NHS: Essential Services
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Baroness Wheeler
To ask Her Majesty’s Government, in the light of the Dr Foster Hospital Guide 2013, how NHS England is monitoring access to essential services and how it intends to address variations in access to and provision of services at clinical commissioning group level.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, to help reduce variations in access to health services, Professor Sir Bruce Keogh, the medical director of NHS England, is working with the medical royal colleges and others to ensure that the NHS is clear about the evidence base for common types of surgical interventions. For example, it will produce guidance for commissioners to help ensure that consistent eligibility criteria are used to access surgical services and so minimise the scope for variation at a local level.
Baroness Wheeler (Lab)
I thank the Minister for his response. Dr Foster’s report shows that the number of knee and hip replacements and cataract removals has fallen to its lowest level in four years, meaning that more than 12 million people now live in areas where the number of these operations has substantially declined. This is despite our elderly population continuing to rise over the same period and these common surgical procedures being vital to ensuring that older people can regain their mobility, keep active and stay living in the community. Does the Minister agree that these are essential treatments? What pressures will be placed on NHS England to ensure that CCGs actually provide them and also that they fulfil their legal obligation to issue guidance to local communities, revealing what their policies are on providing medicines, surgeries and therapeutic interventions?
Earl Howe
My Lords, I should first tell the noble Baroness that we cannot reconcile our own figures with those of Dr Foster. We believe that there has in fact been a significant increase in the number of cataract and knee and hip replacement operations since 2009-10 and not a drop. Regardless of that, I suggest to her that the absolute numbers of operations taking place do not tell us anything about possible rationing or the absence of it. That question can be answered only with the benefit of fuller data. The key to consistent access to these treatments is a common understanding among commissioners of the evidence base in each case. That is exactly what Sir Bruce Keogh is working towards and will provide guidance on in due course.
Baroness Manzoor (LD)
Can the Minister state which local NHS services NHS England has deemed to be essential? If an independent provider of these services gets into financial difficulty, who will provide and pay for those services—NHS England or the clinical commissioning groups?
Earl Howe
My Lords, from April this year, CCGs and NHS England will begin to identify formally those healthcare services that they consider essential to protect in the event of the financial failure of their providers. They will be required to designate such services as commissioner requested services. In doing so, they must have regard to Monitor’s published CRS guidance. Should an independent provider of CRS get into financial difficulty, then Monitor will work with the provider and relevant partners to determine the right solution.
Lord Turnberg (Lab)
My Lords, what safeguards are in place to make sure that CCGs do not have a conflict of interest when they contract for services in which they may have a direct involvement?
Earl Howe
The noble Lord will, I am sure, remember from our debates on the Health and Social Care Bill that NHS England has published guidance for CCGs on managing conflicts. There is also a duty placed on CCGs to have regard to such guidance and CCGs set out in their constitution their proposed arrangements for managing conflicts of interest.
Baroness Finlay of Llandaff (CB)
How are the Government able to monitor how CCGs are commissioning background diagnostic services and imaging services, which are essential for accurate diagnosis in surgical emergencies and will determine whether a patient should be taken to theatre, given that two-thirds of consultants have expressed concern about the level of care of patients at the weekend? I wonder what levers there are for the Government against those clinical commissioning groups which do not ensure that adequate diagnostic facilities are available.
Earl Howe
My Lords, the CCG assurance framework sets out how NHS England will ensure that CCGs are operating effectively to commission safe and high-quality sustainable services within their resources. Underpinning assurance are the developing relationships between CCGs and NHS England, which should not be overlooked. One key source of evidence is the national delivery dashboard, which provides a consistent set of national data on CCG performance. In addition, there is the CCG outcomes indicator set, which will be an important wider source of evidence from 2014-15 onwards.
Baroness Pitkeathley (Lab)
My Lords, I know that the noble Earl has disputed the figures but if the volume of operations such as knee and hip replacements and cataract removals is declining, does he accept that this is likely to cause further problems in the social care sector? If older people do not receive timely treatment that will transform, as these operations do, their mobility and ability to manage at home alone, surely they will continue to need more support in the community, which we know is under pressure because of shortages in local authority funding. We may call these operations non-essential—we often do—but they are not non-essential if you are an older person with mobility problems.
Earl Howe
I fully agree with the noble Baroness and her point about mobility is very well made. However, NHS England has stated to me explicitly that the assumption that there should be a rising trend in the number of operations proportionate to the rise in the number of elderly people may not necessarily be right, so we have to be wary of using a statistic in isolation to prove one thing or the other.
Lord Walton of Detchant (CB)
My Lords, can the Minister say whether it is still government policy that clinical commissioning groups should accept the recommendations of the National Institute for Health and Care Excellence in relation to the availability of expensive drugs in the NHS? What sanctions are available for those that do not comply with those recommendations?
Earl Howe
The noble Lord is right that when NICE gives a positive appraisal on a medicine, whether it is for a rare or a common disease, the funding for that medicine must be available through CCGs or NHS England. If a patient is denied the drug, contrary to the instructions or wishes of their clinician, then there is a route of appeal through either the clinical commissioning group or NHS England.
Health: Birth Defects
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Lord Rooker
To ask Her Majesty’s Government what is their current approach to reducing the number of children born with neural tube defects; and whether they will consider fortifying white bread flour with folic acid as an additional measure.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we encourage women to plan pregnancies, and advise those seeking to become pregnant to take folic acid supplements before conception and for the first 12 weeks of pregnancy, and to increase their intake of folate-rich foods. We are considering our nutrition advisers’ full recommendation to fortify flour with folic acid and will take into account new data on the folate status of the population in reaching our decision.
Lord Rooker (Lab)
My Lords, given that folic supplementation needs to be taken before most women know that they are pregnant, is the Minister concerned that less than 6% of 20 year-olds actually take folic supplements? The follow-up research published earlier this year is now available—on top of the scientific advice that the Government received in 2007 from independent committees and the Food Standards Agency—and shows that putting folic acid in flour causes no side effects for males. Is it not therefore time to change policy and put folic acid in white bread flour, which the BMA says is the most cost-effective way of avoiding the misery of hundreds of affected pregnancies, and to join 50 other countries that are doing the same?
Earl Howe
My Lords, mandatory fortification of food is, by any standards, a big step; it is not a decision to be taken lightly. The issue that we have been facing is that the survey data used by the Scientific Advisory Committee on Nutrition is more than 10 years old. The latest data available on the folate status of the population will be available early next year, and we feel that it is prudent to use that information to assess the risks and benefits of fortifying flour with folic acid before we make our decision.
Baroness Brinton (LD)
My Lords, international academic research since 2005 has shown that including folic acid in bread and cereal products is important and that it reduces neural tube defects by between a quarter and a half, so it undoubtedly helps raise the levels of folic acid in women before and during pregnancy. However, it is not at the level that would remove all possibility of NTDs. Research says that folic acid supplements are recommended, too. What will the Government do to alert women who are thinking about having a baby to take supplements before becoming pregnant?
Earl Howe
My Lords, we recognise that some women do not always access maternity services early or attend regularly for antenatal care, and that poorer outcomes are therefore reported in some cases for mother and baby. Maternity services need to be proactive in engaging all women. To help reduce variation and improve services, NICE has published a comprehensive suite of evidence-based clinical guidelines and quality standards for maternity services. We are also promoting the taking of folic acid supplements through a number of channels including Healthy Start, NHS Choices, Start4Life, and the Information Service for Parents.
Lord Patel (CB)
My Lords, what do the Government think are the contraindications for fortifications of flour with folic acid, knowing that the evidence shows that it would cause a reduction of about 300 in the number of babies born with neural tube defects?
