NHS: Seven-day Working

Earl Howe Excerpts

Thursday 6th February 2014 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, I congratulate my noble friend Lord Ribeiro on securing a debate on this important issue. I know that as a former consultant surgeon and former president of the Royal College of Surgeons this is a subject in which he takes a great deal of interest. I also take this opportunity to pay tribute to the work done on seven-day services by NHS England, the NHS Services Seven Days a Week forum, the Academy of Royal Medical Colleges and the Royal College of Surgeons, among others.

The historical five-day service model offered in many NHS hospitals no longer meets justifiable patient and public expectations of a safe, efficient, effective and responsive service. I very much echo the comments of the noble Lord, Lord Parekh, in that context. Over the past 10 years, a growing body of national and international evidence has emerged that links poor outcomes, including a higher risk of death, to patients admitted to hospital at the weekend, around the world. It is impractical and inefficient to continue to operate a five-day approach when our illnesses and conditions do not limit themselves to office hours. Patients are entitled to receive the same standard of care regardless of the day of the week.

As the largest and most comprehensive health service in the world, the NHS is well positioned to solve the issue of poorer outcomes and reduced levels of service provision at the weekend. That is why NHS England has set out a vision for the NHS which is of a service more closely organised around the lives of the public it serves. To develop this vision, NHS England established the NHS Services Seven Days a Week forum in February last year to consider how NHS services can be improved to provide a more responsive and patient-centred service across the seven-day week.

The forum’s work has been met with nothing but positive feedback and support from the public and patients, the Academy of Medical Royal Colleges and the British Medical Association, among other organisations. The immediate focus for improvement activity will be addressing the need for high-quality urgent and emergency care services, seven days a week. NHS England is also looking to make similar improvements across primary and community health services and social care, and the forum will report in autumn this year, setting out proposals for the creation of a fully integrated service. NHS England’s ambition is for seven-day services to be fully implemented in England by the end of 2016-17.

I recognise that we cannot talk about the idea of seven-day services without giving full consideration to questions of staffing and finance; many noble Lords have raised those issues. NHS providers and their commissioners already face difficult choices when deciding where to invest their resources in order to maximise the outcomes for patients and value for taxpayers. Early indications are that seven-day services have the potential to be part of the solution. However, more information is needed. NHS England is therefore conducting research which will provide a helpful indication of the likely costs providers and commissioners face when considering how to redesign their services to provide comprehensive seven-day care. In addition, to answer my noble friend Lady Brinton, NHS England intends to commission financial and system modelling and analysis of the implications of its strategy for achieving seven-day service provision in the NHS.

My noble friend Lord Ribeiro rightly highlighted the workforce implications of having a consistent, high-quality service seven days a week. The department, alongside NHS England, Health Education England, NHS Employers and a number of strategic partners, is considering that very issue. Its analysis is considering issues such as junior doctors feeling unsupported during weekend working and the resulting need to ensure that education contracts include appropriate seven-day senior supervision; and numbers of diagnostic and scientific staff, with NHS England intending to undertake a thorough assessment of the different roles needed in diagnostic and scientific services to support an extended service.

Of course, many commissioners and providers will need support to address the challenges presented by seven-day services. To that end, NHS Improving Quality has just introduced a new, large-scale transformation change programme, set up in collaboration with all healthcare commissioners and providers, to support the spread of seven-day services over a three-year period.

I realise that the move towards seven-day care will not be easy, but there are encouraging examples of pioneering NHS organisations that have moved to make healthcare services more accessible seven days a week to avoid compromising safety and patient experience. For example, Sheffield Teaching Hospitals NHS Foundation Trust has adopted seven-day service provision, improving patient flow of frail and older people through the emergency pathway. Bed occupancy for emergency care for older patients has now reduced by more than 60 beds. Other examples in my brief include Salisbury District Hospital and the Lancashire Intermediate Support Team, both of which have produced impressive results.

We know that across the country, more hospitals, primary and community care organisations and social care services are working together to break the link between poorer outcomes for patients and the reduced level of service provision at the weekend. We also know that patients and the public want us to act now to make seven-day services a reality in all parts of our NHS.

A number of noble Lords, including my noble friend Lord Ribeiro and the noble Lords, Lord Parekh and Lord Hunt of Kings Heath, raised the issue of cost. Interestingly, there is already evidence that seven-day services can be implemented in a way that does not increase the overall cost of healthcare. The average cost of implementation at trusts pioneering the service was 1.5% to 2% of their total income. Costs vary according to local service models, but research shows that they can be reduced by reconfiguring services and by trusts working collaboratively. Seven-day services at the front end—that is to say, A&E departments—could also pay for themselves by reducing admissions and lengths of stay.

Seven-day services would not work under a one size fits all model—a point made by my noble friend Lord Ribeiro. Local solutions need to be found and pioneering NHS providers and commissioners are already working to develop them.

In answer to the noble Baroness, Lady Masham, on the issue of safety at weekends, we expect all NHS services to be able to meet patients’ needs as they arise. To do this, trusts should adopt the clinical standards developed by the seven-day services forum to drive up clinical outcomes and improve patient experience at weekends.

My noble friend Lady Manzoor referred to the CQC. The CQC and the Chief Inspector of Hospitals are considering how implementation of the clinical standards could best be assessed by the CQC and how this might be reflected in its forthcoming ratings and the judgments it makes when it inspects.

As I said, workforce is a major issue. The noble Baroness, Lady Masham, was right to raise that point. There are over 12,200 more clinical staff in the NHS than there were before the election, thanks to the money we have invested in the service and to the reforms we have carried out. Nevertheless, there is an issue about motivating staff to work at weekends, as the noble Baroness rightly said. We understand that contractual levers and incentives are required to drive change. NHS England and a number of key strategic partners are already looking into this. However, in many cases seven-day services have reportedly already had a positive impact on individuals’ work-life balance, offering greater certainty in planning ahead and flexibility in time off. In addition, the medical royal colleges are all in support of seven-day services. Building seven-day service provision into recruitment, job planning and appraisal processes will help create a sense of common purpose to underpin organisational delivery.

A number of noble Lords, including my noble friends Lord Ribeiro and Lady Barker, referred to the role of GPs. To address that important role in the mix of services the NHS provides, we recently announced the setting up of a £50 million fund to support innovative GP practices in improving services, and in particular access for their patients, including seven-day week access and evening opening hours and the testing of a variety of services including Skype, e-mail and phone consultations.

However, as the noble Lord, Lord Hunt of Kings Heath, emphasised—as did my noble friend Lady Barker—community services and social care are absolutely integral to this as well, particularly when it comes to the care of the frail elderly. Social care and the NHS are priorities for the Government and we know that there is interdependency between the two systems. However, providing more resources is not enough on its own. We have provided more resources from the Department of Health but we need to do more. NHS England is currently working with the Local Government Association to create a health and social care system that is truly seamless so that people receive the right care at the right time and in the right place. The Seven Days a Week forum will report on that work in the autumn, setting out proposals for a fully integrated service.

The Better Care Fund is a key enabler for change, as my noble friend Lady Manzoor pointed out. As part of the process for accessing funding, clinical commissioning groups and local authorities will have to demonstrate, as part of agreed local plans, that they are addressing a number of national conditions, including seven-day services in health and social care.

The noble Lord, Lord Warner, asked whether the Government would expect A&E departments to have weekend consultant cover. We recognise that the consultant contract is a key enabler of seven-day services. In October last year the Government mandated NHS Employers to enter into formal negotiations with the BMA to deliver joint proposals for consultant contract reform, including changes that will support seven-day services.

My noble friend Lord Bridgeman focused on the working time directive. He may know that we asked the president of the Royal College of Surgeons, Professor Norman Williams, to chair an independent task force to look at the implementation of the working time directive, and the impact of the directive on the delivery of patient care and the training of the next generation of doctors. The independent review will provide its report during March 2014. Professor Williams is working with stakeholders from the Royal College of Surgeons, NHS organisations, the BMA, National Voices and others, and we ourselves are working with the task force to ensure that it has appropriate legal and analytical support.

There is a compelling case for healthcare services to be accessible seven days a week. To echo the noble Lord, Lord Parekh, if we were starting the NHS from scratch I very much doubt whether we would design a part-time system. We would surely create a seven-day service to better meet patients’ needs. Seven-day service provision is about equitable access, care and treatment, regardless of the day of the week. It is a cause for some pride that the NHS will be the global pioneer in providing equality of access to consistent, high-quality healthcare seven days a week.

[Lord Hunt of Kings Heath]

My Lords, before the noble Earl sits down, I was remiss in not declaring my interests at the start as chair of a foundation trust, president of GS1 and a consultant trainer with Cumberlege Connections. I know that we all know that, but I have to do it every time.

NHS Property Services Ltd

Earl Howe Excerpts

Thursday 30th January 2014 Lords Chamber

[Lord Warner]

To ask Her Majesty’s Government what assessment they have made of the performance of NHS Property Services Ltd in disposing of surplus properties and operating within their working capital.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, NHS Property Services is on target to dispose of 97 properties by 31 March 2014 and a further 100 properties by 31 March 2015. The department has provided the company with a £350 million flexible working capital loan facility, of which £271 million had been drawn down as at 27 January 2014. This working capital support is in line with the department’s expectations for a start-up company of this size and complexity.

