Diabetes

Earl Howe Excerpts

Tuesday 10th July 2012 Lords Chamber

[Lord Sharkey]

To ask Her Majesty’s Government what data they have on, or what best estimate they can give of, the extent to which the consumption of sugar will contribute to the substantial increase predicted in the incidence of diabetes in England and Wales.

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

My Lords, the Government currently cannot provide an estimate of the extent to which sugar intake will lead to future incidence of diabetes in England and Wales, because, on balance, there is no clear evidence that sugar intake alone specifically causes diabetes. Obesity increases the risk of type 2 diabetes. The habitual consumption of calories in excess of needs for a healthy body weight results in weight gain, irrespective of whether these are from sugar or fat.

[Lord Sharkey]

My Lords, by 2050, on current trends, at least half of adults and a quarter of children are predicted to be obese, which will cause a huge epidemic of diabetes. Many experts agree that the excessive consumption of sugar is a factor in obesity and in diabetes. In fact, US scientists have concluded that sugar consumption levels are now so harmful that sugar should be controlled and taxed in the same way as alcohol and tobacco. Will the Minister give urgent consideration to taxing sugar in processed foods to help avert an imminent public health disaster?

[Earl Howe]

My Lords, we keep the question of taxation under review in the light of emerging international evidence on its impact. That will include looking at the experience of the recently introduced tax on saturated fat in Denmark and what effect it has had on diet and health. With any fiscal measure, there is always a risk of unintended consequences, so we would have to look at this particularly carefully.

[Lord Alton of Liverpool]

My Lords, did the Minister have a chance to see the report from the London School of Tropical Medicine and Hygiene, published earlier this month, which suggested that if obesity levels could be reduced, there would be sufficient food for 1 billion people worldwide. The report pointed particularly to the United States of America and at western Europe. Does this not both justify the Government’s campaign to reduce obesity and illustrate the truth of Gandhi’s remark that there is sufficient in this world for people’s needs but not for their greeds?

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[Earl Howe]

I agree fully with the noble Lord. In this area, the message has to be that a healthy balanced diet is what we should all aspire to. As I mentioned in my initial Answer, obesity is one of the prime drivers for diabetes. If people can moderate their calorie intake to match their energy consumption, the world will be a healthier place.

[Baroness King of Bow]

My Lords, the Minister will be aware that increased sugar consumption leads to obesity and, in my view, diabetes. Is he also aware of the many studies, including one from Princeton University, which show that sugar is potentially addictive and activates endorphins in the brain in a way similar to heroin—I could hardly put down my Jaffa Cake long enough to come and ask this question. Does he not agree that it is important to look at research that shows that scientists have made rats sugar-addicted in just one month by feeding them sugared drinks? Will he revisit the nutritional standards for schools, because 62% of British schools currently do not have tough nutritional guidelines that would reduce sugar consumption among British children?

[Earl Howe]

My Lords, I am aware of that research, which my department is looking at very carefully, but I should put a health warning on it in that we do not yet accept the conclusion that sugar is addictive, although clearly in the case of young children those who get into the habit of consuming sugar are likely to continue doing so, so the noble Baroness is quite right that it is a risk factor in the young. The advice from the School Food Trust is of course to have a healthy diet at school. Many schools are adhering to that, and we are doing our best to promote that with our colleagues in the Department for Education.

[The Countess of Mar]

My Lords, the Minister mentioned unexpected consequences. Does he agree that people who are afraid of eating too much sugar because they might get fat will turn to sugar substitutes such as aspartame? Is he aware that aspartame contains 10% methanol, which, uniquely in the human body, is turned into formaldehyde and has its own neurological hazards? Would he recommend having sugar or sweeteners?

[Earl Howe]

My Lords, the Department of Health recognises that artificially sweetened or low-calorie drinks can play a role in helping people to reduce the number of calories they consume and offer a wide choice of low-calorie options. As for the safety of artificial sweeteners, all food additives, including sweeteners, are thoroughly tested for safety prior to approval and are subject to review by independent expert bodies. The Food Standards Agency considers that all approved sweeteners can be safely consumed at current permitted levels.