Earl Howe
My Lords, I recognise the opinion that is shared among many members of the medical community on this. However, the advice we received from SACN, our expert adviser, clearly showed that there are risks and benefits associated with this proposal. It is not an open-and-shut case. Among the things that we have had to consider are the practical implications of implementing SACN’s advice, which is no small matter.
Lord Hunt of Kings Heath (Lab)
My Lords, does the noble Earl not recognise that in fact the scientific committee he referred to has looked at the issue that he raised and has upheld its previous recommendation that the Government should go ahead? Some 50 countries have already done that; the scientific advice is clear; why on earth are the Government not getting on with it?
Earl Howe
My Lords, as I said, SACN’s recommendations highlighted both the risks and the benefits of this proposal—and I certainly acknowledge that there would be benefits. However, there are also implications. For example, SACN recommended that mandatory fortification should proceed only if accompanied by:
“Action to restrict voluntary fortification of foods with folic acid; measures for careful monitoring of emerging evidence on any adverse effects of long-term exposure to intakes of folic acid … and guidance on supplement use for particular population groups”.
We have to take those recommendations into account before taking any long-term decision.
Lord Turnberg (Lab)
My Lords, is the Minister aware of a recent publication that suggests that folic acid deficiency in men, too, may lead to birth defects in their offspring? Is this not another good reason for fortifying flour?
Baroness Hayman (CB)
My Lords, the Minister said that this was not a decision to be taken lightly, and that is absolutely right, but we now have the experience of 50 other countries. We have had scientific evidence on this issue for many years. The fortification of white bread flour is a targeted measure that could significantly reduce the number of pregnancies, not just births, that involve neural tube defects, and thus prevent a great deal of unnecessary and painful suffering. Will the Minister undertake to look at this matter again as a matter of urgency?
Earl Howe
My Lords, we are looking at this as a matter of urgency. I recognise what the noble Baroness says about the experience of other countries, but we must make policy in relation to the population of our own country, and that involves weighing up both the potential benefits and the potential downsides of any policy.
Smoking: E-cigarettes
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank my noble friend Lord Astor for securing this important and highly topical debate.
As we have heard, e-cigarettes are nicotine-containing devices that work by atomising a nicotine solution which is then breathed in as a vapour by the user. E-cigarettes claim to deliver nicotine to the user without the toxins and carcinogens found in tobacco smoke. They do not involve any combustion and do not produce smoke. E-cigarettes are a very recent innovation. They are available in various shapes and sizes, as we have heard, and many are designed to both look and feel like conventional cigarettes. Some even incorporate a light at the end of the device that glows when the product is being used, to replicate a cigarette. Today, they are marketed as a cheaper and healthier alternative to smoking tobacco. However, e-cigarette manufacturers have avoided directly suggesting that their products are smoking cessation aids, as making such claims would subject their products to regulation as medicines.
I turn to whether e-cigarettes are safe to use. When we compare the use of e-cigarettes to smoking of tobacco, the Department of Health is confidently able to say that e-cigarettes are likely to be much safer to use. That does not mean that e-cigarettes are safe to use; it probably says more about how enormously unsafe it is to smoke tobacco. Nevertheless, the safety of e-cigarettes is yet to be fully established. Given how novel these products are, we need to see much more evidence about their safety, especially regarding the use of e-cigarettes over a long period.
At present, e-cigarettes are sold without any product-specific controls relating to quality and safety in use, or specific provisions on advertising and promotion. There are general product safety provisions that apply to these products, but they are not designed for these sorts of product and are not fit for this purpose. We also must keep in mind that nicotine itself is not only highly addictive but can be highly toxic. Electronic cigarettes are not risk-free. Known and reported health risks include acute effects on lung function, possible pneumonia and other risks related to poor product quality.
My noble friend Lord Astor made reference to Action on Smoking and Health. ASH says that there is significant variation in device effectiveness, nicotine delivery and cartridge nicotine content, both between and sometimes within product brands. ASH cites research that suggests the presence of toxins, released in low concentrations, from the vaporisation process involving certain e-cigarette cartridges. It cites other research that concluded that e-cigarettes have a low toxicity profile, are well tolerated and are associated only with mild adverse effects.
As we have heard during this debate, the e-cigarette market is growing rapidly. More than 300 companies are estimated to be importing or supplying e-cigarettes in the United Kingdom. The e-cigarette market in the UK is estimated to be worth in excess of £100 million, and we know that across the world the tobacco industry is becoming increasingly involved. There is little doubt that awareness of e-cigarettes has increased quickly through advertising and promotion of these products. It has been said that e-cigarettes are being promoted in similar ways to how cigarettes were promoted before we introduced a comprehensive ban on tobacco advertising in this country. I am sure that I am not alone in noticing the vast amount of promotion for e-cigarettes in my local convenience store, or the representatives of e-cigarette companies in shopping malls or outside train stations promoting their products.
The University College London smoking toolkit study is a national study of smoking and smoking cessation in England. The most recent data from the survey suggest that electronic cigarette use by tobacco smokers has increased from around 2% in 2011 to around 14% in August 2013. If this trend were reflected across the UK, it would translate to around 1.4 million smokers who have used electronic cigarettes. There is little evidence to suggest that non-smokers are becoming attracted to using e-cigarettes.
My noble friend Lord Borwick asked about the behaviour of children and young people. ASH commissioned research into the use of e-cigarettes by young people and found that, in Great Britain in 2013, 95% of 11 to 14 year-olds and 90% of 16 to 18 year-olds have never used e-cigarettes. Among young people, e-cigarette use appears to be confined to those who have already tried smoking. Nevertheless, we remain concerned that e-cigarettes could quickly become popular with young people, particularly if they continue to be vigorously advertised and promoted. We are also very aware of concerns expressed that e-cigarettes could act as gateway products for young people into smoking, and will continue to watch the evidence closely.
The Government recognised in the tobacco control plan for England that smokers are harmed by the tar and toxins in tobacco smoke, not necessarily by the nicotine to which they are addicted. There is no way of avoiding these deadly toxins if you inhale smoke from burning tobacco.
Earlier this year, the National Institute for Health and Care Excellence published public health guidance on harm-reduction approaches to smoking. The noble Lord, Lord Hunt, asked about this. NICE recommends the use of licensed medicines only. The guidance suggests that while the best way to reduce smoking illness and death is to encourage smokers to quit completely, there are other ways of reducing the harm from smoking, even though this may involve the continued use of nicotine. If someone does not want to, is not ready to or is unable to stop smoking in one step, the guidance suggests that licensed nicotine replacement therapies could be of use.
My noble friend Lord Borwick asked about the possibility of sponsoring research in this area. We already know quite a lot about the safety profile of nicotine and its use in cutting down and quitting. The evidence we have is that these products are used mainly to cut down and quit.
My noble friend Lord Ridley called for clearer evidence of effectiveness. The problem is that there is not good evidence of effectiveness. These products are not magic bullets, in other words, but even at this stage we feel that we want to exploit the potential that we see in them. He referred to aubergines as potential medicines. I think he would agree with me that people do not eat aubergines in the expectation that that will help them to quit smoking. Clearly, whatever remedy we encourage has to be effective in its ability to cut down and quit the habit of smoking.
There is potentially a place for e-cigarettes within a harm-reduction approach to public health, but only if they meet the requirements set out in the public health guidance; that is, if they are licensed medicines. I would expect that the NHS and health professionals would also only recommend the use of e-cigarettes that are licensed as medicines. My noble friend Lord Astor asked whether we envisaged e-cigarettes being sold on prescription. We want effective products to be widely available, not just on prescription but in general sale outlets such as supermarkets and corner shops.