[Lord Warner (Lab)]

I thank the Minister for his Answer, but what action has been taken to improve the performance of this company in controlling its costs? What action has been taken to reduce its running costs, given the large number of staff that it inherited, and what action has been taken to improve the professional competence of those staff and to collect bad debts, which have been a rising problem for this organisation?

[Earl Howe]

My Lords, on administration costs, the company is already reviewing the way in which its strategic asset management and facilities management functions are structured. It is probably inevitable that the consolidation of 161 PCT and strategic health authority estates into one will throw up duplication, overlap and operational policies that conflict. These all need to be rationalised and a commercial ethos introduced. It is vital that the skills are imported into the organisation to match that challenge.

[Lord Mawson (CB)]

My Lords, for the past six years, we in St Paul’s Way in Tower Hamlets have been pursuing the Government’s policy of integration in health services, bringing together a school, housing, health and community services centre on one street. I was asked to lead this project following a murder and considerable racial violence on this housing estate. The overall transformation project has been very successful, and I must declare an interest. However, the primary care premises elements have stalled and we are going backwards in terms of dental outreach facility. Can the Minister explain how NHS England engages with NHS Property Services, the CCG, local GPs and local partners to deliver in an effective and timely manner the kind of innovative and integrated premises we all agree are essential?

[Earl Howe]

My Lords, I pay tribute to the work that the noble Lord does. However, it is important to understand that the decision as to whether a property in the NHS Property Services portfolio is surplus to requirements and should therefore be sold resides with the commissioners; that is, NHS England and clinical commissioning groups. It is up to the commissioners how they wish to utilise the estate.

[Lord Brabazon of Tara (Con)]

Is my noble friend aware of the situation of Putney Hospital, which closed about 15 years ago and has only recently been sold to Wandsworth Borough Council, but is still undeveloped?

[Earl Howe]

My Lords, I am not aware of the detail of that particular case, but I will gladly write to my noble friend about it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my interests in the register; I should have done that yesterday on another health Question, for which I apologise to the House. Can the Minister confirm that the chairman of this organisation resigned early, that capital money was raided to cover a revenue shortfall and that, only months after the organisation formally started, an investigation has been mounted by the National Audit Office? Given that the shares in this company are owned by Ministers, will Ministers take responsibility and can the noble Earl confirm that this was forecast in the NHS risk register, which the Government have not yet published?

--- Later in debate ---

[Earl Howe]

My Lords, the noble Lord has painted rather a black picture of the company, which we believe has got off to an extremely good start, contrary to his impression. The company’s former chair asked to step down six months earlier than planned because the company had completed the transition phase early, and it was agreed that a chair with a different skill set was needed to oversee the rationalisation of the company.

As regards the company’s cash needs, we made £350 million available to the company as a working capital loan. That was planned some six months ago and was needed in large part due to the slow payment of invoices by the company’s customers, many of whom were themselves new organisations set up as part of the reforms, so it is not altogether surprising that cash flow initially was slow, but the situation is improving.

[Lord Colwyn (Con)]

My Lords, can my noble friend tell us what efficiencies and successes NHS Property Services has actually made?

[Earl Howe]

My Lords, it has been a good start for the company. It has generated £22 million from sales of surplus assets and savings of £2 million a year on the running costs of those disposed properties. The company is also harnessing economies of scale—for example, savings to date of £1.2 million by standardising the procurement of electricity across the whole estate. The company is now exploring how to make savings across other utilities and services, such as legal services.

[Lord Turnberg (Lab)]

My Lords, following the response to my noble friend Lord Hunt’s question, can the noble Earl tell us why the National Audit Office has decided to conduct an investigation so soon after the establishment of this organisation?

[Earl Howe]

My Lords, the National Audit Office is indeed looking at the company—only to assure us and itself that the company is properly organised and structured. We welcome that, as does the company. There was no sinister purpose or concern underlying that process; it is perfectly normal and natural.

[Baroness Manzoor (LD)]

My Lords, can the Minister confirm best value for money on all properties sold and that there has been proper consultation with local organisations on all NHS estates?

[Earl Howe]

My Lords, I can assure my noble friend of that. The company ensures best value by marketing through an arm’s-length open market process, which ensures that the market value is achieved in a sale. Where necessary, the sale price is supported by a district valuer or other third-party independent valuation.

[Baroness O'Cathain (Con)]

My Lords, I ask my noble friend: when people are appointing chairmen to such organisations, could they look at their skill sets in advance rather than getting rid of them because of their lack of skill sets?

--- Later in debate ---

[Earl Howe]

My Lords, it is important to understand that the chairman who has stepped down had a very good set of skill sets, but it is not the skill set that we now need to take the company forward. The task at the beginning was to consolidate a very complex portfolio of properties, and that was done very successfully. The task now is different: it is to manage those properties effectively and to get maximum value for the taxpayer for the properties that are sold.

Children and Families Bill

Earl Howe Excerpts

Wednesday 29th January 2014 Lords Chamber

Moved by

[Earl Howe]

57B: Before Clause 80, insert the following new Clause—
“Regulation of retail packaging etc of tobacco products
(1) The Secretary of State may make regulations under subsection (6) or (8) if the Secretary of State considers that the regulations may contribute at any time to reducing the risk of harm to, or promoting, the health or welfare of people under the age of 18.
(2) Subsection (1) does not prevent the Secretary of State, in making regulations under subsection (6) or (8), from considering whether the regulations may contribute at any time to reducing the risk of harm to, or promoting, the health or welfare of people aged 18 or over.
(3) The Secretary of State may treat regulations under subsection (6) or (8) as capable of contributing to reducing the risk of harm to, or promoting, the health or welfare of people under the age of 18 if the Secretary of State considers that—
(a) at least some of the provisions of the regulations are capable of having that effect, or(b) the regulations are capable of having that effect when taken together with other regulations that were previously made under subsection (6) or (8) and are in force.(4) Regulations under subsection (6) or (8) are to be treated for the purposes of subsection (1) or (2) as capable of contributing to reducing the risk of harm to, or promoting, people’s health or welfare if (for example) they may contribute to any of the following—
(a) discouraging people from starting to use tobacco products;(b) encouraging people to give up using tobacco products;(c) helping people who have given up, or are trying to give up, using tobacco products not to start using them again;(d) reducing the appeal or attractiveness of tobacco products;(e) reducing the potential for elements of the packaging of tobacco products other than health warnings to detract from the effectiveness of those warnings;(f) reducing opportunities for the packaging of tobacco products to mislead consumers about the effects of using them;(g) reducing opportunities for the packaging of tobacco products to create false perceptions about the nature of such products;(h) having an effect on attitudes, beliefs, intentions and behaviours relating to the reduction in use of tobacco products.(5) Regulations under subsection (6) or (8) are to be treated for the purposes of subsection (1) as capable of contributing to reducing the risk of harm to, or promoting, the health or welfare of people under the age of 18 if—
(a) they may contribute to reducing activities by such people which risk harming their health or welfare after they reach the age of 18, or(b) they may benefit such people by reducing the use of tobacco products among people aged 18 or over.(6) The Secretary of State may by regulations make provision about the retail packaging of tobacco products.
(7) Regulations under subsection (6) may in particular impose prohibitions, requirements or limitations relating to—
(a) the markings on the retail packaging of tobacco products (including the use of branding, trademarks or logos);(b) the appearance of such packaging;(c) the materials used for such packaging;(d) the texture of such packaging;(e) the size of such packaging;(f) the shape of such packaging;(g) the means by which such packaging is opened;(h) any other features of the retail packaging of tobacco products which could be used to distinguish between different brands of tobacco product;(i) the number of individual tobacco products contained in an individual packet;(j) the quantity of a tobacco product contained in an individual packet.(8) The Secretary of State may by regulations make provision imposing prohibitions, requirements or limitations relating to—
(a) the markings on tobacco products (including the use of branding, trademarks or logos);(b) the appearance of such products;(c) the size of such products;(d) the shape of such products;(e) the flavour of such products;(f) any other features of tobacco products which could be used to distinguish between different brands of tobacco product.(9) The Secretary of State may by regulations—
(a) create offences which may be committed by persons who produce or supply tobacco products the retail packaging of which breaches prohibitions, requirements or limitations imposed by regulations under subsection (6);(b) create offences which may be committed by persons who produce or supply tobacco products which breach prohibitions, requirements or limitations imposed by regulations under subsection (8);(c) provide for exceptions and defences to such offences;(d) make provision about the liability of others to be convicted of such offences if committed by a body corporate or a Scottish partnership.(10) The Secretary of State may by regulations provide that regulations under subsection (6) or (8) are to be treated for the purposes specified in regulations under this subsection as safety regulations within the meaning of the Consumer Protection Act 1987.
(11) The Secretary of State may by regulations make provision amending, repealing, revoking or otherwise modifying any provision made by or under an enactment (whenever passed or made) in connection with provision made by regulations under any of subsections (6), (8), (9) or (10).
(12) The Secretary of State must—
(a) obtain the consent of the Scottish Ministers before making regulations under any of subsections (6), (8), (9) or (10) containing provision which would (if contained in an Act of the Scottish Parliament) be within the legislative competence of that Parliament;(b) obtain the consent of the Welsh Ministers before making regulations under any of those subsections containing provision which would (if contained in an Act of the National Assembly for Wales) be within the legislative competence of that Assembly;(c) obtain the consent of the Office of the First Minister and deputy First Minister in Northern Ireland before making regulations under any of those subsections containing provision which would (if contained in an Act of the Northern Ireland Assembly) be within the legislative competence of that Assembly. (13) For the purposes of this section a person produces a tobacco product if, in the course of a business and with a view to the product being supplied for consumption in the United Kingdom or through the travel retail sector, the person—
(a) manufactures the product,(b) puts a name, trademark or other distinguishing mark on it by which the person is held out to be its manufacturer or originator, or(c) imports it into the United Kingdom.(14) For the purposes of this section a person supplies a tobacco product if in the course of a business the person—
(a) supplies the product,(b) offers or agrees to supply it, or(c) exposes or possesses it for supply.(15) In this section—
“enactment” includes—
(a) an Act of the Scottish Parliament,(b) a Measure or Act of the National Assembly for Wales, or(c) Northern Ireland legislation;“external packaging”, “internal packaging” and “wrapper” have the meanings given by regulations under subsection (6);
“packaging”, in relation to a tobacco product, means—
(a) the external packaging of that product,(b) any internal packaging of that product,(c) any wrapper of that product, or(d) any other material attached to or included with that product or anything within paragraphs (a) to (c);“retail packaging”, in relation to a tobacco product, means the packaging in which it is, or is intended to be, presented for retail sale;
“retail sale” means sale otherwise than to a person who is acting in the course of a business which is part of the tobacco trade;
“tobacco product” means a product consisting wholly or partly of tobacco and intended to be smoked, sniffed, sucked or chewed;
“travel retail sector” means retail outlets in the United Kingdom at which tobacco products may be purchased only by people travelling on journeys to destinations outside the United Kingdom.”

