco. However, although I sincerely regret the Government’s current intention to withdraw from the European Union in the fullness of time and hope very much that it never happens, the current situation does give us an opportunity. As things stand we are not able to keep the good tobacco regulations and ditch the undesirable ones, but the forthcoming negotiations do give us an opportunity to do a bit of cherry picking.

I therefore ask the Minister, what is the Government’s intention with regard to these and other EU regulations? Do they plan to adopt them all and then repeal the ones they do not like? If so, I call on the Government to consider carefully any deterrent to smokers switching that might result from these regulations, and to repeal the ones that deter them as soon as possible. Of course, that would require careful monitoring and publication of the results. On the other hand, in the unlikely event that the Government plan to repeal all EU regulations and then adopt new UK ones, I call on them to replace only the ones that affect tobacco packaging and marketing to further decrease the public health burden of tobacco and the terrible effects on the health of individuals and the NHS.

Given that all these regret Motions are non-fatal, I do not intend to vote on mine, although if the noble Lord, Lord Callanan, votes on his, my colleagues and I will vote against it. We are where we are. What matters now is what the Government do in future. Lives depend on it.

--- Later in debate ---

[Lord Forsyth of Drumlean]

My Lords, first I congratulate my noble friend Lord Callanan on the very excellent case that he put. I shall not proceed by repeating any of the arguments. I have looked at the regulations, but some people who have spoken in the debate clearly have not.

If someone wanted to sabotage a product, add to the costs of producing that product, limit the scope for competition with that product, and drive out of business small producers, it is hard to see how a more effective job could be done than in respect of the regulations that apply to electronic cigarettes. As far as noble Lords who argued that this is all a plot by the tobacco companies are concerned, one way of ensuring that all of this ends up in the hands of large businesses will be by pursuing exactly these regulations—by limiting choice and, of course, by creating a black market, which will be accessed through the internet, as we have seen occur over and over again in respect of medicinal products.

There seems to be no logic in the regulations. We have already touched on why some advertising is allowed but not others. I find it extraordinary that a Government should want to ban advertising when the evidence that we had from ASH—the noble Lord referred to that—states:

“Perceptions of harm from electronic cigarettes have grown with only 15% of the public accurately believing in 2016 that electronic cigarettes are a lot less harmful than smoking”.

If most people do not realise the benefits of it, what on earth is the logic of preventing people advertising it? How does the noble Baroness, Lady Walmsley, explain that she wants a public information campaign? How can we have a public information campaign without advertising the benefits of electronic cigarettes? Therefore, why is she against the advertising of electronic cigarettes? There is no logic in that.

I hope that noble Lords do not mind me mentioning the fact that my son is 37 years old. He has smoked cigarettes since he was 16, to the best of my knowledge, and probably earlier. He smoked very heavily, but three Christmases ago—I should declare an interest—I bought him an electronic cigarette. As a result, he has reduced the levels of nicotine and of all the things that we have tried—blackmail, bullying, nicotine patches, and everything under the sun—it has worked. The figures show that one-third of the 2.8 million adults who are vaping in this country are ex-smokers. The arguments being put for the public health benefits are overwhelming.

It pains me to say this, but this is a classic example of gold-plating of European regulations by the UK health department. The point is that, because the regulations are gold-plated, there is nothing we can do about them. They are EU regulations and we are required to implement them. I wonder what on earth was going on in the Department of Health that made it do this.

When we see something absurd happening, we should ask, “Cui bono?”. Who benefits from this? Certainly the Government benefit from it because people who are continuing to smoke cigarettes will pay a very considerable amount in tax to the Exchequer. I do not know how much a packet of cigarettes costs, as I have never smoked my life, but I am told it is about £9 for 20 cigarettes. People who start vaping will not spend that in a week. Families on low incomes—and many of the people who smoke heavily are among the lowest- income families—will benefit from something which enables them to deal with the addiction that they have to nicotine and remove themselves from it. Who benefits from this? Certainly not the people who are among the poorest in our country who are smokers. The Exchequer benefits—the Treasury benefits—if people are still smoking cigarettes because it gets its tax on the cigarettes, which is very considerable. Of course, the pharmaceutical companies, which sell the nicotine patches, benefit. The tobacco companies benefit because people are not switching away.