The noble Lord, Lord Hunt, asked how much it would cost an e-cigarette manufacturer to get a medicines licence. The impact assessment that we published estimated that the annualised cost to a single UK e-cigarette importer for complying with medicines regulation ranged from £87,000 to £266,000.
I am particularly grateful to my noble friend Lord Astor for securing this debate because it provides me with the opportunity to explain to your Lordships the action that is under way to regulate e-cigarettes. As the Chief Medical Officer for England has said, since more and more people are using e-cigarettes, it is only right that these products are properly regulated to be safe and work effectively.
A European tobacco products directive was proposed late last year and is now in its final stages of negotiation in Brussels. I can tell noble Lords that no deal has yet been reached in the discussions but the Government hope that agreement might be reached shortly. I reassure your Lordships that the United Kingdom has been active during these negotiations, as we believe that the proposed tobacco products directive will benefit public health and help to reduce the number of young people who take up smoking in the UK.
From the outset, it was envisaged that e-cigarettes would be regulated within the proposed directive. Protecting and promoting public health has always been our starting point, and we want safe and effective nicotine-containing products that can help smokers cut down and quit. The Government took the view that proportionate medicines regulation was the best way to deliver that objective.
Viscount Astor
Does my noble friend consider that e-cigarettes that contain no nicotine at all but contain other flavours will or should come under the tobacco directive?
Earl Howe
My Lords, that is probably the hardest question that my noble friend has asked me during this debate. My answer is that we certainly need to give careful consideration to that issue, which is about products that have the appearance of e-cigarettes but contain no nicotine. We would need to look at how common those products are or are becoming. Frankly, that work has yet to be done, but I am grateful to him for raising the issue.
I was speaking about our approach to the regulation of e-cigarettes, saying that we felt that proportionate medicines regulation was the best way forward. Nevertheless, we must consider carefully the views that have been forthcoming, including from the European Parliament, that there are alternative approaches to the regulation of e-cigarettes. Moving forward, the Government will want to be satisfied that the directive can deliver the right checks and balances on e-cigarettes. It is important to underscore the fact that there is a wide consensus across the European Commission, the European Parliament and European member states that additional regulatory safeguards are needed for this relatively new category of product. We are listening carefully to the genuine debate about how best to take this forward in the directive.
There is also emerging consensus that the advertising of e-cigarettes needs to be controlled. Options for doing so as part of the proposed European directive are under negotiation. In addition, the Committee of Advertising Practice, which writes and maintains the UK advertising codes that are then administered by the Advertising Standards Authority, announced in October that it intends to develop new rules to give clarity to advertisers and to ensure that e-cigarettes are promoted responsibly. It is considering running a public consultation on this issue early in the new year.
The Government’s priority during negotiations is to secure a directive that will reduce as far as possible how attractive e-cigarettes are to young people and closely to monitor the development of this market. When the directive has been settled, we will undertake an analysis to consider whether further action could be taken on a domestic basis, in particular to protect young people from e-cigarettes that contain nicotine. We also need to give further consideration to my noble friend’s question about non-nicotine-containing products, as I mentioned.
Regardless of how e-cigarettes are regulated within the proposed directive, we will still encourage the manufacturers of these products voluntarily to seek medicines licences for their e-cigarettes, so that they can be made available to support smokers to quit in the same way as other forms of nicotine replacement therapy, such as gum and patches. These e-cigarettes could be recommended for use in reducing harm, in accordance with the recently published public health guidelines.
Viscount Ridley
Has my noble friend taken on board the point that both I and the noble Lord, Lord Hunt, raised about the risk of regulation stifling innovation? By stifling innovation and slowing down the rate of take-up of these things, regulation could kill more people by preventing their coming off tobacco cigarettes.
Earl Howe
I most certainly have taken that point on board. I am grateful to my noble friend, who I hope will take some encouragement from what I said about our wish to see take-up of effective products. However, we need to be cautious about allowing products to flood the market that purport to contain certain quantities of nicotine and to deliver them safely but in fact do not. The safety and efficacy of these products are particularly important and we need to look at that.
G8 Summit on Dementia
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Lord Patel
To ask Her Majesty’s Government what was the outcome of the G8 dementia summit.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the G8 agreed to work together to tackle and defeat dementia. The declaration announced the G8’s ambition to identify a cure or a disease-modifying therapy by 2025 and to increase collectively and significantly the amount of funding for dementia research. The G8 also welcomed the UK’s decision to appoint a dementia innovation envoy who will work to attract new sources of finance, including examining the potential for a private and philanthropic fund.
Lord Patel (CB)
My Lords, I thank the Minister for his reply. Dementia is the dreaded diagnosis, particularly for the elderly, as it affects more than 5% of people over 65 and between 20% and 40% of those aged over 85. Because of the increasing number of elderly people, an increasing number of people are affected. I commend the Government and congratulate them on taking the initiative at the G8 and particularly on involving the WHO, because now it will become a global initiative. I have two questions. The first is about the funding that the Government announced. There is a great deal of confusion. Is it new money, money that has already been allocated to research or money that the Department of Health is giving for better diagnosis of dementia? Research on dementia must also focus more widely on understanding the biology of the disease, the inflammatory process and the epidemiology. Ring-fencing around a disease will not necessarily get to the point that the Government wish to get to. Secondly, what impact do the Government think the EU regulation on data protection will have on dementia research?
Earl Howe
The noble Lord asked a number of questions. The Government have stated an ambition to double research funding in dementia. That will depend on the quality of the proposals that come forward and on the rate of scientific progress. We very much hope that arising out of the summit, momentum will be gained, not only in this country but internationally. As regards the noble Lord’s second question, we recognise how important this is for future dementia research and I can tell him that the Government, through the Ministry of Justice, are negotiating with member states in Europe and are aware of the impact that the proposal would have on research. It is likely to be some months before there is an agreed approach between member states and the Commission, and the Parliament is unlikely to vote on the proposal before 2015.
Lord Warner (Lab)
The Minister will no doubt be aware that there is growing interest in this country in assessing whether drugs used for conditions other than dementia might be useful in tackling dementia. Will the Minister say what efforts the Government are going to put into this area as a result of the G8 summit?
Earl Howe
My Lords, we certainly hope that the private and charitable sectors will respond to the call, but at the same time the Government are not dictating to the research funding bodies which projects they should support. The Haldane principle is very important. The noble Lord makes an extremely powerful point, and we would hope that the pharmaceutical companies will wish to step up to the plate.
Baroness Hanham (Con)
My Lords, will the Minister be kind enough to explain exactly what is going to be achieved by training public servants such as bus drivers in dementia, what is the purpose behind it and what we hope those public servants will be able to do?
Earl Howe
My noble friend raises an important issue, because it is going to be increasingly necessary for not only health and care professionals but members of the public to be properly attuned to dementia and the needs of those who have the condition. We want to see all those who deal with the public trained in dementia, at least to a basic level, in a way that is appropriate to their level of engagement with those who suffer from dementia. Dementia training is now a key part of Health Education England’s mandate.
Baroness Greengross (CB)
My Lords, I would like to add my congratulations to the Government, and in particular to the Prime Minister on his personal commitment and on securing the summit focusing on dementia. I ask the Minister whether there are any commitments from other G8 countries, both for research and for the other side of this, which is care and how we help the growing number of people—it will be one in three of us in the near future—who are going to experience dementia, in all the G8 countries and beyond.
Earl Howe
My Lords, it is perhaps too soon to expect concrete proposals from other G8 countries, but I can tell the noble Baroness that the summit was not the end of the story. The G8 countries will be meeting throughout 2014 to build on and develop further agreements. We have agreed to host the first legacy event on social-impact investment in March next year. That will be followed by an event in Japan on what new care and prevention models could look like, and by an event hosted by Canada and France on how industry can harness academic research. There will then be a meeting in the United States in February 2015. We hope that the momentum generated by the summit will elicit the kind of commitments that the noble Baroness rightly seeks.