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, I am very pleased to have tabled government amendments that introduce regulation-making powers to enable the Government to bring in standardised tobacco packaging, if such a decision is made.

I would like to acknowledge the support and positive responses that we have had to the Government’s action on tobacco and its packaging. We have seen support in both your Lordships’ House and in the other place. I have also had discussions with a number of noble Lords. I was pleased as well to see the welcoming comments from the public health community. I wrote to all noble Lords on 17 December explaining the key elements of this new clause. I will summarise the main provisions.

Amendment 57B will provide the Secretary of State for Health with the power to make regulations to standardise packaging of tobacco products, should such a decision be taken by the Government. The regulation-making powers would enable Ministers to regulate internal and external packaging and any other associated materials included with a tobacco product. This would include, for example, not just the outside and the inside of a cigarette pack but also the cellophane or other outer wrapper of a pack.

Ministers may also specify requirements for the products themselves, for example to regulate the appearance of, or branding on, individual cigarettes. The powers will extend to other forms of tobacco, such as hand-rolling tobacco. If standardised packaging is brought into place, we will think carefully about the type of tobacco to which the requirements should apply.

The amendment is clear that before deciding whether to introduce regulations, Ministers must consider that regulations may contribute at any time to reducing the risk of harm to those under 18 or promote their health or welfare. This includes harms that do not appear until later in life because, as we know, the harm to the health of a smoker may not be immediate but may manifest after several years of addiction. Ministers may also consider whether regulations may contribute to reducing the risk of harm to those aged 18 or over, so we could also take into account whether standardised tobacco packaging might help adults who want to quit.

The amendment sets out the elements of the tobacco packaging that could be regulated—for example, the use of colour, branding or logos, the materials used and the texture, size and shape of the packaging. It also sets out the aspects of the tobacco product itself that could be regulated. The Government would not necessarily use all these powers, and if we proceed we will need to decide which aspects to include in any regulations. However, it is prudent to take a comprehensive approach now so that we are prepared for possible future developments and do not inadvertently create loopholes that could be exploited.

The requirements would apply only to the retail packaging of tobacco products, which means the packaging that will or is intended to be used when the product is sold to the public. Manufacturers, distributors and retailers would still be able to use branding such as logos and colours on packaging, provided that they were used only within the tobacco trade—for example, on boxes used for stock management in a warehouse that were not seen by the public.

These provisions will apply on a UK-wide basis, provided that legislative consent Motions are passed by the Parliament or Assemblies of the devolved Administrations. The Governments in Wales and Scotland have already obtained the necessary Motions, and Ministers in Northern Ireland are progressing this.

The Government have also tabled two technical amendments, one making the regulations subject to affirmative resolution procedures and the other extending the provisions to the whole of the United Kingdom. If regulations are made, they will be enforced by local authority trading standards as safety regulations under the Consumer Protection Act. In reviewing the detail of the amendment, we have identified a small gap that we wish to address. As it is currently drafted, Ministers would not be able to take enforcement action if none was taken by a local authority. As a precaution, and in line with other tobacco control legislation, we think it sensible for Ministers to be able to do this and so intend to make a technical amendment to the new clause at Third Reading to allow for this.

I wrote to noble Lords on 27 January about the Government’s intention to table amendments at Third Reading on the proxy purchasing of tobacco and the sale of nicotine products, primarily e-cigarettes, to children. I hope that both measures will be welcomed by your Lordships. I recognise that these amendments come at a late stage in the Bill’s passage, and I apologise for this. I want to be able to give noble Lords as much information as possible, so have invited all Peers to a meeting to discuss the amendments on 3 February and would be happy to meet on an individual basis as well, so that there is time to consider them before the debate at Third Reading.

I shall summarise these amendments. We intend to create a new offence of the proxy purchase of tobacco, which is buying tobacco on behalf of someone underage. Nicotine is highly addictive and it is wrong in principle for adults to be buying cigarettes on behalf of children. We need to close common routes of supply to children. We know that proxy purchasing is a common problem and we need to take clear action to tackle it. There was considerable support for tackling proxy purchasing when it was debated in the Anti-social Behaviour, Crime and Policing Bill. We have also listened carefully to the views of retailers and their representative organisations on this issue.

In addition, we have decided to table an amendment to enable us to make regulations to prohibit the sale of electronic cigarettes to people aged under 18. E-cigarettes deliver nicotine, a highly addictive substance, albeit in a safer way than smoked tobacco. We know that some young people in England are using these products and there is nothing stopping their sale to people under 18. Some in the public health community are very concerned that e-cigarettes could act as a gateway into smoking tobacco, and that their use and promotion can undermine our efforts to reshape the social norms around tobacco use. The revised European tobacco products directive, which achieved political agreement in December last year, covers e-cigarettes but does not include an age of sale restriction. We therefore want to do this domestically through the Bill.

The amendments will apply to England but we are in discussions with the Welsh Government regarding the possibility of extending the provisions to Wales, subject to the necessary legislative consent Motion being secured.

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[Baroness Hughes of Stretford]

No, that is true. I know that the noble Lord is very exercised by these issues, and I respect his point of view. A baby of itself could not move to another room. However—we have these arguments in many ways—the fact that we cannot remove the harm to all children in all situations presented by passive smoking is not an argument in itself for not taking the action that we could take to reduce the harm to the majority of children in the most dangerous situations. That is the argument in support of this amendment.

The third argument we heard was about enforcement. Again, we had some helpful contributions which I was going to make myself, but I shall just mention them. This is primarily not about enforcement, and we have precedence here with the ban on using mobile phones in cars, the mandatory use of seat belts and the ban on smoking in public places. All of those were hotly contested before legislation came in. I particularly remember the ban on smoking in public places because I was involved in it. That measure not only established smoke-free common areas for people but, equally importantly—and it is true of the other two measures—precipitated the biggest reduction in smoking we have seen: a significant and beneficial change in behaviour on a massive scale. That is the issue here, as the noble Baroness, Lady Tyler, pointed out. I have no doubt that this would precipitate a very significant change in behaviour in relation to smoking in cars with children. Particularly when we see so much public support for the measure, I think that we could anticipate that.

I say again that Amendment 57BB is enabling. It would entail further discussion about the practicalities and the detail of the regulation. We fully accept the need for that and welcome it. However, it is an important measure for children and I hope that the House will support it.

[Earl Howe]

My Lords, this has been a fascinating and very helpful debate and I am very pleased with the support that I have heard for the government amendments on standardised packaging. I would like, if I may, to commend noble Lords for their continued work in supporting tobacco control. We all want to drive down rates of smoking in this country and, in particular, to stop young people from taking up smoking in the first place. Let me address the points on standardised packaging first.

The noble Baroness, Lady Finlay, the noble Lord, Lord Faulkner, and my noble friends Lady Tyler and Lord McColl tabled a revised amendment following discussion in Grand Committee, and I see that they reflected the comments that I made in redrafting it. I particularly welcome their support for the Government’s amendments and can reassure them that our amendments would achieve all of the things that they seek to do.

My noble friend Lord Naseby raised a number of legal issues. I would like to reassure him that we have given very careful consideration to the legal situation. We believe that the government amendment gives us sufficient room to proceed with the regulations, should we choose to do so, and introduce standardised packaging, if that is what is decided. He queried the fact that the amendment is drafted in such a way that the devolved Administrations and Assemblies have to give consent, but it is the Secretary of State and not Parliament who gives consent in England. We do of course want Parliament to have a say, which is why we have introduced Amendment 63B to make the regulations subject to the affirmative procedure.

The noble Lord, Lord Stoddart—whose robust state of health I very much welcome—indicated that there has been no proper consultation on standardised packaging. In fact, in 2012 the Government ran a full public consultation and received almost 2,500 substantive responses and well over half a million postcard and petition responses. The consultation asked 15 specific questions and invited comments on the consultation stage impact assessment, which was also published. So it was a very thorough exercise.

