Junior Doctors: Industrial Action

Baroness Walmsley Excerpts

Monday 25th April 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

First, my Lords, I thank the noble Lord for repeating the Statement made in the other place. No one could be in any doubt that tomorrow’s strike will be a very sad day indeed for the NHS and the country. What is so frustrating is that it could, I am convinced, have been prevented. Yesterday the Health Secretary was presented with a genuine and constructive cross-party proposal to pilot the contract and potentially avert this week’s strike. A responsible Health Secretary would have grasped the opportunity immediately or would at least have considered and discussed it. However, all we had was a tweet yesterday morning from the Health Secretary saying, “Labour ‘plan’ is opportunism”. That was a deeply disappointing response.

The proposal was not a Labour plan. It was co-signed by two respected former Ministers, the Conservative Member for Central Suffolk and North Ipswich, and the Liberal Democrat Member for North Norfolk, as well as the SNP’s health spokesperson, the honourable lady the Member for Central Ayrshire. It not only had the support of a number of medical royal colleges, including the Royal College of Surgeons, but, crucially, the BMA had indicated that it was prepared to meet with the Government and discuss calling off Tuesday’s and Wednesday’s action.

The Health Secretary has claimed that a “phased imposition” is the same as a pilot, but can the Minister explain how imposition on a predetermined timescale, with no opportunity to make changes to the proposed contract and no independent evaluation of the impact on patient care, can be the same as a pilot? Surely the Health Secretary should have welcomed independent evaluation. Surely he wants to know how changing this contract contributes in practice to his aspirations for more consistent emergency care across seven days of the week. And surely there was always a strong case for road testing the contract, thus enabling junior hospital doctors and managers in those hospitals to bring about changes in patient care and the outcomes that the Government want to see. The Government claim that any further delay will mean that it will take longer to eliminate the so-called “weekend effect”, but he has failed so far to produce any convincing evidence to show how changing the junior doctors’ contract by itself will deliver that aim.

On safety, NHS England’s update today says that the NHS is pulling out all the stops to minimise the risks to the quality and safety of care. We know that in many cases senior clinical staff will be stepping in to provide cover and ensure the provision of essential services. But there is no escaping the fact that this is a time of unprecedented risk, as regards what happens not just in the next two days but in the months and years ahead.

So can the Minister say how it will be safe to impose a contract when no one knows what the impact will be on recruitment and retention and when everyone in the service fears the worst? How can it be safe when we are running the risk of losing hundreds of women doctors, given the contract’s disproportionate impact on women—which, as the Minister knows, was disclosed by the belated publication of the equality assessment? How can it be safe to impose a contract that risks destroying the morale of junior doctors and to introduce a contract where there is no guarantee that effective and robust safeguards will be in place to control hours worked and shift patterns?

I noted that the Statement made some rather eloquent or exaggerated claims about the amount of money going into the NHS. I do not want to distract our focus from the essential point in question, but I point out to the Minister that we are on the longest period when the amount of real-terms growth going into the NHS has been less than 1% per annum, against an average increase since 1948 of 4% per annum. Our share of GDP spent on health is going back down to the days in the mid-1990s when we were spending about 6% of GDP. When you compare that to the demands being placed on the health service and the workforce demands that the new contract entails, it is very difficult to see how you can square the ambitions of the Secretary of State on the one hand and the practical reality of what resource has been made available.

Even at this late hour—and it is later than when the other place debated this Statement—I hope that sense will be seen and that the Government will recognise that there is a need to come back to the table to discuss not just the contract but the wider issues of the disengagement of the junior doctors, their concerns about the current approach to training, the fear that the imposition of this contract will lead to less well-trained doctors in the future, and indeed the issues around workforce and women doctors which have now been identified but on which I have yet to hear a convincing response from the Government. Even now, the case for getting round the table with the junior doctors is persuasive.

[Baroness Walmsley (LD)]

My Lords, instead of reeling off the litany of justifications and figures that we have just heard, is it not really time for the Secretary of State to put aside his pride, stop being pig-headed and listen to people in the national interest? He is clearly not listening to the junior doctors but will he not now listen to the sensible compromise proposal from other parties, including my own, which, I point out, does not undermine the Government’s objectives in the long term?