Lord Foulkes of Cumnock (Lab)
Is the Minister aware that after the very brief exchange about dementia yesterday, I heard it suggested that dementia should not be grouped in any way with mental illness because of the stigma involved? Surely the solution to that is that we must all work to remove any stigma from all kinds of mental illness.
Earl Howe
The noble Lord is absolutely right, but he will recall that the question yesterday dealt with the WISH summit, which was focused specifically on mental health and not on dementia. I did not mean to imply that there should be any less emphasis on tackling stigma in both areas.
Baroness Brinton (LD)
My Lords, I, too, welcome the result of the G8 dementia summit, but what progress is being made in appointing nurses who specialise in dementia in the same way that there are nurse specialists for cancer, rheumatology and epilepsy? Dementia UK’s admiral nurses are wonderful and provide real help to patients and families, but there are a mere 103 for an estimated population of 800,000 dementia patients.
Earl Howe
My noble friend raises a very important point. I come back to the point that I made a short while ago: people with dementia in practice access all parts of the health and care system. We want all staff who care for people with dementia to be trained to the level of their engagement so as to deliver high-quality care for people with dementia. I mentioned that dementia training was a key part of Health Education England’s mandate. Already, 100,000 NHS staff have received dementia training. As my noble friend will know, decisions on the commissioning of admiral nurses are made locally, but I recognise the work that they do.
Lord Walton of Detchant
Does the Minister accept that much of the increased incidence of dementia is a result of the fact that many of us are living much longer than was the case in the past? Does he further agree that there is clear research evidence to suggest that continuing intellectual and physical activity, care and attention to diet, and control of blood pressure can delay the onset of dementia in many individuals, and that, as a consequence, once early dementia appears, programmes to promote such physical and intellectual activity are very valuable? In such programmes, volunteers play a very important part across the country. What are the Government doing to promote these projects?
Earl Howe
The noble Lord, as ever, makes some extremely good points. My department is looking at the role of volunteers in a number of areas. He is right that increased age is the greatest predictor of dementia. It has been estimated that delaying the onset of dementia by two years could decrease the global disease burden by 22.8 million cases by 2050. The point that the noble Lord makes is therefore well made, and I have no doubt that there will be an increasing focus on this over the coming years.
World Innovation Summit for Health
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Lord Crisp
To ask Her Majesty’s Government what is their response to the recommendation for improving mental health globally made at the World Innovation Summit for Health.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we welcome the recommendations made at the World Innovation Summit for Health and outlined in its report, Transforming Lives and Enhancing Communities. Mental health and well-being is a priority for this Government. Our overarching goal is to ensure that mental health has equal priority with physical health, and that everyone who needs it has timely access to the best available treatment. We hope that other countries will afford it equal priority.
Lord Crisp (CB)
My Lords, I thank the noble Earl for his reply. I should have made it clear when I tabled the Question that I was really looking for a reply from the Department for International Development. I will, however, ask two questions.
I know that the Minister will be as appalled as everyone else by this report and its finding that 700 million people with mental health problems worldwide are not getting treated, as a result of which some find themselves chained up or caged. Does he think the report’s findings and recommendations are relevant in the UK as well as elsewhere, although, obviously, not in relation to being chained up or caged? DfID currently spends, essentially, nothing on mental health. What is it planning to do post-2015 to make sure that nobody is left behind, as the Prime Minister has set out in his report?
Earl Howe
My Lords, the principles espoused at WISH do indeed apply with equal force to mental health services in this country. Those principles are several, but I would draw the noble Lord’s attention to the need to draw on evidence-based practice; to strive for universal mental health coverage; to respect human rights and to take a life-course approach. We try to embody all those things in our mental health services. Regarding DfID, I can tell the noble Lord that there are a number of multilateral and bilateral programmes which are in train and supported by the Government. We are supporting work in the Caribbean and Bermuda and promoting work in a number of countries in sub-Saharan Africa. I would be happy to write to the noble Lord with a complete list of these.
Earl Howe
My Lords, in broad terms, dementia falls outside the scope of mental health but it is, of course, closely allied. Many of the principles that apply to good mental health care apply equally to dementia. We are, again, doing our best, in responding to the Prime Minister’s challenge on dementia, to ensure that those who contract this dreadful condition are looked after with dignity and respect in the appropriate setting.
Baroness Wheeler (Lab)
My Lords, the WISH report, to which the Government are signed up, recommends key improvements to community care for mental health by 2020. Yet the recent FoI survey of 51 NHS mental health trusts by BBC News and Community Care magazine shows overall budgets shrinking by over 2%, including those for community mental health support teams, despite referrals to them rising by 13%. How is this consistent with pledging to achieve the WISH goal by 2020? What leadership and direction will the Government give to preventing this very disturbing situation from getting worse?
Earl Howe
My Lords, we need to hold the NHS to account by reference to the outcomes that it achieves. I do not belittle the need to spend sufficient sums of money. The National Survey of Investment in Adult Mental Health Services has indicated that reported spend on mental health services has continued to hold reasonably steady over time. I reiterate that mental health and well-being is a priority for the Government, as I hope the noble Baroness knows. We have clear indicators in the NHS outcomes framework, which will ensure that NHS England will need to focus on this area very closely.
Lord Alderdice (LD)
My Lords, it is extremely welcome that my noble friend has emphasised again that for the Government, under the Health and Social Care Act, parity of esteem between physical and mental health is to be maintained in this country. Perhaps I might press my noble friend a little further than the noble Lord, Lord Crisp, did. Have there been discussions between the Department of Health and DfID about DfID espousing parity of esteem for physical and mental health in its proposals, and have there been discussions with other government departments, such as the FCO, about the increasing abuse of mental health and psychiatry facilities for political prisoners in various parts of the world, not least in some of those countries with which we have good relations, including Russia?
Earl Howe
I will write to my noble friend on the issue of political prisoners. On his main point of principle about parity of esteem, that principle—which essentially works to ensure that mental health has equal priority with physical health—is central to government-funded mental health programmes overseas; in particular, DfID funds programmes that promote the rights of people with mental health disorders to ensure that their needs are equally met. We recently invested £2 million for an additional three years’ support to the Disability Rights Fund, which makes disability, including mental health issues, a key international development priority.
Baroness Hollins (CB)
My Lords, people with learning disabilities are disproportionately affected by mental health problems, with three times as many people experiencing such issues. In this country we are very well aware of that, and despite our own problems, such as Winterbourne View, we actually lead the world in research and service development. This is not recognised in global initiatives such as the summit just referred to by my noble friend. What will the Government do to try to raise awareness of the mental health needs of this particularly vulnerable group of people?
Earl Howe
Often overseas we are working with very scant resources and the key is to build up the skills at primary care level in countries that are developing and may not have regarded those with learning disabilities as a priority for healthcare. It is a slow process but one that we are trying our best to support. Again, I would be happy to write to the noble Baroness with details.
Olympic Legacy (S&T Report)
Earl Howe Excerpts(11 years, 2 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, first, I congratulate the noble Lord, Lord Krebs, on securing this debate and on the excellent work of the Select Committee on Science and Technology, which he chairs, in highlighting the important issues associated with sport and exercise science and medicine. The Government have welcomed the Committee’s report and its focus on the quality and application of research in this area.
We agree that the biomedical basis for improving performance of elite athletes needs to be of the highest quality possible and meet international peer review standards. For this reason, UK Sport and the English Institute of Sport have robust processes in place to quality-assure the projects that they support. For example, all projects are reviewed by an independent research advisory group, which includes a number of leading experts in the field of sport science.