The noble Lord, Lord Stoddart, suggested that this was the thin end of the wedge, if I can put it that way, and might herald similar measures in relation to junk food. I think we need to remember that tobacco is a uniquely harmful consumer good. Tobacco kills one in two long-term smokers. There is no safe level of smoking. That is why we have a range of specific legislation and an international treaty around tobacco control.

My noble friend Lord Naseby referred to illicit tobacco. We received a wide range of responses to the question in the consultation on illicit tobacco. They are summarised in the consultation report. In 2000, around 21% of the UK cigarette market was illicit. The latest estimate from HMRC, for 2012-13, is that this has dropped to around 9%. It is too high, I concede, but we are heading in a positive direction.

The noble Baroness, Lady Howarth, asked about the timetable for the regulations. I emphasise here that I do not want to pre-empt any decision that the Government may make on whether to proceed with standardised tobacco packaging, and I know that the noble Baroness understands that; but equally for that reason, it would be premature to set out a detailed timetable. What I can confirm is that the regulations would be subject to the affirmative procedure to ensure an appropriate opportunity for parliamentary scrutiny in both Houses. She may like to be aware that before being laid in Parliament, any draft regulation that seeks to regulate tobacco packaging would need to be notified to the European Commission and member states. There is a process that goes with that, which would mean that we would not be able to lay regulations instantly after taking a positive decision. I am happy, however, to reiterate the Government’s commitment to make a decision quickly when we receive Sir Cyril Chantler’s independent report. Tabling these amendments is, I hope, evidence of our commitment to act without delay if we decide to go ahead. But the Government, as I am sure she appreciates, must rightly consider the wider issues raised by this policy, and I can assure her that we will do so.

I can understand the intention of the noble Lord, Lord Hunt, in tabling both of his amendments, Amendments 57BA and 61, which seek to compel Ministers to introduce standardised packaging. However, I am sure that he will not be surprised to hear me say that we cannot accept provisions that tie our hands in this way. One of the amendments imposes an arbitrary timetable for government action, and both pre-empt Ministers’ proper and careful decision-making, involving consideration of all the relevant issues. Litigation by the tobacco industry is always a risk when introducing tobacco control legislation. Indeed, the World Health Organisation says that one of the six main forms of tobacco industry interference in public health is the intimidation of Governments with litigation or the threat of litigation. Government must have time and space to give proper consideration to the wider issues raised by standardised packaging of tobacco, and demonstrate that it has done so. Doing so will also reduce the risk of successful litigation. I do appreciate the desire to go faster but we must follow the proper decision-making process to enable us to arrive at the right policy decision. It is right that we should wait for Sir Cyril’s report. Once we do, I say again, we will make a decision quickly.

The noble Lord, Lord Hunt, asked me to put on the record that we will definitely introduce the regulations should the case be made and should we be persuaded of the case that Sir Cyril presents. I hope that I have been clear about that. I will repeat the comments made by my honourable friend the Minister for Public Health when she announced the review:

“The Government will introduce standardised tobacco packaging if, following the review and consideration of the wider issues raised by this policy, we are satisfied that there are sufficient grounds to proceed, including public health benefit”.—[Official Report, 28/11/13; col. WS 96.]

I thank the noble Lord, Lord Faulkner, the noble Baroness, Lady Finlay, and my noble friends Lady Tyler and Lord McColl for having made clear their intention not to press their amendment on standardised packaging. I hope that the noble Baroness, Lady Hughes, and the noble Lord, Lord Hunt, will do the same with theirs.

I turn to smoking in cars. Since we considered the issue at the previous stage of the Bill, I have met a number of noble Lords who support the idea of legislating to stop smoking in cars with children present. I have also listened very carefully to the debate as it has proceeded this afternoon. One thing is clear from those meetings and the debate—we all want to eradicate smoking in cars carrying children. None of us wants to see children continuing to be exposed to harmful second-hand smoke, whether in the home or the family car. However, although we agree on the destination, I have to acknowledge that there are differing views on the most effective route. As your Lordships will know, the Government believe that encouraging positive and lasting behaviour change by making smokers aware of the significant health risks of second-hand smoke will be more effective than resorting to the use of legislation—which is of course a blunt instrument—to tackle the problem. I believe very clearly that we should consider resorting to the use of legislation only if our work to promote positive changes in behaviour is shown not to have had the desired effect.

When we debated this issue in Grand Committee, a good deal of time was spent considering the practicalities of enforcing an offence of smoking in cars carrying children. I do not propose to rehearse those arguments in detail again today. Nevertheless, I want to encourage your Lordships to reflect on just how difficult it would be to enforce such a provision. My noble friend Lord Cormack referred to this. In my view, there would be substantial challenges in enforcing any such legislation, particularly with respect to vehicles travelling at speed. Currently, local authorities enforce smoke-free legislation, but they do not have the powers or the means to require moving vehicles to pull over. We would need therefore to set up a complex and probably resource-intensive enforcement regime, which would need to involve the police. These remaining questions of how to achieve effective enforcement undermine the credibility of the measures that have been proposed. If it were known that there was little chance of enforcement action, I have to ask whether individuals would comply with the law.

[Lord Hunt of Kings Heath]

I am most grateful to the noble Earl. Would he accept that my amendment has been drafted in a way that allows your Lordships to vote on the principle but then allows for work to be done, hopefully cross-party, and for the Government to bring in regulations, during which some of these matters could be talked out thoroughly?

[Earl Howe]

I have noted the way the noble Lord’s amendment has been drafted. However, we need to be very careful before accepting it, for the reasons that I am explaining now. One of the points made about enforcement was that we could make a useful comparison with seat-belt legislation. I understand why that comparison has been made but it needs to be borne in mind that we are not comparing like with like. Seat-belt legislation is a road safety measure which is properly enforced by the police; smoking in cars is a public health matter and the police have no public health role or functions. That is part of the reason that the issue is so complex. Before launching into the kind of amendment that the noble Lord, Lord Hunt, invites us to accept, we need to take stock of these questions. There is no point in putting something on the statute book if it is impractical to implement.

[Baroness Masham of Ilton]

Can I just ask the noble Earl whether the police have a duty in respect of alcohol abuse and violence in the streets?

[Earl Howe]

My Lords, the police obviously have public order responsibilities, which they can enforce—but not public health responsibilities, which is rather a different issue.

[Lord Faulkner of Worcester]

With the growing number of jurisdictions now adopting measures of the sort that are proposed in the amendment, will the Minister at least give an assurance that the department will look at the experience in countries where smoking in cars when children are present has been banned and look particularly at the way in which it is being enforced there, and by whom?

[Earl Howe]

I am coming in a minute to talk about consultation, which is one of the questions that my noble friend Lord Ribeiro asked, and I hope I can at least utter some words of comfort to the noble Lord, Lord Faulkner, as regards his question.

I will focus for a moment on why the Government prefer to achieve behaviour change without recourse to imposing the law. We believe that our approach is making a distinct impact, both in terms of raising awareness and, more importantly, changing behaviour. There is a very simple point to be made here, which was made by my noble friend Lady Tyler. I cannot believe that any parent would want, knowingly, to expose their child or children to harm. I am convinced that smoking in family cars and the home is much more likely to be due to a simple lack of understanding among smokers about how damaging to health second-hand smoke can be. Our social marketing campaigns remind us that more than 80% of cigarette smoke is invisible. Our campaigns have used the strap-line:

“If you could see what’s really there you wouldn’t smoke”.

That is why we are focusing our efforts on raising awareness of the harm caused and on encouraging smokers to modify their smoking behaviour.

The noble Baroness, Lady Masham, referred to pregnant women and whether we would regulate to protect them. I understand of course how vulnerable the child is when still in the womb, and the noble Baroness rightly raised the issue of how harmful second-hand smoke can be, especially for people with respiratory conditions such as asthma.

[Baroness Hughes of Stretford]

Does the Minister not agree that the impact of the legislation prohibiting smoking in public places, to protect the public and people working in common areas, had a much greater and more immediate impact than all the public awareness work that was done before then?

[Earl Howe]

I am the first to say that legislation passed by the previous Administration has had a marked and profound effect and has been widely welcomed. However, we are now dealing with something that we know can be influenced by public marketing campaigns. I shall mention how effective those have been in a moment.

With regard to pregnant women, there is a need to encourage everybody to be aware of the risks to health from second-hand smoke. We are achieving high levels of awareness as well as changing attitudes and behaviours. Almost three-quarters of those surveyed said that our campaigns had made them realise that smoking out of an open door or window was not enough to protect children from second-hand smoke. More than a third of those who saw the adverts reported that they had taken action to reduce their children’s exposure to second-hand smoke after seeing them. Those results emerged from the evaluation of last year’s campaign and the campaign that we ran in 2012.

I have to say that I am slightly surprised to hear how strongly the Opposition feel about creating legislation to end smoking in cars, because that is at odds with the position that they took on this issue when in government. The 2010 tobacco control strategy included commitments on smoking in cars that align entirely with my Government’s current approach. That strategy said:

“By increasing the level of awareness of the harms of secondhand smoke, particularly to children, we will encourage people to voluntarily make their homes and private cars completely smokefree”.

That is the stance that the party opposite took when in government and, to pay a little tribute to them, we have followed their lead. Your Lordships will recognise that there is a long way to go. Achieving behaviour change in public health takes time but we are heading in the right direction and the key is maintaining the momentum we are generating.