[Baroness Trumpington]

My Lords, this morning I was in a Waitrose and I looked at all the packets of cereals. Each one had a different sugar-based flavour, such as chocolate and apricot, and all the cereals contained sugar of different kinds. What is the Minister’s reaction to that?

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[Earl Howe]

My noble friend draws attention to an area of concern. Cereals of that kind are particularly attractive to children, although I would say that the good news here is that added sugar consumption among children has fallen during the past few years, which is perhaps a sign that the messages on the levels of sugar that children can safely consume is getting through to parents.

[Lord Collins of Highbury]

My Lords, I am grateful to the noble Earl for reminding us that a small reduction in weight maintained over time can reduce the risk of developing type 2 diabetes. I must admit that I wish that I knew that when I stopped smoking and piled on the weight. As a consequence, I am type 2 diabetic. It is true that small improvements in eating and drinking habits can reduce the risk. I ask the noble Earl, as I asked him last November, whether the Government will take this threat seriously and undertake to lead a major awareness programme about what to do to avoid type 2 diabetes.

[Earl Howe]

My Lords, there is a great deal going on in this extremely important area. I am grateful to the noble Lord for emphasising its importance. There is a ring-fenced budget for public health, and weight gain is one of the key indicators in the public health outcomes framework. There is the Change for Life campaign, which has, I think, gained enormous credibility among the public and professionals. We are engaging with the food industry through the public health responsibility deal to take forward the calorie reduction pledge. There are NHS health check programmes, which are being rolled out throughout the country, and at GP level there are the nine tests which GPs are advised to undertake with diabetic patients. The rate at which those tests are being done has gone up very encouragingly over the past few years.

NHS: Annual Report and Care Objectives

Earl Howe Excerpts

Wednesday 4th July 2012 Lords Chamber

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

My Lords, with the leave of the House, I shall now repeat a Statement made earlier today by my right honourable friend the Secretary of State for Health in another place on the subject of the Secretary of State’s report to Parliament on the health service, the Secretary of State’s mandate to the NHS Commissioning Board and the NHS Constitution. The Statement is as follows:

“With permission, Mr Speaker, I would like to make a Statement about my first annual report to Parliament on the health service, published today, alongside the report on the NHS Constitution and the draft mandate to the NHS Commissioning Board.

This year, the NHS has made major progress in the transition to a new system, one based on clinical leadership, patient empowerment and a resolute focus on improving outcomes for patients. In a year of change, as the annual report shows, NHS staff have performed admirably. Waiting times remain low and stable, below the level at the election, with the number of people waiting over a year at its lowest ever level. Today, only 4,317 patients are waiting more than a year for treatment, dramatically lower than in May 2010. Nationally, all waiting-time standards for diagnostic tests and cancer treatment have been met.

The £600 million Cancer Drugs Fund has helped over 12,500 patients to access the drugs previously denied them. We have extended screening programmes, potentially saving an extra 1,100 lives from breast and bowel cancer every year by 2015. More than 90 per cent of adult patients admitted to hospital–around 260,000 every week–are now assessed for venous thromboembolism, a world-leading programme. In 2011 and 2012, 528,000 people began treatment under the expanded Improving Access to Psychological Therapies programme, up from just 182,000 in 2009-10, with almost half saying they have recovered. Following the success of the telehealth and telecare whole system demonstrator programme, including a 45% fall in mortality, we are on course to transform the lives of 3 million people with long-term conditions over the next five years.

The NHS is also improving people’s experience of care. Patients are reporting better outcomes for hip and knee replacements and for hernias. In the latest GP patient survey, 88% of patients rated their GP practice as good or very good. The outpatient survey shows clear improvements in the cleanliness of wards and patients reporting that they were treated with respect and dignity. MORI’s independent public perceptions of the NHS survey shows that satisfaction with the NHS remains high at 70%. Mixed-sex accommodation breaches are down 96%. MRSA infections are down 25% in a year, while C. difficile infections are down 17%.

Real progress, too, is being made in public health. More than 570,000 families have signed up to Change4Life. And our support for the school games and Change4Life sports clubs in schools is helping to secure the Olympic legacy. The Responsibility Deal has seen the elimination of artificial trans-fats, falling levels of salt in our diets and better alcohol labelling. By the end of the year, over 70% of high street fast food and takeaway chains will show calories on the menu. To drive forward research into key areas like dementia, I have announced a record £800 million for 11 National Institute for Health Research Centres and 20 Biomedical Research Units.