There are two big differences between the euphemistic “gradual introduction” that he is proposing and the pilot projects proposed by other parties. The first is that of course a pilot scheme can be independently evaluated. If the Secretary of State is so confident that this scheme will not damage patients or doctors, why is he afraid of proper evaluation? The proper and safe implementation of the new contract is surely worth a very small delay. Secondly, a pilot would mean that all junior doctors evaluated in a hospital would be on the same contract, whereas piecemeal introduction, which he is proposing, could mean that two doctors working side by side in the same department were on totally different contracts. Does the Minister not agree that this would be deeply divisive, as well as very difficult practically?

I am also very concerned about the idea of consultants manning A&E departments this week. While I am grateful to them for being willing to step forward in the interests of patient safety, I am concerned that it might work in the opposite direction in their own departments. Who will take the difficult decisions in, for example, cardiology or vascular medicine when urgent cases come up and the consultant is setting somebody’s broken finger in A&E? Has the Minister thought about that?

Should not the Secretary of State consider his position? Is he really the right person to solve this dispute? Patient safety, not the future of his own job, should be his prime consideration. This week, that will be at risk—website or no website.

[Lord Prior of Brampton]

My Lords, I am personally massively sympathetic to the concerns expressed to me by many junior doctors over the last three or four months, and in fact over the last 12 or 13 years. For family and personal reasons, too, I feel hugely in sympathy with the situation in which they find themselves. There is no doubt that the training of junior doctors is wholly inadequate. Their placements are short term and they move from one rota to another, with many rotas unfilled. There is a lack of teamwork now that the old firm has gone and nothing has replaced it. There is also a lack of leadership and mentorship for juniors.

When I compare the training and TLC that junior doctors get with that received by those going into accounting, law, big corporates, investment banking or other areas like that, I think that the lot of the junior doctor is not a good one. I remember reading a paper, probably 10 years ago, by Dame Carol Black when she was president of the Royal College of Physicians. She talked about the deprofessionalisation of the profession, and that really will come to pass if we are not careful. So I am hugely in sympathy with many of these issues and I have particular sympathy for women—especially young women with families and so on.

But let us be honest about this. That is not what this contractual dispute is about. Those are the big issues but this dispute is about pay on Saturdays. That is the issue that the contract fell down on. The noble Lord and the noble Baroness opposite talked about a pilot—but are we really talking about piloting a different Saturday pay structure? Everything else was agreed between the BMA and Sir David Dalton. To be honest, it is disingenuous to say that we could pilot something like that. Fundamentally, this is about pay, and I think that the junior doctors have got it wrong when they go on strike and withdraw emergency cover over an issue related to premium pay on Saturdays. It is simply not a big enough issue to cross the threshold of withdrawing emergency cover. They must recognise that. There will be a time to address the more fundamental issues affecting the training of junior doctors, and they must be addressed for the sake of the profession, of patients and of hospitals—but, sadly, that is not the issue that we are confronting today.

Two other important issues were raised. In answer to the noble Baroness, not all cardiologists and cardiac surgeons are rushing off to an A&E department. They will cover urgent and emergency cases in their own specialties as well.

Although in a way it is not for debate today, the noble Lord, Lord Hunt, raised the very fundamental, long-term problem of whether there are the resources within the system to deliver the ambitions that we all have for a world-class health service. Maybe today is not the time to answer that: we should probably focus on the matter in hand.

NHS: New Junior Doctor Contract

Baroness Walmsley Excerpts

Monday 18th April 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the noble Lord has raised two substantial points. The first is the difference between introduction and imposition. The fact is that, in the context of the NHS, where there is really only one offer, the difference between introduction and imposition is very small. Technically, it is true that individual employers are responsible for its imposition, but in reality, as the noble Lord will know from all his years in the Department of Health, the Secretary of State has considerable powers in this matter. I do not think the noble Lord would want all trusts to cut their own deals locally—there has to be an actual contract. It is true that when the legislation for foundation trusts was brought forward by the noble Lord’s Government a few years ago, they were given the power to negotiate their terms and conditions locally but, with the exceptions of, I think, Southend and possibly Guy’s and St Thomas’, they have chosen to stick with the national contract.

On the noble Lord’s last point about a way through, there are no winners from this dispute. The patients are very clear losers, and it is tragic that we have got to the situation that we have. The threshold for withdrawing emergency cover from hospitals needs to be a lot higher than the one the junior doctors are adopting on this occasion.