That is why I am pleased to announce that the Government will run another smoke-free homes and cars campaign this year, as explained in my letter to noble Lords earlier this week. We are finalising the details with colleagues in Public Health England, but our intention is that the campaign will take place in the spring. In addition to a mix of TV and digital advertising, we will work with local and commercial partners to spread the message through their networks. The campaign will be designed to maximise the potential of social media in making our messages clear and accessible to as many people as possible. I hope that that serves to reassure your Lordships that the Government are working hard to make progress in this important area. Our approach is to change smoking behaviour in both the home and family car.

In addition to the campaign activity, we will look at what more we might do to speed up the pace of change. Some local authorities are taking forward excellent work with their local communities to promote not only smoke-free homes and cars but also smoke-free environments such as playgrounds. Working with Public Health England, we will encourage more of this good practice to denormalise smoking, particularly in settings where children are present. I have asked Public Health England to look at what more we can do to spread this good practice.

This year’s smoke-free homes and cars campaign will be the Government’s third successive one, as I mentioned. At its conclusion, we will undertake a complete analysis of the progress that we have made through the campaigns. At that point the Government will give careful consideration to whether our action has had a meaningful impact in reducing smoking in cars carrying children. If health Ministers are not satisfied with the progress made, we will give serious consideration to what more can be done. I can tell my noble friend Lord Ribeiro that we will, if need be, conduct a public consultation so that we can understand how others feel about this issue, and to enable us to consider further the practicality and likely effectiveness of other measures to tackle smoking in cars carrying children, including legislative measures. I do not rule out legislation if our current course does not deliver the desired effect.

The Government take this matter extremely seriously, particularly the issue of reducing the uptake of smoking by young people. We have tabled the amendment today on standardised packaging. We intend to make proxy purchasing of tobacco an offence and prohibit the sale of electronic cigarettes to people under 18. If the Government are not satisfied with progress after this year’s smoke-free homes and cars campaign, we will give serious consideration to what more could be done, including a public consultation. I hope that that indicates our seriousness of purpose.

On the amendments that have been tabled by the Opposition I repeat what I said in Grand Committee. If we cannot credibly enforce the law, the law loses credibility. I appreciate the strength of feeling on this matter. I can assure noble Lords that we will continue to work with all interested parties to protect children from second-hand smoke. I hope that in the light of the assurances that I have given that the noble Lord will not press his amendment on that topic.

Amendment 57BA (to Amendment 57B) not moved.

NHS: Cancer Treatment

Earl Howe Excerpts

Wednesday 29th January 2014 Lords Chamber

[Baroness Pitkeathley]

To ask Her Majesty’s Government what action they propose to take to ensure that older people receive equal access to NHS cancer treatment.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

In December, the national clinical director for cancer at NHS England launched a call for action on the treatment for older people. NHS England is now setting up an advisory group to identify where improvements in cancer services for older people can be made. It is also supporting an initiative to ensure that patients are better informed about the options available to them and that they are fully involved in decisions about their treatment.

[Baroness Pitkeathley (Lab)]

I thank the Minister for that welcome Answer, but is he aware of the recently published Macmillan Cancer Support report, which shows that up to as 10,000 cancer patients die needlessly each year because of blatant ageism among doctors? For example, recommendations for chemotherapy diminish by as much as half if you are over 70. Since we are an ageing population and half of all new cancer diagnoses are in people over 70, does the Minister agree that it is of the utmost importance that we ensure that people are treated as individuals regardless of their age? How will he ensure that this view is held also among GPs and hospital consultants?

[Earl Howe]

My Lords, I completely agree. The noble Baroness is right that a series of reports has shown that the NHS has too often failed to provide the best possible services to older people. We cannot save lives without tackling inequalities. The NHS has a statutory duty to reduce health inequalities and to improve the health of those with the poorest outcomes. A ban on age discrimination in the NHS services was introduced in 2012, meaning that NHS services need to do everything they can to ensure that they do not discriminate against older people. We will hold the NHS to account for that through the mandate and the NHS outcomes framework.

[Lord Turnberg (Lab)]

To what extent are these shocking figures due to lack of funding for cancer services? In that light, what is the Government’s plan for the cancer drugs fund?

[Earl Howe]

My Lords, the noble Lord may recall that the Government pledged an additional £750 million to support the cancer strategy. We are doing that, and a range of actions are proceeding there. On the cancer drugs fund, we initially pledged a total of £600 million for the first three years of the fund and we recently pledged another £400 million, making £1 billion in all. I am pleased to say that the cancer drugs fund has so far helped more than 38,000 patients.

[Lord Walton of Detchant (CB)]

My Lords, some two weeks ago, the Minister agreed that, when NICE recommends that a particular form of treatment should be given to patients with cancer, rare cancers and other rare diseases, it is incumbent on clinical commissioning groups to see that those drugs are prescribed. Does the Minister agree that clinical criteria must be employed in reaching decisions as to which patients are to receive those drugs and that age alone must never be a barrier to the prescription of drugs in patients with cancers of that type?

[Earl Howe]

My Lords, I agree. The noble Lord may recall that in December 2012 we worked on a project with Macmillan Cancer Support and Age UK to improve uptake of treatment in older people. That established some key principles for the delivery of age-friendly cancer services. In December 2013, NHS England published an analysis of chemotherapy uptake in older people, and that report reaffirmed those principles and set out some new recommendations around improving the uptake of chemotherapy.

[Baroness Gardner of Parkes (Con)]

My Lords, in the previous reply the Minister said he had looked at figures for chemotherapy for older people. Has he looked at the figures for radiotherapy for cancer patients of an age, in particular for intensity-modulated radiotherapy, which is not reaching its target but is considered a great improvement on the previous type of radiotherapy being used for cancer cases?

[Earl Howe]

My Lords, the Government invested £23 million aimed at increasing the capacity of radiotherapy centres in England to deliver intensity-modulated radiotherapy. The latest analysis shows that the median average of IMRT activity in England is at 29%, with the vast majority of centres delivering at 24% or above. That 24% was the magic figure recommended a few years ago by the national radiotherapy implementation group. We continue to monitor progress and local action plans closely.

[Baroness Masham of Ilton (CB)]

My Lords, I declare an interest as vice-chair of the all-party cancer group. Does the Minister agree that many older people develop cancer and, therefore, to stop treatment would ensure that many Members of your Lordships’ House would not get treatment? Will he therefore take this really very seriously?

[Earl Howe]

My Lords, I am with the noble Baroness all the way in wishing to see your Lordships live a healthy and long life but, as regards the population generally, I hope that I have made clear the Government’s determination to see that all citizens of this country receive treatment according to their ability to benefit from it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure we are all with the noble Baroness in those sentiments. Can I refer the noble Earl back to the research that my noble friend referred to? The report seems to show that survival rates for cancer patients over the age of 75 are very poor in this country compared with other European countries. The noble Earl has said that he will ensure that action is taken through the mandate to NHS England. Should he not give instructions to clinical commissioning groups to start commissioning cancer services with no age discrimination?

[Earl Howe]

My Lords, commissioning is an important ingredient in this, but there is a range of actions that we can take and have taken. We know that low levels of awareness and late diagnosis are particular problems for older patients, so it is welcome news that Public Health England is to run a national campaign to raise awareness of breast cancer in women over the age of 70. We are also raising the screening age for breast cancer to include women aged 71 to 73, and the extension of the NHS bowel cancer screening programme to men and women aged 74 is now complete.

Health: Confidential Patient Information

Earl Howe Excerpts

Thursday 23rd January 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I refer noble Lords to my interests in the register.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, while we have concerns about the EU proposals, there has been no cause to conduct an assessment of the sort suggested at this stage. The Government do not sell confidential patient information to companies. Drug and insurance companies can receive patient confidential information only where they have a legal gateway, either consent of the patient or some form of statutory authority. In these circumstances the cost of providing information may be recovered, but it is not sold.

[Lord Hunt of Kings Heath]

My Lords, clearly there is great advantage in using patient research in large-scale research projects. However, can the noble Earl assure the House that patient confidentiality can be assured? Also, is it right that projects such as the UK Biobank could be put in jeopardy were the proposed European legislation to be enacted in its current draft form?

[Earl Howe]

My Lords, under the 2012 Act, the Health and Social Care Information Centre cannot release data that could be used to identify an individual without a legal basis to do so. As a result, there are strict controls about how such information is released. As regards the UK Biobank, the noble Lord is right to be concerned because the proposed text from the so-called LIBE committee would rule out the work of the UK Biobank, in that it would need explicit and time-limited consent for any research project that it undertook, instead of being able to support a range of research purposes, as it now can, using its existing consenting mechanism. So there is cause for concern if this text is adopted, but that is not yet clear.

[Baroness Pitkeathley (Lab)]

My Lords, many noble Lords will have received recently a leaflet through their letter box, saying that their records are going to be made available unless they opt out. The means of opting out is to contact your GP. First, has anyone noticed how difficult it is to contact your GP in some circumstances? Secondly, would it have been beyond the wit of the department to include a simple, tick-box form for people to use? Does the absence of such a simple process lead us to conclude that the Government do not actually want people to opt out of making their records available?