All of this and a million more people with an NHS dentist, every ambulance trust meeting their call response times, 96% of patients waiting for fewer than four hours in A&E, QIPP savings across the NHS of £5.8 billion in the first year of the efficiency challenge and NHS commissioning bodies delivering a £1.6 billion surplus, carried forward into this financial year. Yes, all of this and a new system taking shape. The NHS Commissioning Board has been established, health and well-being boards are preparing to shape and integrate local services and 212 clinical commissioning groups, managing more than £30 billion in delegated budgets, are preparing to lead local services from April next year. We are also starting to measure outcomes comprehensively for the first time. Far from buckling under pressure, with the right leadership and the right framework, NHS staff are performing brilliantly.

In addition to the NHS annual report, I am today publishing a report on the NHS Constitution. The Health and Social Care Act 2012 strengthens the legal foundation for the constitution, including a duty on commissioners and providers to promote and use it. This report, the first by a Secretary of State, will help commissioners and providers to assess how well the constitution has reinforced the principles and values of the NHS, the degree to which it has supported high-quality patient care and whether patients, the public and staff are aware of their rights.

I am grateful to the NHS Future Forum and to its chair, Professor Steve Field, for their advice on the effect of the NHS Constitution. I have asked them whether there is further scope to strengthen the principles of the constitution before a full public consultation in the autumn. Any amendments would be reflected in a revised constitution, published by April 2013.

Rooted in the values of the constitution, we will drive further improvement across the NHS through a set of objectives called the mandate to the NHS Commissioning Board. The draft mandate is also published today. The mandate will redefine the relationship between Government and the NHS, with Ministers stepping back from day-to-day interference in the service. Through the mandate we will set the Commissioning Board’s annual financial allocation and clearly set out what the Government expect it to achieve with that allocation, based on the measures set out in the NHS outcomes framework.

These include measures of quality, such as whether people recover quickly from treatment, and also people’s experiences, including whether they are treated as well as they expect, and whether they would be happy for family and friends to be cared for in a similar way. It will promote front-line autonomy, giving clinical commissioners the freedom and flexibility to respond to local needs—freedoms balanced by accountability.

Each year, the Commissioning Board will state how it intends to deliver the objectives and requirements of the mandate, reporting on its performance at the end of that year. The Secretary of State will then present to Parliament an assessment of the board’s performance. If there are particular concerns, Ministers will, for example, ask the board to report publicly on what action it had taken or ask the chair to write a letter setting out a plan for improvement. Today’s publication of the draft mandate marks the beginning of a 12-week consultation. I look forward to working with patients, clinicians, staff and other stakeholders to finalise the mandate in the autumn.

These documents show how a new exciting chapter is opening up for the NHS. Starting with strong performance and robust finances, we are driving towards integrated services and community-based care. It will be a new era based on openness and transparency, and focused on what matters most to patients—health outcomes, care quality, safety and experience. It will be an era in which every part of the NHS—the Secretary of State, the Commissioning Board, clinical commissioning groups and healthcare providers—is publicly held to account for what is achieved. For the first time, Parliament, patients and the public will know exactly how the NHS is performing locally, nationally and internationally. It will be a new era in which patients feel in control, clinicians lead services and outcomes are among the best in the world. I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, I would like to rise, as I usually do, to thank the noble Lord for his response, but I cannot do that on this occasion. The noble Lord must know that most of what he said was absolute rubbish. It sounded suspiciously to me like the words of his right honourable friend Mr Burnham in another place. In fact, I listened to Mr Burnham earlier and I thought that I recognised verbatim some of his turns of phrase in the speech that the noble Lord has just made.

I counsel noble Lords not to accept most of what the noble Lord, Lord Hunt, has just said about the performance of the NHS. He began by saying that the NHS has had two lost years, that we are engaged in an ideological experiment, and that there has been a loss of financial grip and wholesale closure of services. None of that is true. I am disappointed in the noble Lord because he is usually much more constructive and usually much readier to acknowledge the wonderful efforts of those who work in the health service and the achievements that they have brought to us throughout the year. I did not hear him mention those efforts and how grateful we all should be to those who work in the NHS for what they do for us.