So what on earth are the Government doing, promoting the interests of the tobacco companies and the large pharmaceuticals—because that is the effect of this? The detail in the regulations is unbelievable. They even spell out which typeface—Helvetica—appears on the warnings, and whether it should be bold or italic. That is North Korean stuff: it is utterly absurd regulation. We may laugh at it, but, as the noble Lord, Lord Campbell-Savours, pointed out, it means that small businesses up and down the country will have to comply with these regulations, work out what they mean, change all their literature and everything else, and, as a result, be driven out of business.

We are in a bit of a quandary here, because there is much in these regulations that is quite desirable. When we have left the European Union, we will be in a position where we can hold our Ministers to account, hold votes and actually make these things happen. I had not realised that this is a very clever operation by the Department of Health. This is what you do: you have some absurd regulations, which you know you are not going to get through the House of Commons. So you persuade Brussels to include them in an EU directive; and heigh-ho, they have to sail through both Houses, because there is nothing we can do. We all take part in this pantomime, where we explain all the reasons why they should be changed, knowing full well that there is very little we can do about it until we leave the European Union.

So I congratulate my noble friend on his efforts and hope that, when the Government are free to do so, they will rethink these absurd regulations, which will undoubtedly cost lives. They are a classic example of how big business is able to use Brussels, together with lobbying organisations, to the disadvantage—and, in this case, life-threatening disadvantage—of the citizens of this country.

[Baroness Walmsley]

May I correct something that the noble Lord, Lord Forsyth, said? He suggested that there was an inconsistency in my remarks. I point out to him that my regret Motion regrets the advertising ban. If there were no advertising ban, it would be perfectly possible to have a public information campaign.

[Baroness Young of Old Scone]

My Lords, after the excursion by the noble Lord, Lord Forsyth, into Europe bashing, may I bring the House back to the subject in hand, which is these regulations?

The noble Lord, Lord Rennard, hit the nail on the head. Why are the major tobacco companies all piling into these products and their manufacture, distribution and promotion globally? It is not because, in a spirit of public protection, they want to see smokers take up these products rather than the main part of their activities, which will continue to be the pushing of tobacco globally.

We have to ask ourselves why there is a need for regulation in this area. The reality is that electronic cigarettes are effective in reducing, in the case of smokers, their reliance on tobacco, but this needs to be associated with a wider tobacco control strategy and some good, targeted, mass promotion—not of individual products in the vaping field but with the concept that, if you are a smoker, vaping may be one of the things, among others, that can help you. That must include psychological support as well as simply a change of product. I hope, too, that the Government will ponder on further increases in the price of tobacco; at the end of the day, that is the most effective way of reducing demand. Perhaps we can hear from the Minister what the Government are planning to do to ensure that there is public promotion of vaping as an alternative for smokers, access to good-quality, evidence-based stop smoking services and changes in costs.

We should not delude ourselves that tobacco manufacturers are getting into vaping products simply to allow people who are smoking currently to reduce their risk. They are getting into it because that, in their view, is the double whammy: an alternative product that can run alongside their very damaging products, which will continue, and a little bit of what in the environment movement used to be called “greenwashing”—I do not know what one would call it in the public health movement—in order to make their image more acceptable publicly. Therefore, I would not support the amendment of the noble Lord, Lord Callanan.

NHS: Unsafe Hospital Discharges

Baroness Walmsley Excerpts

Wednesday 15th June 2016 Lords Chamber

Asked by

[Baroness Walmsley]

To ask Her Majesty’s Government what action they are taking, in the light of the report of the Parliamentary and Health Service Ombudsman, to prevent unsafe discharges of frail and elderly people from hospital.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, unsafe discharge of frail elderly patients is unacceptable. Discharge can be very complex, and the integration of health and social care is vital for safe, joined-up care. We are using sustainability and transformation plans to promote integration, supported by the better care fund, creating a seven-day NHS and supporting local systems to develop integrated discharge systems and new models of care.

[Baroness Walmsley (LD)]

I thank the Minister for his reply, but is he aware that the ombudsman reports patients being discharged before they are clinically ready, without being assessed or consulted and without a care plan or their family being told that they are coming? Does he know why this is still happening 12 months after Healthwatch England’s report on the same issue? Does he agree that this not only puts an enormous financial burden on the NHS but is an appalling way to treat vulnerable people?

[Lord Prior of Brampton]

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”.

That is the issue on which we should be focusing.