[Earl Howe]

My Lords, everybody in the country has a right to object to their data being shared. Those objections will always be respected. A practical way had to be found to enable that process to happen, and we believe that it is not unreasonable to expect a patient to have a conversation with their GP. I will, however, take the noble Baroness’s suggestions on board and feed them in.

[Lord Willis of Knaresborough (LD)]

Does my noble friend agree that while patients can object to having their records sent, they cannot, in fact, legally prevent the GP sending those records to the central repository? It is at that point that the discussion as to whether those records should be sold on and used by pharmaceutical companies and others is important. Does he agree that it is important that companies carrying out research into new drugs and compounds can access patient records, because they are an important dataset for making sure that we have better healthcare for our people?

[Earl Howe]

My noble friend is correct. The UK has a unique advantage in being able to link patients’ data records for the purposes of research and for effective healthcare commissioning. It would be extremely concerning if European law prevented that. I believe and hope that patients will be encouraged that there will be no abuse of identifiable information. The controls around this are very strict and, in the main, only anonymised data are required for research purposes.

[Baroness Finlay of Llandaff (CB)]

Can the Minister explain if there are circumstances in which personal confidential data might be used and analysed, such as in a public health emergency, and what the safeguards are surrounding that access?

[Earl Howe]

My Lords, there are circumstances in which potentially identifiable data can be released, but they are very severely circumscribed. A public health emergency is one, but Section 251 of the National Health Service Act 2006 could also allow identifiable information to be shared for specific purposes. However, the controls around that are extremely strict and the only people who can take that decision are the Secretary of State and the Health Research Authority—and then only after expert advice from the Confidentiality Advisory Group.

[Baroness Manzoor (LD)]

My Lords, some patients do not understand the implications and possible effects of the proposed EU legislation. What steps are being considered to ensure that those patients have full understanding?

[Earl Howe]

My Lords, until we are clear about the text that is agreed at European level, it is difficult to issue public advice on what the effect of that proposed measure would be. The text is still being argued over. While my noble friend is absolutely right that a public information exercise would be advisable once we are aware, we are not at that point yet.

Health: Dementia

Earl Howe Excerpts

Wednesday 22nd January 2014 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, this has been an excellent short debate. I thank all contributors but, in particular, my noble friend Lady Gardner for having tabled this important subject and for having introduced it with such insight.

As has been said, dementia is one of the biggest challenges society is facing, but it is a challenge that we are determined to get to grips with. That is why dementia is a major priority for the UK Government, and my right honourable friend the Prime Minister launched the dementia challenge last year. We must fight back on an international scale, which is why we hosted the first G8 summit on dementia in December, as the noble Baroness, Lady Greengross, kindly mentioned, and we will continue to provide global leadership.

Five years ago, the national dementia strategy was developed. It has achieved a lot and laid the foundations for real change in how people with dementia and their carers are helped to live well with the condition. However, we recognised the need to build on the strategy and that is why the Prime Minister’s challenge on dementia is the main vehicle driving change and improvement across health and care in the community and for research. The Prime Minister’s challenge runs to 2015, not just outliving the dementia strategy but broadening its vision and providing better accountability. The challenge sets out the Government’s commitment to increase diagnosis rates, raise awareness and understanding, and double funding for research into dementia by 2015.

There are 670,000 people in England with dementia, a number expected to double in the next 30 years. Dementia costs society an estimated £19 billion a year, and currently less than half of all people with dementia have a formal diagnosis. One of the main aims of the Prime Minister’s challenge is to improve awareness of the condition by creating dementia-friendly communities. If we are to help people to live well with dementia, we need all areas of society to become dementia-friendly—not just health and social care but banks, supermarkets, bus stations, post offices and all the different forms of local public services. All those places can become more dementia-aware and supportive of people with dementia and, if they do, people with dementia will benefit enormously, continuing to connect with society in ways we all take for granted.

Last October, Lloyds Bank and the Alzheimer’s Society launched a charter encouraging banks and building societies to join them in becoming dementia-friendly, and we need other companies to follow suit. I was impressed by all that I heard from the noble Lord, Lord Jones, about Airbus. The noble Baroness, Lady Turner, in her moving speech, referred to the importance of local support for people with dementia, and I wholeheartedly agreed with what she said.

The Dementia Friends scheme, which aims to make 1 million people more aware and understanding of dementia, is helping to break down the barriers between people with the condition and their local communities, with funding from the Department of Health and the Cabinet Office. The noble Lord, Lord Jones, was absolutely right in all that he said on this subject. My right honourable friends the Prime Minister and Deputy Prime Minister and Ministers at the Department of Health are all Dementia Friends, as are more than 500 Department of Health staff. I myself am a Dementia Friend. It has helped me to understand the impact that this condition has not just on the individual but on their families who care for them. Dementia Friends is one of several components in creating dementia-friendly communities. Alzheimer’s Society guidance sets out the criteria for becoming a dementia-friendly community, and already 34 communities, from York to Plymouth, have signed up to the scheme, with others having expressed an interest in doing so.

This spring, Public Health England, working with the Alzheimer’s Society, will launch a three-year £12 million social movement to make the nation more aware of dementia and enable people to understand how they can help those with the condition. The “Dementia Movement” will aim to do three main things. The first will be to reduce fear and stigma through activity that improves public attitudes towards dementia and gives more people the confidence to engage with those with dementia. It will also aim to increase social connectedness—for example, by prompting and supporting conversations between people in the early stages of dementia and their families, friends and neighbours. It will aim, too, to improve skills by recruiting people into the Dementia Friends programme so that more people know how to help those with dementia. The movement will target business partners in the private, public and voluntary sectors, and urge them to continue to implement the Dementia Friends programme within their organisations, giving their employees an understanding of the supportive action that they can take to help people with dementia.

The noble Baroness, Lady Greengross, spoke with great authority about the importance of diagnosis, co-ordinated care and support, and I very much agreed with what she said. The noble Lord, Lord Jones, also laid emphasis on timely diagnosis. Raising awareness of the signs and symptoms of dementia is the first step towards getting a formal diagnosis—one that will lead to people being able to access advice, information, care and support. The number of people with a diagnosis is increasing year on year, but the noble Lord, Lord Hunt, was right: still only just under half of all people with dementia have a diagnosis. That is simply not good enough and it is why NHS England has committed to raising the diagnosis rate to two-thirds by 2015.

Clinical commissioning groups are working with their local councils and other partners to better understand how widespread dementia is in their communities, including among people living in local care homes. This will mean that they can identify and support people with dementia in a timely way. GPs are now able to use the new directed enhanced service to improve the diagnosis of dementia by asking people in certain at-risk groups about their memory. This proactive approach should help to identify patients who are showing the early signs of dementia.

The noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt, asked about steps being taken to ensure the identification and treatment of comorbidities in people with dementia. If I may say so, that question is extremely pertinent. NHS England has committed to increasing the dementia diagnosis rate, as I mentioned. A diagnosis of dementia is vital in accessing support and treatment across the board, not just for dementia but for all comorbid conditions.

Once people have a diagnosis. they need to understand the implications of the condition and how they can access advice, information and support to help them and their carers to live as well as they can with the condition. If the condition is advanced, some people will need care and support immediately, but those diagnosed at an earlier stage may need only advice and information. The noble Lord, Lord Hunt, rightly stressed the need to provide information post-diagnosis.

My noble friend Lady Gardner mentioned the important role of charities, as did the noble Lord, Lord Jones, who rightly praised the work of the Alzheimer’s Society. The dementia guide is given to a person with dementia when they receive a diagnosis, and almost 100,000 copies have been distributed since last July. The NHS Choices website has dedicated pages for dementia, highlighting the range of services and support available to people with dementia and their carers. Regional NHS websites, such as myhealthlondon.nhs.uk provide details of healthcare and voluntary services available locally. A free national helpline helps carers to access information about local and national services and individual advice and support.

My noble friend referred to the need for good nursing. Services are no good without a skilled workforce. That is why Health Education England is ensuring that staff are dementia-trained. In November, it hit its target to deliver dementia training to 100,000 staff ahead of schedule, and it will continue to roll out training to improve the skills of the workforce. We want people with dementia to receive a better quality of care from informed and trained staff through the CQUIN programme. NHS England has asked all hospitals to identify a senior clinical lead for dementia, to ensure that carers of people with dementia are adequately supported, and that this is reported at board level. Every person joining the social care workforce will undertake common induction standards, which include aspects of dementia awareness. In addition, a number of units and qualifications at vocational levels 2 and 3 have been developed by Skills for Care and Skills for Health to support the development of the social care and health workforce, working with people with dementia.

The noble Lord, Lord Hunt, and my noble friend Lady Gardner asked about research. Doubling funding for research, as I mentioned, is part of the Prime Minister’s challenge, and the quality and quantity of research proposals for dementia are improving. Last year £20 million was awarded to six proposals which will look at areas such as Living Well with Dementia and dementia-associated visual impairment. All the G8 countries signed up to the communiqué at the end of the conference and one of the pledges was significantly to increase the amount spent on dementia research.

As I have outlined, there are a range of services and information sources available to support people with dementia and their carers, but this is only the beginning and we have a long way to go until everyone with dementia is able to live as well as they can with the condition. We are not resting on our laurels. The Government are committed to doing more. We are currently working with our partners in the NHS, social care, local government, public health and the Alzheimer’s Society on a call to action to improve post-diagnosis support for people with dementia and their carers—support on which the noble Lord, Lord Jones, rightly laid emphasis. The work is at an early stage but, over the next couple of months, we will be developing an offer of what should be available to everyone to ensure that we have achieved the Government’s goal of people with dementia and their carers having access to services to help them live well within our society for longer.