I do not see in any of the figures that I read out the picture that the noble Lord presented to us. The NHS has delivered QIPP savings—that is part of the £20 billion Nicholson challenge that noble Lords will know about—of £5.8 billion. It is on track—this year the expected QIPP savings are £4.9 billion. The NHS delivered a surplus last year of £2.1 billion—£1.6 billion in the commissioning sector and £600 million in the provider sector. The commissioners’ surplus of £1.6 billion will be returned to them in full this year. To me, that is not a sign of financial strain. Yes, there are trusts that are reporting a gross operating deficit. How many are there? There are eight, in the entire country of England. Those, of course, are a matter of concern but we are working with those trusts to help them to resolve their difficulties—difficulties that very often originate from PFI deals set up under the previous Administration that were unsustainable. I am not decrying PFI as a tool or a lever, but the fact is that some of the business cases were very poorly founded.

The noble Lord asked whether we had instructed services to be rationed. I noted the other day the document published by the Labour Party on its NHS Check. What we have said is that PCTs should not make commissioning decisions on the basis of cost alone in deciding whether to commission a particular procedure. PCTs should consider the benefits of the procedure as well as the cost, but they could reasonably take a view that the evidence on a procedure suggests that it will not normally offer sufficient clinical benefit to justify its cost. That is nothing particularly new but it is very important. In other words, the resources involved may be better used in providing other treatments that have a greater impact in preventing or addressing ill health. No healthcare system in the world can afford to provide every possible treatment, irrespective of the evidence of whether it will do any good. The noble Lord is trying to paint a picture of the NHS denying treatment to people, while what it is doing is sensibly looking at what is value for money.

The noble Lord referred to patient satisfaction. When the public are asked to rate their satisfaction with services, their response may well be influenced by a wide range of factors. Our own polling of the general public, undertaken independently by MORI and published last month, shows that satisfaction with NHS is broadly stable at around 70%. Those are, by and large, people who have used the NHS recently. Of course we acknowledge that there is some disquiet among the public about the reforms to the NHS, which have indeed been misrepresented quite widely. However, acute trusts are not buckling under the strain; they are doing extremely well. Is primary care stepping up to the plate? Are CCGs focused on the big issues? In my experience, the clinical commissioning groups that are forming around the country are having exactly the right conversations. They are conversing with secondary care clinicians, public health specialists and those in social care, and looking at how care can be joined up across the system. It is an exciting opportunity for primary care.

The noble Lord asked about how patients could get choice in primary care. Well, the NHS constitution provides for the right to choice. The noble Lord will know that we have agreed two things with the BMA. One is that the boundaries of PCT practices can be varied, so that if somebody moves a few streets down the road they can still stay at their GP of choice rather than having to move. That is surely welcome. We have pilots around the country operating to look at whether commuters who come into the centre of London, for example, would like to have their GP near their place of work, not necessarily near their home. We will look to see what the lessons are from that; it is entirely right that patients should be given that choice.

The noble Lord referred to the Government not letting go and the tight grip from the centre. I do not know who he has been talking to. This afternoon I went to see the National Association of Primary Care and had a very good discussion; the climate of opinion there was that we had the balance just right between allowing it to influence clinical leaders locally, on the one hand and, on the other, the Department of Health providing sensible guidance and pointers to facilitate the process of clinical engagement.

On social care funding, no, we have not given up on Dilnot—far from it. The principles of Dilnot are sound, and we are working with the Opposition, as the noble Lord knows, to see what the best and most affordable formula might be, and the principles around that formula. I have said in recent days and repeat today that along with the White Paper we shall publish a progress report on funding and the draft Bill, which will be subject to pre-legislative scrutiny.

The noble Lord said that there was no difference between targets and indicators. I beg to differ there. There is an enormous difference between a target that is centrally set by government and an indicator, which is a meaningful signal devised by clinicians themselves to help them to drive up the quality of their own care. That is the difference—and that is what we want to see in the commissioning outcomes framework, which will stem from the NHS outcomes framework embodied in the mandate.