Our elite sport programme is the envy of the world. UK athletes continue to perform strongly at the highest levels, thanks to the funding and technical support they receive from UK Sport and the home country sports institutes. Based on Team GB’s performance, there is no reason to doubt the quality or appropriateness of the research.
In the light of this success, it makes sense for this knowledge to be shared so that it might benefit non-elite sports men and women. Indeed, there are a number of ways in which UK Sport disseminates research findings. However, it is important to remember that the end goal of research is to support and maximise athletic performance on the world stage. Although UK Sport and the English Institute of Sport concede that more could be done to disseminate their findings, they need to do so without compromising the UK’s competitive edge.
The committee’s report rightly highlights the societal and economic costs of inactivity—a point well made by the noble Lord, Lord Hunt—and the benefits of exercise in promoting health and treating chronic disease. Indeed, the UK CMOs’ report, Start Active, Stay Active, contains recommendations across the life course on the levels of physical activity needed to achieve these benefits. The noble Lord, Lord Hunt, mentioned the research funded by my department. I can tell him that the department’s National Institute for Health Research funds a wide range of research on the benefits of physical activity.
I completely agree with my noble friend Lord Selborne that it is of crucial importance that breakthroughs in sport and exercise science and medicine are translated into health benefits for patients and the public whenever relevant and applicable. For example, characterising the mechanisms by which heart function improves with exercise in elite athletes and the military can help explain how heart function is impaired in people with diabetes or with high blood pressure. There are numerous examples of where the work of UK Sport and the English Institute of Sport is linked to benefits in the health and wellness domains. These typically involve partnerships with universities and necessitate the sharing of knowledge—for example, vitamin D supplements for bone injury and soft tissue injury recovery. There are a number of other channels, including formal and informal events where knowledge is shared within and outside the elite sport community. I think we can therefore be reassured about one of my noble friend’s central points—that taxpayer funding should lead to benefits to the wider public.
Translational health research is a high priority for the Government. In August 2011 we announced a record £800 million to support this through biomedical research centres and units funded by the National Institute for Health Research. Some of this money has been used to establish a new research unit at Leicester and Loughborough. This unit is helping to expand lifestyle interventions available for the prevention and treatment of chronic diseases. The funding is also enabling the NIHR biomedical research centre at University College London Hospital to study the mechanisms through which exercise promotes health, and how to deliver effective exercise strategies.
An important link in all this, which was mentioned by the noble Lord, Lord Krebs, is the first ever National Centre for Sport and Exercise Medicine, a legacy bid commitment of the 2012 London Games. The £30 million project funded by health is on track, with the London hub now actively functioning and treating patients. Loughborough is anticipated to become operational in 2014, and Sheffield will be the final site to become operational in late 2015. As well as supporting elite athletes, the centre’s influence will extend to local NHS hospitals and primary care facilities to provide a service for anyone who plays sport. Public Health England is overseeing the continuing development of the national centre and is keen to ensure that the centre performs a clear leadership role for sport and exercise science and medicine for the next five years and beyond. Public Health England is supporting the national centre to position it as an international voice on sport and exercise medicine, with strong links with the wider physical activity agenda and a global academic platform. PHE is considering an outline business case for funding in 2014-15 to support co-ordination across the national centre and as pump priming for long-term sustainability. The centre is keen to be seen as an independent organisation which generates income through direct patient care and research funding. It has appointed R&D leads to start that work. We can see the makings of the centre as a sustainable long-term organisation going forward.
The noble Lord asked about the centre as a source of a national strategy. Public Health England is, once again, working with the national centre to develop a sport and exercise medicine network of academics to help collaboration in research funding bids across multiple academic units. However, potential for conflict of interests has emerged as a stumbling block in developing a national research strategy.
In the context of public health, the noble Lord, Lord Hunt, asked about the role of health and well-being boards and his view that they should be prioritising investment in exercise. Many noble Lords would identify with that view but we must remember that health and well-being boards have been given, quite explicitly, the freedom to prioritise their own spending in relation to local public health priorities. However, I expect Public Health England to show the way in the area for local health and well-being boards to follow.
We envisage that the national centre will continue to attract grants from the research councils and deliver work of the highest quality, with the support of their world-leading host institutions.
Given the important health benefits of physical activity, the Select Committee was right to focus attention on the training of health professionals at all levels to be able to prescribe exercise for prevention and treatment. Clearly, the content and training curricula for doctors is determined by the medical schools and royal colleges, but the Department of Health will work closely with Public Health England and other interested organisations to make the case for physical activity in healthcare. On a more practical level, I am pleased to announce that Public Health England has commissioned an e-learning module on physical activity for healthcare professionals, to be distributed by BMJ Learning.
The noble Lord, Lord Krebs, mentioned the National Institute for Health and Clinical Excellence. NICE plays an important role in turning research evidence into authoritative and practical guidance for practitioners and commissioners. Where appropriate, both its public health and clinical guidance recognise the contribution that physical activity can play in the prevention, management and treatment of particular conditions, ranging from obesity to osteoarthritis and low back pain. I assure the noble Lord that many of NICE’s clinical guidelines recognise the important role that exercise and physical activity can play in the management of individual conditions. For example, its clinical guidelines on osteoarthritis and low back pain already recommend exercise. I am confident that NICE will continue to consider the role of exercise and physical activity in the management of particular conditions, where the evidence allows.
The noble Lord, Lord Hunt, asked about the scope for disseminating exercise guidance for specific chronic conditions to GPs. We are exploring the options for a national dissemination of this learning, which would need to be underpinned by better training for doctors in the benefits of physical activity. The new e-learning package commissioned by Public Health England represents an important step in that direction.
Exercise professionals also play an important role in supporting the most vulnerable patients to exercise as part of their treatment for a range of conditions—for example, as part of cardiac rehabilitation. Ukactive has been working with the royal colleges and training organisations for the fitness industry to develop new professional and operational standards for exercise referral. That work is awaiting the update by NICE of its existing recommendations on the use of exercise referral schemes, which it plans to publish in September next year.
The noble Lord, Lord Krebs, asked about the possibility of incorporating physical activity into an indicator in the quality and outcomes framework. This year saw the introduction of two new QOF indicators for physical activity. Those measured the percentage of patients with hypertension who had been screened for inactivity and, of those not meeting the guidelines, the percentage offered brief advice on how to be active. I have to tell him that these indicators have been retired from the 2014-15 QOF as part of the exercise to free up space for GPs to provide more personalised care. That agreement saw a reduction of the QOF by more than a third. However, the NHS health check programme continues to recommend that patients should be screened for their physical activity levels and the delivery of brief advice or an exercise referral for those who are shown to be inactive. At the same time, we are actively considering the case for continued monitoring of the retired QOF indicators to help inform NHS England’s developing primary care strategy.
We are committed to the dissemination of the UK Chief Medical Officer’s guidelines for physical activity, to both the public and medical professionals, and we are working with Public Health England and other organisations to help make healthcare professionals aware of those guidelines.
My noble friend Lord Addington asked why there are not more sports injury people in A&E to treat soft tissue injuries. I agree that athletes understand the importance of prevention. Sport and exercise medicine is, as he knows, a young specialism. Part of the work of the National Centre for Sport and Exercise Medicine will be to scale up sports and exercise medicine services and it will be important to ensure that supply is linked to demand.