[Baroness Walmsley (LD)]

My Lords, this Statement comes at a time when the latest figures for A&E performance are the worst ever—1% lower, we were told last week, than the figure for January, which was the previous worst ever. The staff are very close to exhaustion. Thirty-five per cent of the doctors in this country were born abroad—the highest level in the OECD. With this very long-running dispute, many junior doctors are now saying that they are going to go abroad, and the Government have not told us whether they will increase the number of places for trainee doctors to try to compensate for that. We, and the doctors themselves, really need to know.

I would also like the BMA to tell us what percentage of its members now want to strike, because I think that it has given us old figures. However, if the Government want a seven-day NHS, this is absolutely the wrong time to target the junior doctors. They need to do some proper negotiation and not hold the sword of Damocles over the heads of some of the most important public servants we have.

[Lord Prior of Brampton]

My Lords, the noble Baroness talks about a proper negotiation. This negotiation has gone on for three years and there have been 75 meetings about this contract. It is hard to know what a proper negotiation is when you have that number of meetings over that period of time. The junior doctors may not recognise this but the Government feel that 73 different concessions were made during that period. In many ways this has gone on for too long, and that is why, when Sir David Dalton got involved towards the end of the contract negotiations, his advice was, “You’ve got to settle this”. We cannot go on and on negotiating and discussing these matters.

On the other point that the noble Baroness raised, the pressure on our emergency services is huge at the moment. She is right that the A&E performance in January was very poor, but it is simply the case that demand on our A&E departments is huge.

E-cigarettes: Regulation

Baroness Walmsley Excerpts

Monday 7th March 2016 Lords Chamber

[Lord Prior of Brampton]

I also congratulate the noble Lord on giving up cigarettes and taking up these other products. I do not know whether he has tried unicorn blood or crab leg flavours, but a multitude of flavours is available on the market. The directive has come about purely because of the feeling that although nicotine is better than smoking, it is not perfect.

[Baroness Walmsley (LD)]

My Lords, although these products are clearly much less harmful than smoking tobacco, they are not entirely harmless. They have a lot of noxious chemicals in them. What are the Government doing to inform people about the research on the potential hazards of these products, including the reduction in resistance to infections, reduction in fertility and changes in behaviour patterns?

[Lord Prior of Brampton]

My Lords, as I said, these new products are not perfect but are substantially better than smoking cigarettes. One of the purposes of the new directive is that there should be proper labelling on the products.

Pharmacies: Funding

Baroness Walmsley Excerpts

Wednesday 2nd March 2016 Lords Chamber

Asked by

[Baroness Walmsley]

To ask Her Majesty’s Government what steps they will take to ensure that every community continues to be served by a local pharmacy, in the light of their plans to cut funding to pharmacies in October.

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

My Lords, community pharmacies are a vital part of the NHS. The Government believe efficiencies can be made without compromising the quality of services or public access to them. Our aim is to ensure that community pharmacies upon which people depend continue to thrive. We are consulting on a pharmacy access scheme which will provide more NHS funds to certain pharmacies compared to others, considering factors such as location and the health needs of the local population.

[Baroness Walmsley (LD)]

I thank the Minister for his reply. Has he made any assessment of the value of the services provided by pharmacies to the NHS, local communities and local authorities in assisting with their public health responsibilities? In light of the importance of all these services and the potential for expansion in future, is it not rather arbitrary of the Government to make these cuts that I understand could cause the closure of 3,000 pharmacies? Then they will sit back and wait for the survival of the economic fittest.

[Lord Prior of Brampton]

My Lords, it is important that we recognise the fundamental changes happening in the market that community pharmacies operate in. With the growth of online ordering of prescriptions, the large-scale automation of dispensing and the integration of health services within which community pharmacies are absolutely vital, the industry will have to change.

National Health Service: Workforce Race Equality Standard

Baroness Walmsley Excerpts

Wednesday 24th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the whole purpose of the WRES is to shine a light on the performance of each trust in the country. The CQC will be including it in its well-led domain from March of this year and has already begun to incorporate it into its inspection processes. As the noble Lord knows, in Bradford where he is the chairman of a trust, we have a huge amount of progress to make.