In view of time, I hardly want to rehearse again the rejoinder to the noble Lord’s final comment about privatisation. He should know that the Health and Social Care Act prohibits the takeover of any foundation trust by a private organisation. It simply cannot happen. There is no equity capital to be purchased, for one thing. Privatisation means different things to different people. Yes, if we are talking about choice for patients between an NHS provider and an independent sector provider or a charity, we should welcome that, because choice in that context drives up quality. If we are talking about selling NHS assets and hospitals to the private sector, that is off the agenda—and it will be permanently off the agenda, as far as I am concerned. The Health and Social Care Act ensures that there is no bias in favour of the private sector when commissioners are designing care in their locality, so that as far as possible there will be a level playing field between all types of provider. There is no hidden agenda in this area.

I hope that I have covered most of the points covered by the noble Lord and I hope that he will think again about some of the criticisms that he unfairly levelled against the NHS.

[Baroness Barker]

My Lords, I thank the Minister for introducing a highly innovative document. This is the first time that the NHS has ever been treated in this way, with a document of this kind brought to Parliament and put out to consultation. I am delighted that in such a milestone document mental health has not been forgotten and is included alongside physical health.

I wish to ask the Minister three quick questions, because this document is important and the process of consultation about it is important for the future of the NHS. First, in the section on commissioning, will the Minister tell us whether he believes that the document fully reflects the decision taken in this House during the passage of the Health and Social Care Act that commissioners should not be under any obligation to put services out to tender when there is a justifiable case not to do so in the best interests of patient care? I want to make sure that he believes, as I do, that that point needs to be stressed during this period of consultation.

Secondly, with reference to the Public Administration Committee report in 2011 about the need for government to have robust accountability and audit trails as services are increasingly delivered by other providers, will the noble Lord reassure the House what the processes will be, given all the work that was done by my noble friend Lady Williams of Crosby about the capacity of Parliament and the Secretary of State to have sufficient information to judge whether or not the aims and aspirations of the document have been met in practice? How will it be evaluated and what data will be made available to Parliament to make that judgment?

Finally, I welcome the part of the mandate about the NHS in its broader context, but does the Minister agree that the omission of any mention of housing is a serious one—in particular aids and adaptations, which are so important to prevention of ill health and for the reablement of people who have been in acute care?

[Earl Howe]

My Lords, I am grateful to my noble friend. On her first question about commissioning and the matter that we discussed during the passage of the Health and Social Care Act, she will remember that the cardinal principle of “any qualified provider” is that it is for commissioners to judge whether putting a service out to tender is in the best interests of patients. If there is no need to bring in competition, there is no obligation on a commissioner to do so. Why should they wish to? On the other hand, a service may be failing. The classic example that I always give is that of children’s wheelchair services. In some parts of the country it is appalling. There is every reason in the world for a community service like that to be put out to tender. Nobody argues with that, if it delivers a better service at the same or roughly equivalent price. So I can reassure her on that point.

On accountability and audit trails, the way in which the board will hold the service to account will be based on the commissioning outcomes framework very largely, but of course there will be very tight financial controls through the accounting officer of every CCG. Broadly speaking, the service will be held to account through the results achieved for patients, the quality of care and the outcomes. There will be metrics attached to those—the indicators that I referred to, which fall below the NHS outcomes framework, as it were.

My noble friend will notice in the mandate that we have quite consciously not articulated umpteen sets of targets or indicators for particular disease areas, such as cancer or coronary heart disease. Once we started to do that, we would produce a volume 500 pages long; nobody wants that—the clear message that we had was that the mandate should be brief, succinct and to the point. That is what we have produced in draft, and we would be very interested to hear what noble Lords think about that. I encourage all noble Lords to feed in their views as to whether we have got the balance right.

On housing aids, I do not think there is anything specifically in the mandate on that. On the other hand, one of the features of the integration of services will be for the health service to work much more closely with social care. We believe that the health and well-being boards will provide the best forum to do that. I hope that through mechanisms such as pooled budgets—and indeed the support that my department is already giving local authorities to bolster their social care budget—such housing aids can be maintained as we move into the future.

[Lord Walton of Detchant]

My Lords, many aspects of the Statement are most welcome. I particularly commend the reference to the enhancement of research in the National Health Service, which was one of the concerns widely expressed during the debates on the Health and Social Care Bill, which is now an Act. Turning to that Act, can the Minister say what progress is going to be made and what help will be given to the major general hospitals that are intended to become foundation trusts but which at the moment have no particular prospect of becoming so for a variety of reasons?