Health: Flour Fortification

Earl Howe Excerpts

Tuesday 21st January 2014 Lords Chamber

[Lord Rooker]

To ask Her Majesty’s Government what is their assessment of the public health impact of the current programme of fortifying flour; and whether they have plans to extend the programme.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, the Government considered the health impact of the current programme of fortifying flour as part of the Red Tape Challenge review of the bread and flour regulations and concluded that it does deliver public health benefits. We are currently considering the case of mandatory fortification of flour with folic acid and will reach a decision when we have considered new data on the folate status of the population due early this year.

[Lord Rooker (Lab)]

I thank the Minister for his Answer but ask him to speed up that review. Is he aware of the major new peer-reviewed research from the Wolfson Institute, which surveyed half a million women over a 10-year period and found out that folic supplementation is going down? It concluded that the current policy is failing and creating health inequalities. We know that now. Is this not a real worry?

[Earl Howe]

My Lords, I am not aware of that study but I shall of course make myself familiar with it. I do not doubt that it will feature in the consideration that we give to this issue, which I can assure the noble Lord we will do as speedily as we can. It is important to say that adding to the list of fortificants would be a major step and we need to be absolutely sure that it is the right one.

[Baroness Gardner of Parkes (Con)]

My Lords, is it not a fact that in the United States bread is already fortified not only with folic acid, which of course prevents spina bifida in newly born children, but also vitamin D? At present there is a great deal of concern here that none of us is getting enough vitamin D due to the lack of sunlight in winter. Would it not be a good thing for us to have that benefit? Can the Minister also assure me that if this applies to wheat it will cover wholemeal as well as ordinary loaves, as we recommend people to eat those?

[Earl Howe]

On my noble friend’s last question, we are slightly jumping ahead of ourselves because we need to decide on the principle before we decide on which types of wheat might be fortified. However, I recognise my noble friend’s main point. Indeed, the Scientific Advisory Committee on Nutrition, in recommending mandatory fortification of flour with folic acid, sought to highlight the benefits of fortification as well as the risks. It was a balanced recommendation. We value it and we will look at the advice very closely indeed.

[Lord Krebs (CB)]

My Lords, what has the Minister’s department made of its evaluation of folic acid fortification in the many countries that have implemented it, including the United States, as has already been mentioned, Canada and Australia? What has been the balance of risk and benefit in those countries?

[Earl Howe]

I am aware that we have looked at the experience of other countries, but, as I am sure the noble Lord will accept, we need to take a decision on this that is right for all of our population rather than another country’s population. That is why we want to make the decision evaluating risks and benefits based on the most up-to-date data of the folate status of our own population.

[Lord Turnberg (Lab)]

My Lords, the case for fortifying flour with folic acid is now incontrovertible. It is both safe and effective in preventing spina bifida. I should like to follow up the question of the noble Baroness, Lady Gardner, about vitamin D fortification, as there is a rising incidence of rickets in children, particularly Asian children, and we really should take that seriously.

[Earl Howe]

The noble Lord is absolutely right. I agree with him that the incidence of rickets is a cause for concern. At the same time, he characterises the case for mandatory fortification as incontrovertible. There are risks that SACN pointed out. Its advice to government stated that fortification of flour with folic acid might have adverse effects on neurological function in people aged 65 years and over with vitamin B12 deficiency. Treatment with folic acid can alleviate or mask the anaemia and therefore delay the diagnosis of vitamin B12 deficiency, which can lead to irreversible effects.

[Lord Patel (CB)]

The noble Earl referred to two things. His immediate answer just now suggested that folic acid levels might interfere with B12 anaemia in older people. That would require a dosage of about 15 milligrams per day; the dosage we are talking about for fortification would hardly reach 1 milligram per day. The risk, therefore, is pretty minimal. Secondly, he suggested in his opening Answer that the folate level of the population might help to devise the policy. How would that help to devise the policy for women in early pregnancy who need the folic acid to reduce the incidence of neural tube defects?

[Earl Howe]

I am sure the noble Lord would agree that we have to take a decision based on the most up-to-date data. The data that we had prior to this were 10 years old and it is important to take a decision in the context of the nutritional state of health of the population. On his first question, all I can say is that the risk to which I referred was considered as part of SACN’s overall assessment and we will draw on that in reaching our decisions on the fortification of flour and give it the appropriate weight that it deserves.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the issue of up-to-date information, as the noble Lord, Lord Rooker, has said, we now have the Wolfson study, which actually leads that organisation to recommend that all countries should introduce folic acid fortification. The Government already have the recommendation of the Scientific Advisory Committee on Nutrition for mandatory fortification. Yes, it says it should be accompanied by actions to restrict voluntary fortification of food with folic acid for the reasons to which noble Lords have already referred. Why on earth are the Government delaying action on this?

[Earl Howe]

My Lords, I can only repeat what I said before, which was that taking this step would be a major step by any standards. We must base it on a proper assessment of the risks and benefits. We have some excellent advice from SACN and we need to evaluate that advice fully before taking a decision.

[Baroness Hollins (CB)]

My Lords, does the Minister agree that the public education campaign has failed and that given that most pregnancies are unplanned and that the risk period for low folate levels is in the first 28 days, before a woman is aware that she is pregnant, there is actually some urgency to act?

[Earl Howe]

My Lords, I recognise the issues raised by the noble Baroness. We will of course take those into account.

[Baroness Hayman (CB)]

My Lords, it is more than 20 years since the MRC study on this issue first had to be abandoned because it was considered inappropriate not to give folic acid supplements to the women who were involved. When the noble Earl reads the latest study, I suggest that he will find it “incontrovertible”, to use the word of the noble Lord, Lord Turnberg. The noble Earl said in December that the Government were looking at this issue urgently. Will they now look to act urgently?

[Earl Howe]

My Lords, I give the noble Baroness an assurance that we are treating this with suitable urgency. I cannot give her a date as to when a decision will be announced but it will be as soon as possible.

Mesothelioma: Research Funding

Earl Howe Excerpts

Thursday 16th January 2014 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, I thank the noble Lord, Lord Alton, for having tabled this debate. Mesothelioma is, as we have heard, a terrible and devastating condition. There is no cure and uncertainties remain about the best available approaches to diagnosis, treatment and care. It is therefore completely right and appropriate that mesothelioma research has been discussed a number of times, both here in your Lordships’ House and in the House of Commons.

Funding is, of course, needed for further research to be carried out. The four largest insurance companies have previously made a donation of £3 million between them, and this is supporting valuable research into the disease. A higher level of funding has come from government—through the Medical Research Council and the National Institute for Health Research. Together, these funders spent more than £2.2 million in 2012-13.

The MRC is supporting ongoing research relating to mesothelioma at the MRC Toxicology Unit and is also funding two current fellowships. The NIHR is funding two projects in mesothelioma through its Research for Patient Benefit programme, and its clinical research network is recruiting patients to a total of eight studies, including industry trials. The NIHR funds 14 experimental cancer medicine centres across England with joint funding from Cancer Research UK, and these centres have four studies focused on mesothelioma.

However, as I have said previously, the issue holding back progress into research into mesothelioma is not—as a number of noble Lords have intimated—a lack of funding but the lack of sufficient research applications. I want to clarify and stress that the work currently being funded is of high quality, and that is consequent upon high-quality applications.

Money is available to fund more research, but measures are needed to stimulate an increase in the level of research activity. That is why the Government have committed to doing four things and I am delighted to have this opportunity to report on progress to the noble Lord, Lord Kakkar, in particular, and other noble Lords who have spoken with considerable insight in today’s debate.

First, we promised to set up a partnership to bring together patients, carers and clinicians to identify what the research priorities are. This is now well under way and a formal launch event took place successfully last month. It is supported and guided by the James Lind Alliance, which is a non-profit initiative overseen by the NIHR Evaluation, Trials and Studies Coordinating Centre. The partnership has a steering group of 16 people, comprising six patient/carer representatives and 10 clinical representatives.

The next stage is a survey asking patients, families and healthcare professionals for their unanswered questions about mesothelioma treatment. The partnership will then prioritise the questions that these groups agree are the most important and the end result will be a top-10 list of mesothelioma questions for researchers to answer. The partnership plans to have the list ready by the end of this year, when it will be disseminated, and work will begin with the NIHR to turn the priorities into fundable research questions.

Secondly, the NIHR will highlight to the research community that it wants to encourage research applications in mesothelioma. The launch of this highlight notice will take place in advance of the identification of research questions by the priority-setting partnership to prepare researchers.

Thirdly, the NIHR Research Design Service will be able to help prospective applicants develop competitive research proposals. This service is well established and has 10 regional bases across England. It supports researchers to develop and design high-quality proposals for submission to the NIHR itself and to other national, peer-reviewed funding competitions for applied health or social care research. The service provides expert advice to researchers on all aspects of preparing grant applications in these fields, including advice on research methodology, clinical trials, patient involvement, and ethics and governance.