[Baroness Walmsley (LD)]

My Lords, what is being done to ensure fair career progression further down the ladder? Unless we get people moving up, we will never have BME medical directors. Further, is he prepared to comment on diversity among the personnel in the recruitment agencies themselves that work for the NHS?

[Lord Prior of Brampton]

My Lords, the noble Baroness makes a good point. In a way the WRES focuses very much on the more senior grades in the NHS, but we need to focus on progression from band 4 into 5 and 6 as well. It is an important point that needs to be taken on board. As far as recruitment is concerned, it is very important that we have people from BME backgrounds on the recruitment panels. Getting the right people is crucial, and if that means going to external recruitment agencies when we have to, we should not rule that out.

Accident and Emergency Services: Staffing

Baroness Walmsley Excerpts

Tuesday 23rd February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, seven-day working clearly goes far beyond junior doctors; it requires senior doctors, pharmacists, social workers, and primary care as well as acute care if we are to deliver a full seven-day service. As my noble friend knows, that is our objective over the next five years.

[Baroness Walmsley (LD)]

My Lords, does the Minister endorse the principle of Kirsty Williams’s Private Member’s Bill in the Welsh Assembly, the Safe Nurse Staffing Levels (Wales) Bill, which, having passed with all-party support, now ensures safe staffing levels in all wards in Wales? Will the UK Government follow the example of the Liberal Democrats in Wales?

[Lord Prior of Brampton]

My Lords, I can perhaps be excused for not following all that carefully Private Members’ Bills in the Welsh Assembly promoted by the Liberal Democrats. Safe staffing is obviously very important. I quote Mike Richards on this, who says that it is,

“important to look at staffing in a flexible way which is focused on the quality of care, patient safety and efficiency rather than just numbers and ratios of staff”.

That is extremely important.

Allied Health Professionals: Training

Baroness Walmsley Excerpts

Monday 8th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, as I said, overall there is a small net increase of 334. That is largely for paramedics, where HEE believes that there is a more serious shortage than for other allied health professions. As I said, we have seen a significant increase in AHPs of more than 16% over the last five years and we expect that growth to continue after 2017.

[Baroness Walmsley (LD)]

My Lords, how will the Government achieve their objectives in relation to modernised cancer treatment and an enhanced role for radiographers when Health Education England is cutting the number of training places for therapeutic radiographers by 4.3%?

[Lord Prior of Brampton]

Actually, I think the number of radiographers is going up slightly. I will check, if I can, and write to the noble Baroness. It is also worth mentioning that the number of medical endoscopists is planned to go up by 200 over the next three years.

Junior Doctors

Baroness Walmsley Excerpts

Monday 8th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the noble Lord said he had three questions; I think there were only two questions there, which is unusual, if I may say so. We do not want to impose a contract. We want the BMA to come back and continue the talks and we still hope that that will happen. Clearly, imposing a contract is not what we ever wanted to do when this whole process started. As was said in the Statement, the Secretary of State’s door is open and we hope that we can resolve these difficult issues in a negotiated, consensual way.

On the noble Lord’s second question, he rightly said that this is an appalling situation, but actually I describe it more as a tragedy. Let me quote from a trainee doctor:

“I feel undermined and not valued at work and I have seen how this flagging morale among colleagues has caused more than ever to leave the profession. It is a hard job that takes dedication and stamina to continue. But as we are criticised and treated as ‘cogs in a wheel’ rather than as individual professionals, I think we will see ever increasing numbers of people leaving this profession”.

That was in 2005, after the contract came in. The issues facing the junior doctors go back a long way. It is not just about plain time on Saturdays or this particular contract but about how we value, reward, train and trust junior doctors. That is the issue we must come to when the current dispute is resolved.

[Baroness Walmsley (LD)]

My Lords, I think that the Minister did not answer the question from the noble Lord, Lord Hunt, about which hospital chief executives believe that the junior doctors’ contract is what is getting in the way of seven-day services. Surely the state of primary care, which is stretched all over the country, and the lack of diagnostics, laboratory services, X-rays and so on in hospitals are much more significant.