Perhaps I may also briefly mention something that was not covered in the Statement—the crucial importance of issues relating to the education of healthcare professionals, a matter to which I, and many of my colleagues, referred during the debates on the Act. What progress has made on establishing the so-called clinical senates? I know that according to Sir David Nicholson we can no longer talk about regions—we can talk about sub-national structures. What is going to happen to those clinical senates that are going to have the responsibility of holding the postgraduate deans and the programmes of education and training which they will in future supervise?

The other thing about which we were very concerned was the commissioning of highly specialised services which, during the debates, it was agreed would become the responsibility of the national Commissioning Board. What progress has been made in developing the outreach centres under the national Commissioning Board that will be responsible for commissioning those highly specialised services at a local level? In relation to that, there is an issue that is quite crucial and important—the future of the organisation presently called the Advisory Group for National Specialised Services. It has a budget at the moment of about £100,000 a year. It has been able to support the introduction and use of remedies for treatment of a number of exceptionally rare diseases. It fulfils a vital function. Will it be absorbed and taken over by the national Commissioning Board? Will that body then carry on with those responsibilities? These are quite important issues about which many of us are concerned.

[Earl Howe]

The noble Lord asked me a number of questions and I will do my best to answer them. First, on education and training, the news is that on 28 June Health Education England was legally established as a special health authority and held its first board meeting. From October this year, Health Education England will start to provide national leadership and oversight to the new education and training framework in England. It will take on, as the noble Lord knows, its full responsibilities from April 2013. The chair, Sir Keith Pearson, and the chief executive, Ian Cumming, have been appointed. Both are men of very high calibre, as I am sure the noble Lord knows.

On the matter of clinical senates, the plans for those will develop over the summer. My advice from Sir David Nicholson is that he should be able to provide further and better particulars in the autumn on how they will look. The noble Lord is absolutely right that they will play an important part in helping to advise not only commissioners in the health service but also the local education and training boards about configuration.

On specialised services, the draft mandate emphasises the importance of driving improvements in the £20 billion of services commissioned directly by the board, including specialised services for people with rare or very rare conditions. One of our proposed objectives in the draft mandate asks the board to put in place arrangements to demonstrate transparently that these services are of high quality and represent value for money. Objective 21 is the crucial one to which I would refer the noble Lord.

On the question about the Advisory Group for National Specialised Services, we will be making an announcement about AGNSS as soon as we can. There is work in train at the moment to look at exactly how AGNSS’s work, which of course is very valuable, can be transposed into the new system. Unfortunately, I do not have any definite news for the noble Lord at the moment.

As regards assistance for foundation trusts, the noble Lord asked about the foundation trust pipeline. I would refer him to page 28 of the Secretary of State’s annual report. Broadly speaking, however, apart from a few financially distressed trusts, some of which I have already referred to, we believe that the great majority of NHS trusts will be ready to take on foundation trust status either in the spring of 2014 or fairly soon thereafter. We have no reason to think that the timetable we discussed during the passage of the Bill has slipped materially.

[Baroness Williams of Crosby]

I add my appreciation to that of my noble friend Lady Barker to the Government for putting so much information before Parliament and for inviting Parliament to help work out some of the massive changes that will be required to enable the NHS to deal with the problems confronting it. I also welcome my noble friend the Minister’s comments making it clear that a level playing field now exists between the NHS and the private sector, contrary to widespread views that the NHS is coming to a messy end.

I have one important question for my noble friend which echoes in some ways the question asked by the noble Lord, Lord Walton of Detchant. It concerns the issue of primary care which he was discussing with the noble Lord, Lord Hunt. Clearly, a reconfiguration of health will be heavily dependent on the ability of the primary care sector to deal with a great many of the issues that come before it and to pass them on to the community or ancillary professions wherever possible in order to avoid unnecessary attributions or referrals to hospital. In that context there is one very disturbing issue which we have to address and on which I would particularly welcome the Minister’s comments. He will know, as most of us in the House who are concerned with the health service will know, that there has been a much more rapid increase in the number of young men and women trained for consultancy than for general practice—the figure is something like three times the increase for GPs in the past five years. Given that there is in general practice a very rapidly rising proportion of young women, there is an issue of maternity care and the necessary reduction in hours associated with many young women GPs. I say that with the recognition that it creates some problems. I think that most of us in the House would agree that their quality is equal to that of the men but often they do need periods of shorter service.