The noble Lord, Lord Krebs, asked about the quality assurance of research initiated by the DCMS. I have already alluded to that very briefly. There is no specific monitoring or assessment undertaken by the DCMS of the research commissioned by its arm’s-length bodies. However, UK Sport acknowledges that further steps are necessary to provide stringent assessments of standards and has already made progress on this for the next funding cycle from 2013-17. This includes the appointment of an independent, technically structured sub-committee in addition to the research advisory group that has been in existence for a number of years. That will provide a more extensive overview of all investments in science, medicine and engineering.
Sport is a key part of a wider physical activity agenda, with an important role to play in getting and keeping people active and thereby improving their health and well-being. All sport is physical activity but an important part of Sport England’s youth and community strategy is pilot funding to support how sport can best contribute to improving health and, at the same time, grow weekly sports participation. There are important links between elite sport and the health of the public.
Aligned to the ambition of getting more people participating in sport once a week, Sport England has focused its work on tackling inactivity as this is where we can make a significant contribution to reducing health inequalities and produce the greatest potential health benefits.
Returning to elite sport, the fruits of National Lottery funding are there to be seen in Team GB’s recent success in the Olympics. I was reminded today that in 1996 GB won only one gold medal. In 2000, that went up to 11; in 2004 it was 9; in 2008 it was 19; and last year it was 29 gold medals.
However, the lasting impact of sport and healthy living has always been at the centre of the legacy ambitions of the Olympic and Paralympic Games. Our 10-point plan includes: elite sport, world-class facilities, major sports events, community sport, the strategy for youth and community sport, the charity Join In, school games, physical education and disability sport. For example, there will be £150 million a year for primary school sport starting in September 2013 and £1 billion over four years to boost youth and community sport.
In his Autumn Statement, my right honourable friend the Chancellor of the Exchequer announced that the Government will provide £150 million of funding to continue the school sport premium into the academic year 2015-16, meaning that primary schools will be able to put in place longer-term plans to improve their PE and sport provision. This is not just about elite sport. It will help people start to be and stay active, whether through sport or wider physical activities.
My noble friend Lord Moynihan asked about a cross-government push. The Olympic and Paralympic Legacy Cabinet Committee is the focal point for legacy and is well placed to ensure a joined-up approach to sport and physical activity. The Department of Health is obviously the lead department for health in promoting physical activity. We are working with other departments to support active lifestyles. Departments have jointly made available £300 million to raise the game in primary school sport. The Department for Transport awarded £77 million to increase cycling in eight of our major cities, with £1.2 million from the Department of Health to support walking. More than a million more people are playing sport than in 2005. I suggest to noble Lords that that progress is positive. As regards the Government’s effort, all this adds up to a significant investment in health-enhancing physical activity, driven by what we have learnt from sport and exercise science and medicine.
NHS: Walk-in Centres
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Baroness Wheeler
To ask Her Majesty’s Government what plans they have in respect of the closures of NHS walk-in centres over the past three years, in the light of the preliminary report made by Monitor.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, since 2007, the local NHS has been responsible for NHS walk-in centres. It is for local commissioners to decide on the availability of these services. It is also for local commissioners to determine how walk-in centres fit into plans locally, rather than being governed by a top-down imposition of services. They make such decisions by involving patients and by using their clinical expertise to determine the pattern of local services and where walk-in centres fit in with this.
Baroness Wheeler (Lab)
I thank the Minister for his response. However, 76 NHS walk-in centres have been closed over the past three years and the Monitor report makes clear that this is often without proper consultation locally on alternative provision, leading to increased pressure on A&E and urgent care services. In Monitor’s survey, one in five patients using the centres said that they would have visited the nearest A&E department had the centre not been there. Monitor also finds in a number of cases that the closure decision has been made by CCGs, with member GP practices themselves having a financial interest in whether or not the service continues. What action will the Government take to ensure that, if future closures of walk-in centres are considered, the public will be properly consulted and patients will have access to an equivalent level of service?
Earl Howe
My Lords, when any service change is proposed, we expect that the four tests which the Government laid down early on in their term of office should be followed. One of those is a patient and public consultation or involvement in the decision. Another is clinical buy-in. I can give the noble Baroness the assurance that this is what local area teams of NHS England would expect to see in any proposals involving the closure of a walk-in centre.
Baroness Brinton (LD)
My Lords, does my noble friend share my concern that the NHS is paying twice for patients who regularly use walk-in centres due to the capitation payment to GPs and activity payment to other care systems? Could part of the alternative provision to closed walk-in centres be that all GP practices follow the good practice of those who already extend opening hours for early and late sessions and Saturdays?
Earl Howe
The noble Baroness makes an extremely good point. One of the findings of the Monitor review was that, when responsibility for walk-in centres was handed down to local commissioners in 2007, many of them were decommissioned because they were duplicating services locally and GPs felt that they were paying twice for the same thing. I am sure that the ideas the noble Baroness has put forward will have a resonance in many areas.
Baroness Masham of Ilton (CB)
My Lords, is it true that doctors are being paid not to send patients to hospital? Does the Minister agree that when patients are ill they have no alternative but to go to A&E departments?
Earl Howe
I agree with the noble Baroness that A&E often presents the easiest and most convenient route into the NHS. That is why Sir Bruce Keogh is currently conducting his system-wide review and looking at pressures on the system. I am not aware of any doctors who are being paid not to refer patients to hospital. Indeed, as the noble Baroness may be aware, the BMA has been steadfast in its opposition to any such scheme.
Baroness Wall of New Barnet (Lab)
My Lords, the noble Earl suggested in his response earlier that part of the problem might be that the commissioners felt that they were paying twice. Obviously, GPs are paid for the people on their lists; those same people could use the call centre and they would have to be paid again. How does this fit with the view—certainly the view on the policy—that you can belong to any GP throughout the country, which is exactly what should happen and, if it did, we would not have this dilemma? Walk-in centres are hugely important. I assure the House that, from the point of view of the provider trust, they are absolutely vital to stop people coming into A&E and possibly being admitted.
Earl Howe
My Lords, I would not deny for a second that walk-in centres had a role in many places, and indeed the fact that so many are still open is proof of that. However, it is a mixed picture. Those centres that have closed are in many cases ones where doctors locally have perceived that, in one form or another, there is adequate provision for patients, whether through pharmacies, GP surgeries or community services of a different kind.
Lord Mawhinney (Con)
My Lords, how many proposals for walk-in centre closures have been advanced to public consultation over the past three years and then have not been proceeded with as a consequence of the consultation?
Earl Howe
My Lords, I cannot give my noble friend the answer because that is not information that we collect in the department but, as I said earlier to the noble Baroness, Lady Wheeler, we expect consultation to take place in local areas so that patients and the public at least have a chance to voice their views.
Lord Turnberg (Lab)
My Lords, when these centres were introduced, most people believed that they were a very good thing; I think they still think that. They help to take the load off A&E departments and GPs. Does the noble Earl agree that one of the problems is that there is no overarching co-ordination between A&E departments, GPs and these centres? Furthermore, there are no overarching similar funding arrangements. Should we not do something about that?
Earl Howe
Yes, my Lords, and that is exactly why Sir Bruce Keogh has been tasked to look system-wide not simply at walk-in centres but at the entire community and urgent and emergency care network to make sure that patients go where is most appropriate for them, that there is not undue pressure on any single part of the system, and that tariffs reflect the right balance of patient flows.
Lord Brooke of Alverthorpe (Lab)
My Lords, if there is an expectation that there should be consultation with patients and it does not take place, who is accountable for that failure?
Earl Howe
In some cases, a change of services will be so minor that formal consultation with patients is not required under the existing rules if, for example, a service moves a few yards down the road or something of that kind. However, it is the responsibility of the commissioner—either NHS England or a clinical commissioning group—to make sure that consultation where appropriate does take place.