My own question is about plain time, which I believe is the sticking point. It occurs to me that the best way of ensuring patient safety is to make sure that we do not have tired doctors. Can the Minister convince me about the fact that we are being told that junior doctors will not have to work any more hours than they do now? If you are extending plain time from 8 am until 10 pm, instead of 7 pm, and into Saturdays, then it strikes me as quite possible that they will work much longer hours. I would be very interested to know what the average working week of a junior doctor is now compared to 20 years ago, because it strikes me that we are in danger of going backwards.

[Lord Prior of Brampton]

My Lords, I apologise for not replying to the question earlier about the number of chief execs. The point is that this is not just about junior doctors; I think we all understand that totally. We are hoping to have more primary care, more social care, more diagnostics and more senior consultant cover at weekends, which will support junior doctors and make their lives better at night time and over the weekend. As far as the hours are concerned, the new contract proposal puts far greater safeguards over the amount of time that junior doctors will be working. I think that is largely accepted by the junior doctors. Going forward, the maximum number of consecutive nights will be down from seven to four; the maximum number of long shifts—that is, over 10 hours—will be down from seven to five; the number of consecutive late shifts will be down from 12. We are putting in those safeguards to ensure that we do not go back to the bad old days of very long hours. They were the bad old days on one level but if you actually talk to most doctors, they did get tired and it affected safety but it built a sense of teamwork, camaraderie and purpose in hospitals. We need to be careful about rubbishing the old days when they built up a lot of really serious, good professional work.

Opticians Act 1989

Baroness Walmsley Excerpts

Monday 8th February 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, first, I apologise to my noble friend Lord Newby for missing the first half-minute of his speech. I am afraid that I was not informed that this debate was to start 15 minutes early; I thought that I was 10 minutes early.

I thank my noble friend for explaining what this debate is all about and for putting the case for looking at this issue again so comprehensively that there is no need for me to repeat it. To me, there are three principles that should apply when considering this matter.

First, the best interests of the patient must come first, so we must ask ourselves whether changing the law would or could do any harm to patients. Secondly, we need to consider whether availability of this new eyewear would deter people from getting a full eye test from a qualified ophthalmologist. Thirdly, would the state of the current law prevent patients receiving any additional benefits that might be available to them through the over-the-counter availability of this new product? We should bear in mind that, when the law went through Parliament, there was no such thing as self-adjustable eyewear, so perhaps it is time to review it.

In considering this matter, we must be impartial to both those already in the optical services business and to those who want to get into it. Could the briefings we have received amount to vested interests? Some noble Lords think so. I am afraid that I think that those who have provided the briefings might have vested interests, although it is perfectly reasonable for them all to make their case and I am sure that they are all providing legitimate information. That is why I ask the Minister whether the Government will set up a completely independent impartial investigation to receive evidence from both sides of the argument and make a truly impartial recommendation, and then will they act on it at the earliest opportunity?

The evidence we have received from the manufacturer Adlens suggests several benefits and no harms. Like the noble Lord, Lord Faulkner of Worcester, I really must congratulate it on its charitable work in Rwanda and other places. It is doing some very important and worthwhile work, which will benefit the economy of that poor country enormously, as well as individual patients. However, it stands to make money in the UK if the law is changed, so we should be aware of that. Mind you, it would probably be a very small amount compared to what companies make in the USA and Japan where these glasses are already allowed to be sold off prescription.

On the other side of the argument is the General Optical Council, the Optical Confederation, the professionals and the retailers who have a financial interest in selling the fixed-prescription spectacles which they prescribe. Of course, they also have a professional duty to put the patient’s eye health first, and I am sure that is their priority.

There would be a very strong argument for refusing to change the law if clear evidence existed that the availability of these adjustable spectacles over the counter deterred people from having a proper eye test—but I have seen no such evidence. We must bear in mind that eye tests are not just done to diagnose and correct vision but also, as the noble Lord, Lord Faulkner of Worcester, pointed out, to screen for eye health and indicators of other types of ill-health. They are very important, which is why we give them free to children and older people.

The fact is that we have been choosing our own vision correction for years. When I go to the optician, I select “red” or “green” and lens 1 or lens 2 all the time. I am selecting my own correction. What, therefore, is the difference between doing that and twiddling a little screw on your own spectacles to get the correction that you need? I accept that these may not be suitable for people with serious astigmatism, but those people probably would not choose them anyway because the quality of vision would not be as good as that from their correct fixed-lens prescription.