Finally, there is the very serious problem of the substantial bulge in GP retirement that is coming up in the next couple of years, as the Minister will know. My question echoes that of the noble Lord, Lord Walton, in terms of training and education. What provision is being made to encourage young men and women to go into general practice; is adequate provision being made to train them; and are there incentives for them to enter into the profession in that capacity?

[Earl Howe]

As so often, my noble friend has alighted on a real issue and I am grateful to her. She is right that we are not seeing enough trainee doctors going into general practice. The previous Government and we have had informal targets for new GPs. We have not met those targets for a few years now. It is a matter of concern and we are working very closely with the universities, the Royal College of GPs and others to see how the numbers can be rectified. It is not just a numbers game because, as she rightly alluded to, we should increasingly be seeing a better sharing-out of responsibilities in the community between not only GPs but community nurses, practice nurses, midwives, health visitors and others. There is quite a lot of work to be done there.

My noble friend is right about women GPs, and headcount numbers in that context are not always the most reliable indicator of the workforce number. This is part of the reason why we set up Health Education England, because with the advice of the Centre for Workforce Intelligence, the body that advises the Government on long-range forecasts of workforce needs, and the input from local providers—primary care providers, not just hospitals—of what they see as their needs into the future, we ought to get a much better handle on long-term needs for the different professional disciplines.

I do not at all brush aside this problem. I hope my noble friend realises that this is a real issue and we are grappling with it. Actually the NHS has grappled with it for a number of years, partly unsuccessfully, but we hope to do better with the new configuration that we have debated so often.

[Baroness Wall of New Barnet]

My Lords, I welcome the report and in particular I thank the noble Earl for his emphasis—which I would like him to re-emphasise when he responds—on just how hard people are working in the NHS. As always, I reflect my own experience. I do not live in a different world from other people and I certainly know from the trust that I am chair of that people are working exceedingly hard.

Although there are some reservations, if I may say so to the noble Earl, around the progress we are having, I think that that is more about people getting used to what the changes mean. In particular, I want to focus on the CCGs. As the noble Earl knows, my trust has a hospital in Barnet and one in Enfield. Barnet CCG is firing away and working brilliantly. Enfield is still trying very hard to get its act together. The noble Earl knows how much I care about this, and the effect is that we are not getting the primary care out in Enfield where we need it. I would have liked the report to have focused more on moving away from hospitals—which I know is supposed to be heresy for someone who is the chair of a provider trust, but I really believe this—and making sure that we have the opportunity for more primary healthcare and support for those CCGs to be urged forward.

I know we have only a minute so I am not going to say anything else because I know other colleagues have been waiting desperately to get in, but there is a lot more I could say.

[Earl Howe]

The short answer to the noble Baroness is that she is, of course, absolutely right about service redesign locally. It involves the kinds of conversations that are already happening in many areas between primary and secondary care clinicians to see how we can bring about that shift that most experts agree is desirable and certainly patients want to see. This is an ongoing conversation. I do not know as much as I should about the noble Baroness’s particular area of the country, but I will gladly follow that up with her after this.

[Lord Cormack]

My Lords, very briefly, my noble friend indicated progress towards the elimination of mixed-sex wards. This issue causes quite a degree of anguish in the country. When can we expect to see the end of them?

[Earl Howe]

My Lords, my noble friend is absolutely right. However, the NHS has made staggering progress. The reduction in mixed-sex accommodation has been virtually—but not quite—total, but it is something that we continue to emphasise to the health service and which will continue to matter, in the context of the NHS outcomes framework, in the patient experience domain, which is contained in the mandate.

NHS: Spending Formula

Earl Howe Excerpts

Tuesday 3rd July 2012 Lords Chamber

[Baroness Quin]

To ask Her Majesty’s Government whether they intend to make changes to the formula governing levels of NHS spending in the different NHS regions in England.