Finally, we have made a commitment to convene a meeting of leading researchers to discuss and develop new proposals for studies. Initiatives like this are one reason why it is so valuable to have the National Cancer Research Institute, the NCRI, which enables the major funders of cancer research to work in strategic partnership. I can report that NCRI officials held a meeting with clinical research leads yesterday, 15 January, to develop plans for bringing researchers together, and a representative from the British Lung Foundation also participated. The outcome was encouraging: the NCRI will be organising a mesothelioma workshop in the early summer with the aim of encouraging competitive grant applications in the field of mesothelioma. This will cover the full spectrum of basic, translational and clinical research.

Several noble Lords have—not unnaturally—spoken of a need for an ongoing role for the insurance industry in funding mesothelioma research. While the Government have money available to fund high-quality mesothelioma research proposals, we are also encouraging insurers to provide further funding. My honourable friend the Minister for Disabled People, Mike Penning, has met the Association of British Insurers, and following that meeting I have written to the association’s director general, Otto Thoresen. I am pleased to say that he has confirmed in a reply today that a further £250,000 will be paid directly to the British Lung Foundation. He has also confirmed the industry’s commitment to explore with the Government the range of future funding options. We would welcome another opportunity to meet insurers to discuss this.

[Lord Borwick]

I thank the Minister for that news. I also have a copy of the letter. The £250,000 is very useful, but it is less than one single claim from a sufferer of this disease. This has to be a short-term solution. If the voluntary agreement mentioned by the noble Earl does not happen for some reason, will the noble Earl push for legislation to make it happen compulsorily?

[Earl Howe]

My Lords, I note my noble friend’s question. My best answer to him at this stage is “one step at a time”. However, I can assure him that we will use our best endeavours to see a successful outcome from our discussions with the insurance industry. It is perhaps premature for me to go further at this stage.

[Lord Alton of Liverpool]

My Lords, I am grateful to the Minister, and I promise not to interrupt again, but can he provide further clarity about this £250,000? Is it drawn only from the four companies that have been referred to? How many of the 150 companies are contributing to it? What does it represent in terms of what is currently available from the industry?

[Earl Howe]

My Lords, as this is a time-limited debate, perhaps the noble Lord would accept my undertaking to write to him with those details. I am not sure, in fact, that I have them, because the letter, although extremely welcome, is quite brief in the detail it gives on the source of the funding.

[Lord Wills]

I am very grateful to the noble Earl for giving way. I shall be brief. Will he write within the next three months to everyone who has spoken today reporting on the progress of the conversations with the ABI about the range of options he has just referred to?

[Earl Howe]

I would be happy to do that.

Both the Government and the industry recognise the potential for insurers individually to sponsor specific research infrastructure or projects in mesothelioma, which would provide an excellent way for the industry to remain engaged following the earlier donation. I am pleased to report that the Department of Health is convening a high-level meeting with the association and the British Lung Foundation to explore practical ways to take that forward.

The noble Lord, Lord Alton, spoke powerfully about the need for sustainable funding in this area. I re-emphasise the point that I made a minute ago: research funding is available for good-quality research and what we lack are research applications. What we need, in our view, is to get innovative research ideas that will make a real difference, and that is what the NCRI meeting will hopefully do. The research ideas put forward by the noble Baroness, Lady Finlay, in her intervention are of course very pertinent. She speaks with great authority in this area. They are all questions that the NCRI discussions can address. That meeting will be an opportunity to take a strategic approach, and it requires getting the right people together. The NCRI event will involve researchers from within the mesothelioma community, and from a wider field, and research funders.

It is worth noting that spend on lung cancer research by the NCRI member organisations, including the main public funders of cancer research, has more than quadrupled over the past decade. It has increased from £3.5 million in 2002 to £14.8 million in 2012. That is because of the quality of research proposals that have come forward and the interest shown by the research community.

In conclusion, the Government are strongly committed to ensuring progress is made in research into how best to diagnose and treat this dreadful disease, and care for those affected. A number of very powerful points have been made in this debate. I will pick up those that I have not been able to cover and will write to noble Lords. I have outlined the steps that we are taking, and I hope that noble Lords are assured that these measures will deliver what they, and indeed we in the Government, are seeking.

Committee adjourned at 5.56 pm.

Public Health Responsibility Deal

Earl Howe Excerpts

Tuesday 14th January 2014 Lords Chamber

[Lord Sharkey]

To ask Her Majesty’s Government what progress they have made in persuading further fast food chains to sign up to the Public Health Responsibility Deal pledge on calorie reduction.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

We are working hard to persuade other fast food chains to join the wide range of food businesses which have already signed up to the public health responsibility deal calorie reduction pledge and to sign up to other food network pledges. Eleven fast food partners are signatories of the responsibility deal and are taking action in a range of areas including calorie reduction. These partners cover most of the food sold in the fast food sector.

[Lord Sharkey (LD)]

I think the Minister will agree that these public health responsibility deal pledges are very useful. Given the dangers of excessive sugar in our diets, will the Minister consider adding a specific sugar-reduction pledge to the current list—with specific targets, as is already the case for salt—and will he help reduce sugar consumption by following the latest advice of Dr Susan Jebb, chair of the department’s public health responsibility deal food network, and removing fruit juice from the five-a-day recommendations?

[Earl Howe]

My Lords, I shall take my noble friend’s final question back with me. We will certainly look at it. However, I stress that our current emphasis is on overall calorie reduction, of which sugar can form a part. The scope for a reformulation to reduce sugar levels varies widely depending on the food and a reduction in sugar levels does not always mean that the overall calorie content is reduced—for example, when sugar is replaced by starch or other ingredients. The Scientific Advisory Committee on Nutrition—SACN—is currently undertaking a review of carbo- hydrates and is looking at sugar as part of that. Its report will inform our future thinking.

[Lord Palmer (CB)]

Is the Minister aware that one supermarket chain has announced today that it is going to remove all sweets from its checkout tills? Would it not be a good idea for the noble Earl to invite other supermarket chains to do exactly the same?

--- Later in debate ---

[Earl Howe]

My Lords, we are talking to the supermarket chains about those very matters, and I welcome the action that has been taken. The noble Lord may like to know that, as part of the responsibility deal calorie reduction pledge, Coca-Cola has reduced calories in some of its soft-drink brands by at least 30%, Mars has reduced its single chocolate portions to no more than 250 calories and Tesco has reduced by more than 1 billion the number of calories sold in its own-brand soft drinks.

[Lord Foulkes of Cumnock (Lab)]

My Lords, will the Minister help the House by publishing a list of meetings which Ministers, special advisers and senior civil servants have had with fast food companies in the past year?

[Earl Howe]

My Lords, I shall take that request away and write to the noble Lord.

[Lord McColl of Dulwich (Con)]

Does the Minister approve of the letter, which will shortly be sent to all Members of this House and of another place, asking them to measure their waist and to ensure that it is less than half their height? That would apply to quite a few Members opposite, who are clearly eating too much of the gross national product.

[Earl Howe]

My Lords, we should welcome any measure that encourages us all to improve our diet, to reduce physical inactivity and to be aware of what we need to do to keep our weight under control. I do welcome that letter.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I hope that the noble Earl will encourage his own noble colleagues to look at themselves in the mirror in the light of that unwarranted attack on my own Benches. Perhaps I can just refer the noble Earl to the report of the National Obesity Forum yesterday, which suggested that, on one of the worst-case scenarios, more than half of the population of this country will be obese by 2050. Does he not think that the volunteer approach may no longer be appropriate? Do the Government not have to take a greater lead on this?

[Earl Howe]

My Lords, there are certainly no grounds for complacency on obesity levels throughout the nation. However, the current data do not support the claim by the National Obesity Forum. In 2007, the Foresight team projected that, based on data from 1993-2004, more than half the population could be obese by 2050 if no action is taken. An analysis based on recent data suggests a flatter trend than the one projected by the Foresight team. I do not agree that we should belittle the responsibility deal. It has many worthwhile achievements to its credit and they are being added to month by month.

[Lord Elystan-Morgan (CB)]

Although appreciating this scurrilous attack on rotundity, does the noble Earl recollect the immortal words of Shakespeare in “Julius Caesar”:

“Let me have men about me that are fat; … Yond Cassius has a lean and hungry look”.

--- Later in debate ---

[Earl Howe]

I am sure my noble friend Lord McColl would agree that one can go too far in that direction.

[Lord Tebbit (Con)]

My Lords, do the Government not accept that people ought to know that if they stuff themselves silly with high-calorie rubbish foods they will get fat? It is their responsibility. All the forums and other nonsense are merely trying to divorce people from the consequences of their own stupid actions.

[Earl Howe]

My noble friend is absolutely right to place his finger on a central point that, in the end, it is up to individuals to take responsibility for their own state of health.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, if individuals are required to take responsibility but they do not know what they are consuming because the manufacturers or producers do not let them know, or indeed the Government are complicit in not pressing those manufacturers to let people know what they are consuming, should there not be a responsibility on the Government? For example, no one knows the calories in alcohol. There has been no change since this responsibility deal was introduced and there is no change in prospect.

[Earl Howe]

My Lords, under the responsibility deal, 92 producers and retailers have committed to having 80% of bottles and cans in the UK displaying unit and health information and a pregnancy warning by the end of last year. That is a worthwhile step forward. As regards the calorie labelling of alcoholic drinks, that, as the noble Lord will know, is an EU competence. It is subject to discussion at this time, but most large retailers include the calorie content of alcohol products on their websites, and that information is also available elsewhere.

NHS: Essential Services

Earl Howe Excerpts

Tuesday 14th January 2014 Lords Chamber

[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.