Concerns have been expressed about the safety of driving in self-corrected glasses. I was impressed by the study done by the University of Michigan Transportation Research Institute, which showed that there is no statistically significant difference between US drivers wearing prescription glasses and those wearing self-adjusted glasses in their ability to see a hazard ahead. I have seen no evidence to the contrary but, of course, it would be the task of the independent committee that I am calling for to see whether there is any.

As I said earlier, I would be concerned if ownership of these glasses were to deter regular eye examinations, but, again, the evidence I have seen is to the contrary. When over-the-counter reading glasses became available, there was no evidence that this deterred people from getting their eyes tested. Indeed, they need to do so in order to determine what strength to buy from the local chemist. Rather, government agencies and professionals alike believe that the best way to persuade people to look after their eyes and get them tested regularly is by public information and education. A number of these programmes have been mentioned, and they have been around in the UK for years; I am sure Governments would not spend money on them if they did not work.

These new products would have considerable value as a temporary solution for three groups of people: older people may need three different pairs of glasses for different tasks—I know I do—and many find it difficult to afford three pairs; people who have had cataract operations have a period during which their eyesight is settling down and might find these useful then; and new diabetics, whose eyesight may vary while they are working out the right dose of medication to control their blood sugar, may also find these a useful temporary solution. In the last two cases, it is very unlikely that an optometrist would prescribe several pairs of glasses just for a few months. Of course, it is vital that people get their eyes checked regularly, particularly diabetics as there are a number of risks to vision associated with diabetes. However, a pair of these new glasses could be part of their solution.

The fact is that we are already in charge of our own eye health. I recently had to apply for a new driving licence and, as part of the process, had to confirm that I have an appropriate level of vision to drive a car safely. Nobody asked me to get an optician to verify that, although I am in the habit of having regular eye tests and would recommend that everybody do so. In addition, correction prescriptions do not have a finishing date on them, so you can buy contact lenses on the internet using a prescription that is years old if you want to, even though that may no longer be the correct prescription for you. This solution would be a great deal better than that.

I am inclined to allow people to take responsibility for their own eye health, and I thought that a Conservative Government, being in favour of the free market, would be inclined to allow these glasses to be sold without prescription and to give people a choice. However, the cautious thing to do is to set up a truly independent inquiry. I hope the Government will do that, and then the evidence can speak for itself, as can the patients.

Drugs

Baroness Walmsley Excerpts

Thursday 4th February 2016 Grand Committee

[Baroness Walmsley (LD)]

My Lords, I thank the noble Lord, Lord Patel of Bradford, for raising this important issue. The increase in the number of deaths from drugs poisoning is a matter of great concern, since every single death is an indication of failure—failure of individual services and failure of the system of health and care to look after that patient. I refer to “the patient” because my party has always believed that individual drug abuse should be regarded as a health issue, and is not always a police issue. The pushers and dealers, however, are a very different matter.

As has been said, although some are suicides, most of these deaths are accidental, caused by lack of knowledge of the strength of the drugs that people are taking, or someone’s lack of understanding of their own body’s ability to process the chemicals. I will return to that point later. Accidental deaths also occur when a person is not in full possession of his or her faculties and has a fatal accident. I have read the various reports that have tried to analyse the statistics, and that is clearly a very complicated and difficult task, because in many cases there are several causal factors and they are hard to untangle. Few of those who die from drug use have one single simple problem. About one-third of patients abuse alcohol as well as banned or prescription drugs, and many have mental health problems. There is clearly interaction between the various issues.

A recent report called “Solutions from the Frontline” by MEAM—Making Every Adult Matter, an alliance of mental health charities chaired by my noble friend Lady Tyler of Enfield—calculated that there are 58,000 people who face homelessness, substance abuse, mental health problems and offending behaviour, distributed all over Britain. Of course, not all of them are at risk of accidental death because of their drug problems, but clearly their risk rises because of their multiplicity of needs and the great difficulty that services find in reaching and helping them. The problems get worse because people experiencing multiple needs are also likely to live in poverty and experience stigma, discrimination, isolation and loneliness—and, of course, loneliness is a great mental health and suicide risk. Although the ONS report indicates a large protective factor when people are in treatment, which is encouraging to know, those services are suffering, as we have heard from the noble Lord, Lord Patel of Bradford.