Mesothelioma
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Lord Alton of Liverpool
To ask Her Majesty’s Government what funding has been secured for research into the causes of and potential cures of mesothelioma.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government are fully committed to research into the causes of this dreadful disease and into potential treatments. The usual practice of the main public funders of health research is not to ring-fence funds for expenditure on particular diseases, and funding is available for high-quality research proposals. With its partners, the Department of Health is actively pursuing a package of measures that we believe will stimulate an increase in the level of research on mesothelioma.
Lord Alton of Liverpool (CB)
While thanking the noble Earl for his reply, does he recall the assurance he gave to the House, when an all-party amendment—which would have created a small, statutory levy to support mesothelioma funding—was defeated by 199 votes to 192, that insurance companies would voluntarily step up to the plate? Given that there have been 2,400 deaths from mesothelioma this year, with 60,000 anticipated over the next 25 years, and with the imminent ending of even the existing insurance industry funding, would it not be shameful to leave unfunded research that could save lives and prevent vast expenditure on compensation? The Mesothelioma Bill is now before another place, with an amendment supported by both Conservative and Labour Members of the House of Commons. Surely Ministers should be looking again at this practical way of finding a cure for this deadly disease.
Earl Howe
My Lords, I understand that the British Lung Foundation has had discussions with representatives of the insurance industry about extending the funding for research, but that no commitment has been made by the industry so far as to future funding. As I made clear during the debate, the issue holding back progress is not the lack of available funding—there is plenty of that—but the lack of sufficient high-quality research applications. The money previously donated by insurers is supporting valuable research, as the noble Lord, Lord Alton, has said. At the moment, a greater volume of mesothelioma research is supported by the Government, and we believe that the package of measures that I mentioned will stimulate an increase in that volume.
Lord Beecham (Lab)
My Lords, I refer to my interest in the register. Section 48 of the Legal Aid, Sentencing and Punishment of Offenders Act 2012 requires the Government to review the application to mesothelioma claims of the provisions banning conditional fees. The Government have announced that, in the light of a consultation as yet unpublished, they will not treat those cases differently from other claims. They seek to conflate this issue with entirely different provisions in the Mesothelioma Bill.
Is the Minister aware that the Civil Justice Council has been unable to agree whether the current consultation,
“fulfils the conditions set out in Section 48 of LASPO”?
Is this not another example of the Government cravenly caving in to the demands of their friends in the insurance industry and ignoring the strong feelings of this House in support of those suffering from this terrible disease?
Earl Howe
I am sure that the noble Lord wants to take advantage of this opportunity to raise that particular issue, but it is a rather different one from the Question posed by the noble Lord, Lord Alton. However, I will take his question away and ensure that a letter is sent to him in response.
Lord Ribeiro (Con)
My Lords, the Government are to be congratulated on introducing the Cancer Drugs Fund, but how do they anticipate that the vital research which needs to be done into mesothelioma will continue to be funded without legislation to compel those insurance companies which so far have not stepped up to the plate to make a contribution?
Earl Howe
My Lords, as my noble friend will be aware, four insurance companies have stepped up to the plate with funding of £3 million, which admittedly is nearing its end, but I do not think that we can belittle that contribution. My noble friend may be interested to know that the MRC and the NIHR together spent more than £2.2 million on mesothelioma research in 2012-13, which is a larger sum than for many other disease areas. I say again that the issue is not the lack of funding because the research funding in both the MRC and the NIHR has been protected. What is lacking are suitable proposals.
Lord Howarth of Newport (Lab)
My Lords, does the Minister share the disappointment expressed by the noble Lord, Lord Alton, which I certainly do, that following the scandalous mistreatment of mesothelioma sufferers by employer’s liability insurers over decades, there has been no commitment from those four employer’s liability insurers or from the rest of the industry to continue funding beyond next year? Whatever arrangements are made to secure the continuation of research in this vital field, can the Minister be more precise on how the Government will bring their influence to bear to ensure that the research is of suitable quality?
Earl Howe
My Lords, we have committed to doing four things, the first of which will be to set up a partnership to bring together patients, carers and clinicians to identify what the priorities in research are. Secondly, the NIHR will highlight to the research community that it wants to encourage research applications in this area. The NIHR Research Design Service will be able to help prospective applicants develop competitive research proposals, and we will convene a meeting of leading researchers to discuss and develop new proposals for studies. I think that those four measures together will deliver what the noble Lord seeks.
Lord Avebury (LD)
My Lords, does my noble friend acknowledge that the £3 million has run out and that there is a danger that the talented clinicians who have been working on mesothelioma as a result of that fund will move on to other subjects? However, the Association of British Insurers has told me that it would be prepared to consider a new scheme funded jointly by all employer’s liability insurers and the Government, so I wonder if the Government will approach the ABI to see if that scheme could be taken a little further.
Lord Walton of Detchant (CB)
My Lords, what makes mesothelioma such a fatal disease is the length of the incubation period, in that individuals who have been exposed to asbestos may not develop the disease until many years later; indeed, 2,000 new cases have been reported this year. The developments to which the Minister has referred are helpful and encouraging, but have the Government been able to persuade the relevant insurance companies to increase significantly their contribution to the research programme?
Earl Howe
My Lords, I said earlier that the discussions between the British Lung Foundation and the insurance industry have not so far resulted in a pledge for further funding, but as my noble friend Lord Avebury has indicated, that door may be open. However, we should bear in mind that asking insurance companies to fund research is an unusual mechanism in itself. I suggest that we should not push the envelope too far because in the end the cost will fall on the industry.
Health and Social Care Act 2012: Risk Register
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Lord Brooke of Alverthorpe
To ask Her Majesty’s Government whether they will now publish the risk register prepared in advance of the passage through Parliament of the Health and Social Care Act 2012.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, it remains the Government’s position that they will not be publishing the transition risk register. The decision to withhold the risk register was based on the principle that Governments, together with their civil servants, need to be able to consider all aspects of policy formation, including its risks, in private. It remains our view that a full and candid assessment of risk and the mitigating action required to manage it is carried out within a safe space.
Lord Brooke of Alverthorpe (Lab)
My Lords, the House will be grateful to the Minister for reminding us of the Government’s position and of what is in the public domain, but I remind him that the Question is about what the Cabinet and the Secretary of State decided should not be in the public domain. Is there no shame or embarrassment on the part of the Government, who have imposed, quite rightly, a duty of candour on the NHS but who decline to practise that policy themselves by being candid with the public, particularly with those of us who use the NHS? What are the Government hiding? If it is nothing, they should publish the register tomorrow and put it away.
Earl Howe
My Lords, the Government are fully committed to transparency and openness, but they need also to be able to manage large and complex projects and programmes efficiently and effectively. If requests for information are made that threaten to compromise their ability to do that, as is the case here, then the Government have to weigh up whether releasing what is being asked for is, on balance and bearing in mind the consequences, in the public interest. Up to now, we have taken the view that the public interest is not served by publication.
Baroness Brinton (LD)
My Lords, the previous Government refused to release Department of Health strategic risk registers in response to three requests under the Freedom of Information Act. Can my noble friend the Minister tell the House whether there is a discernible difference between this Government and the previous one in their approach to the publishing of risk registers?
Earl Howe
That is a helpful question. I do not believe there is a difference. As the noble Baroness rightly said, on a number of occasions the previous Government refused to disclose the risk registers, and they did so for perfectly good reasons, one of which was to enable the safe space that I referred to earlier.
Lord Mawhinney (Con)
My Lords, will my noble friend accept that many in your Lordships’ House will welcome this reaffirmation of the Government’s policy, particularly those who have had the privilege of being Ministers?
Lord Grocott (Lab)
Will the Minister, who is clearly not going to give the information from the risk register, perhaps give us a clue along the following lines? Given the experience of the reform in operation, have any of the risks that were identified in the private risk register come to pass, or is everything going wonderfully well?