I shall concentrate my remarks on dual diagnosis, and on offenders and ex-offenders. According to MEAM, people experiencing multiple needs often have ineffective contact with services, as in most cases services are designed to deal with one problem at a time and to support people with single severe conditions. This can mean that people with multiple needs are more likely to access emergency, rather than planned, services, such as going to accident and emergency rather than their local GP. Accessing services in this way is costly as well as risky: estimates suggest that costs for the 58,000 individuals nationally are between £1.1 billion and £2.1 billion per year. So it is absolutely vital that people who are registered as being addicted to drugs, especially the depressive opiates such as heroin, have their mental health needs assessed and addressed. This is not always happening, partly because of cuts and partly because of shortages of staff with the right experience. Many patients claim that mental health crisis services are not there for them and many have to wait far too long for routine therapies. I do not underestimate the difficulty of dealing with these patients but we must make more effort to do so, for their own sake as well as for the sake of the NHS budget.

The recommendations of the MEAM report include asking the Government to ensure that funding structures prioritise recovery and rehabilitation and allow local areas to develop a flexible response. As part of this, they should consider a new national focus on multiple needs. Locally, commissioners should be accountable for ensuring that local areas have joined-up services and identify where people with multiple needs could fall through the gaps. At the front line, services should involve staff and people with multiple needs working together in designing programmes and the environments where they are to be delivered.

As for drug-using offenders, of course there are a lot of treatment programmes in prison although we know that security in many prisons is poor and they say you can access any drug you like in most prisons. It should, of course, be easier to help addicts when you have them incarcerated in prison than it is when they are part of the general population, and a lot of good work is done. However, I am not convinced that the underlying mental health problems are always addressed in the same way. It is difficult for a lay person like me to understand whether it is the mental health problem that brings people to take drugs in the first place or the drugs themselves that cause mental health problems. I understand it can be either way round, but what matters is to accept that dual diagnosis is not always properly addressed; it is very risky, and we need to do something about it.

The other issue that I would like to raise is continuity of services after release. There is supposed to be a seamless transition into community services but too often that does not happen, perhaps because the services are not there, the person drops out, or the professionals concerned are too busy to work with each other and do not realise how important and effective that is. A very senior psychiatrist told me only yesterday that, if someone gets clean while in prison and then comes out and starts using again, they are at greater risk of dying. While they are under treatment their liver stops having to process the poisonous chemicals in the drugs, so it stops being able to do so. If an ex-offender then starts using again, they should be advised to start on a very low dose and build up, but actually they tend to go back on the high dose they were used to using before they went to prison. This is too much for the body to cope with and it kills them. The dose they were accustomed to before prison now becomes an overdose.

Obviously, we do not want ex-addicts to come out of prison to start again at all but, if they do, they should be made aware of the danger and they should have continuity of care until their rehabilitation is well embedded. Often a patient has very good motivation to keep off drugs but, if something goes wrong in their life, such as losing a job or becoming homeless, the mental health problems recur and they do not have the support or resilience to resist self-medication with drugs that make them feel better.

The mention of resilience brings me to my final point. The roots of mental illness often go back a very long way. We must address the issue we are debating today in the very long term. By that I mean that we need to focus on two things in schools: education about the harms of drug and alcohol use and prevention of mental ill-health among children and young people. We need schools to be able to recognise mental health problems and know how and where to get help. They should also positively promote good mental health and well-being and help their pupils to develop resilient personalities. Of course, we should also go even further back in life and provide mental health therapists in all maternity units and help new mothers bond well with their children, given the crucial importance of attachment to the child’s future mental health. I wonder whether the increase in deaths is not because more people are taking drugs—from what the noble Lord, Lord Patel of Bradford, said, that is not the case—but are we getting more mental health problems that push users over the edge?

Good mental health does not happen by accident any more than good physical health. Just as we need to foster good physical health through diet, exercise and avoiding risky behaviours, so we also need to be aware that good mental health can be fostered. This should be part of the healthy community plans of all local authorities as well as schools, but sadly it is often at the bottom of their priority list because they have the money to do only what is mandatory. But by ignoring this we are storing up problems for the future. I would ask the Minister to be kind enough to comment on the points I have made and let noble Lords know how the Government are dealing with them.