Earl Howe
My Lords, the risk register, as the noble Lord knows, is simply a tool that records the risk assessment process and the actions that need to be taken to mitigate those risks. However, to be effective, the process has to be robust and consider all likely implications—and indeed some that are not so likely—of a proposed course of action. The candid recording of risks enables them to be effectively managed. However, as the noble Lord knows, we have gone as far as we can in publishing the areas of risk that are contained within the risk register. I remind the noble Lord that in 2012 we published an extensive document that set out quite a lot of detail. That document is still available on the department’s website.
Lord Hunt of Kings Heath (Lab)
My Lords, I refer noble Lords to my health interests. To return to the Question asked by my noble friend, is it not a fact that officials warned Ministers that they would be introducing a shambolic reform of the health service? Those officials, much-maligned by the noble Lord’s ministerial colleagues, have been proved to be absolutely right. As we are all looking forward to the new musical by the noble Lord, Lord Lloyd-Webber, can the noble Earl tell me which will be published first: the full Profumo papers or the noble Earl’s risk register?
Earl Howe
My Lords, I do not accept the noble Lord’s description of the transition, which has gone extremely smoothly. By most measures the NHS is performing very well indeed. Waiting times are low and stable, the number of people waiting more than 12 months has plummeted since 2010, hospital-acquired infections are at an all-time recorded low, we have more doctors and healthcare professionals in the system, and mixed-sex accommodation has been reduced to minimal levels. That does not indicate to me that the reforms have had a damaging effect—quite the reverse.
Lord Dobbs (Con)
My Lords, I am not sure whether a risk register was published before the war in Iraq. However, will my noble friend use his best influence on his colleagues in government to make sure that in the interests of candour the Chilcot report is published as soon as possible? We have all waited long enough for answers on that particular affair.
Baroness Armstrong of Hill Top (Lab)
My Lords, if the reforms are going so well, why does the Secretary of State, who now presides over an Act that said that the health service would be at a long arm’s length from Ministers, now see the key people in the health service at least once a week? Why does he take it upon himself personally to interfere in ways that during the passage of the Bill the Minister here told us very clearly Ministers would no longer be doing?
Earl Howe
The noble Baroness would have cause to complain if, in accordance with the debates that we had in this House on accountability, my right honourable friend did not hold the NHS to account on some of the areas of its activities where there were concerns. That is exactly what he does, and he does it quite properly.
Lord Hughes of Woodside (Lab)
Is it not the case, in relation to the Chilcot report, that it is not the Government who are holding it up but something else? Will the Minister not hide behind red herrings like that? It is he and his Government who are refusing to publish the risk register, and they surely must do so.
Earl Howe
My Lords, over the passage of time a view can be taken about the sensitivity of the Department of Health risk register. That is what we have undertaken to do and what we will do. Next spring, we will reach one of the regular review points for the risk register. I can tell the noble Lord that work to review the register has already started in anticipation of that date.
Health: Talking Therapy
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Baroness Royall of Blaisdon
To ask Her Majesty’s Government whether they have plans to create a legal right to talking therapy as part of their commitment to ensure parity of esteem between mental and physical health.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the department has no plans to create a legal right to talking therapies. Mental health and parity of esteem are key priorities for NHS England. The Government’s mandate to NHS England makes it clear that everyone who needs it should have timely access to evidence-based services, which involves extending access to talking therapies. We are working with NHS England to develop standards on access and waiting times across mental health from 2015.
Baroness Royall of Blaisdon (Lab)
My Lords, I am grateful to the noble Earl for his Answer, but I still have serious concerns about the services that mental health patients receive. I do not often quote the noble Lord, Lord Freud, but last month he said that,
“the association between poor mental health and poverty is clear”.—[Official Report, 7/11/13; col. 324.]
However, despite people’s increasing stress due to poverty, the cost of living and zero-hours contracts, the Government have cut mental health spending in real terms in the past two years. Funding for therapies not included in IAPT has been cut by 5%, despite ministerial assurances that this would not happen. Last week, the We Need to Talk coalition released a report that revealed that more than half of mental health patients are waiting at least three months for treatment. Can the Minister commit to reducing those waiting times by March 2015, the date by which time the Government are committed to making progress towards that important parity of esteem?
Earl Howe
My Lords, I agree that waiting times for talking therapies are too long, and we are taking energetic steps to address that within the bounds of affordability. In the context of the noble Baroness’s main Question, what surely matters is the quality of outcomes, rather than just the extent of inputs. We set the outcomes that we expect the NHS to achieve in the NHS outcomes framework. There are a number of outcomes in there specifically for people with mental health problems, and others, about the quality of services. It is up to commissioners to prioritise their resources to meet those outcomes for the population based on assessments of need, and we will hold them to account for that.
Lord Alderdice (LD)
My Lords, I entirely support my noble friend’s commitment to good outcomes, but those also require sufficient inputs. If the noble Baroness’s request for a right to talking therapy were implemented tomorrow, it would completely collapse because there simply are not enough trained therapists to provide the care that is required. What measures are the Government taking to ensure that in future there will be sufficient trained therapists to provide the parity of care for those with mental illness that is available to those with physical illness?
Lord Patel of Bradford (Lab)
My Lords, following on from what the noble Lord, Lord Alderdice, said about having staff who can provide appropriate talking therapies, and what the Minister himself said about someone who needs a service receiving it, we have a long history in the mental health field of mental health practitioners not referring certain minority-ethnic groups such as the south Asian and black African communities for talking therapies. I believe that that is still the case with referrals to the CBT programme. What are the Government doing to address this imbalance?
Earl Howe
I can tell the noble Lord that IAPT is working with a number of BME groups to promote wider access to the service from all sections of the community. A grant scheme will shortly be launched to encourage community-based interventions to increase uptake of talking therapies, including from BME groups.
Lord Elystan-Morgan (CB)
My Lords, will the Minister kindly tell the House roughly what percentage of in-patients and out-patients suffer from mental health problems compared with those who suffer from physical health problems? Can he say, roughly, how the resources of the NHS are divided between the two camps on a revenue basis? I have the clear impression that traditionally mental health has been short-changed for very many years.
Earl Howe
My Lords, the noble Lord’s perception would be shared by many, which is why we have been very clear in our mandate to NHS England that parity of esteem is of the essence, and we will hold the service to account for that. I do not have the specific statistics that the noble Lord seeks but we know that more people are being treated in secondary mental health services now than two or three years ago. However, the proportion who needed to be admitted to in-patient psychiatric care fell over that period, and that reflects increasing emphasis on care in the community.
Baroness McIntosh of Hudnall (Lab)
My Lords, as someone who has benefited from CBT on a number of occasions, may I ask whether the noble Earl agrees that it is not just a question of whether people need the therapy but rather that they receive enough of it? Following the question of the noble Lord, Lord Alderdice, about the number of people who could benefit from this, what is the average number of sessions of talking therapy that a National Health Service mental health patient will receive and is it, generally speaking, enough?
Lord Elton (Con)
Will my noble friend assure the House that this rule of parity will be introduced in the Prison Service as well as the National Health Service generally?
The Earl of Sandwich (CB)
Does the noble Earl share my concern about the overprescription of psychiatric drugs? Can he think of anything to do about this apart from encouraging CBT and talking therapies?
Earl Howe
My Lords, the noble Earl is right. I share his concern, and I think it has been a widespread concern across the mental health community. Nowadays, the guidance given to doctors is much broader than the guidance that was given some years ago. It embraces the talking therapies in particular and it seeks to avoid the overprescription of sometimes very strong pharmaceutical products.