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

My Lords, from 2013-14, the NHS Commissioning Board will allocate resources to clinical commissioning groups and the Department of Health will make a ring-fenced public health grant to local authorities. The Secretary of State has asked the independent Advisory Committee on Resource Allocation to develop formulae for both CCGs and local authorities. We published ACRA’s interim recommendations for local authorities on 14 June and its recommendations on CCG funding will be published in due course.

[Baroness Quin]

Is the Minister aware of the deep concern in the north-east and other parts of the north of England that if the Government, as has been rumoured, move away from using deprivation and health inequalities as an important criterion, and simply use an age criterion, areas of the north where life expectancy is lower will lose out, compared to more affluent areas in the south? This and other government-trailed proposals, such as regional public sector pay or regionalised benefits, as well as the daily reality of more job losses and more house repossessions in the north than in the south, are adding to concerns that there will be a dramatic worsening of the north-south divide. Will the Minister and his colleagues commit themselves to narrowing that divide, rather than widening it further?

[Earl Howe]

My Lords, yes. I am aware that this has been said, and it is based on a misapprehension, perhaps as a result of misunderstanding what my right honourable friend the Secretary of State said a few weeks ago. He was not suggesting that deprivation should not be a part of the future funding formula, but simply that age should continue to be the primary factor, as it currently is and should be, in the context of our intention to reduce inequalities of access to health services.

[Lord Walton of Detchant]

Is the Minister aware that a number of major surveys carried out by all-party groups into conditions such as muscular dystrophy and other neuromuscular diseases, Parkinson’s disease and, most recently, dementia have demonstrated gross inequalities in the standards of care, longevity and other important factors, in different parts of the country? The Neurological Alliance has pointed, in another major report, to serious discrepancies in relation to neurological and rehabilitation services in different parts of the UK. Will the proposals that the Minister has described do something to correct these serious inequities?

[Earl Howe]

My Lords, to a certain extent, we must say here that we are where we are. There is a lot of justice in what the noble Lord has said. We know that services in certain parts of the country are underfunded, compared to the level of clinical need and disability, and commensurately that some services are overfunded in other parts of the country. However, we cannot move suddenly to a position where we redress the balance. That would destabilise services. We certainly believe in equal access where there is commensurate need for the services, particularly those to which the noble Lord referred.

[Lord Brookman]

We are still the United Kingdom and the Question of the noble Baroness, Lady Quin, is very valid. I am originally from the valleys of south Wales. Life is pretty tough there. I hope that the National Health Service will provide equal service to the people in the valleys of south Wales as it does in the more prosperous areas of the country. Will the Minister confirm that that will be the case?

[Earl Howe]

My Lords, it is of course for the devolved Administration in Wales to decide on their own allocation of the health budget for Wales. That is not within my gift, as the noble Lord will understand. However, certainly within England we would expect the funding allocations to support the principle of securing equivalent access to NHS services, relative to the prospective burden of disease and disability. Because we have an independent NHS Commissioning Board, people can be assured that this will put beyond doubt that allocations are driven as far as possible by each population’s need for healthcare services and not by extraneous factors.

[Baroness Greengross]

My Lords, later this afternoon the All-Party Group on Dementia, which I am privileged to chair, will launch a report on the rates of diagnosis, the challenge of dementia and how it can be met. We know that more than half of all people with the disease have not been diagnosed. Diagnosis offers access to a memory clinic that can reduce the impact of the disease or postpone its worst effects. Is the Minister aware that the variations across the country are horrific and that people do not know where to go? Will the Government do something to ensure that everybody has access to the care and support that they need in an area that they can reach?

[Earl Howe]

My Lords, we come back to the issue of age in this context. I say again that we believe, as did the previous Government, that age is the primary driver of an individual’s need for health services. The very young and the elderly, whose populations are not evenly distributed throughout the country, tend to make more use of health services than the rest of the population—the noble Baroness gave a very graphic and important example of where that applies. This principle is reflected in the most recent PCT-weighted capitation formula. As I said earlier, there are imbalances that, over time, we will seek to correct.

[Baroness Tyler of Enfield]

My Lords, accepting that —as the Minister said—we are where we are, could he explain what evidence base is being used to determine the allocation of resources to CCGs?

[Earl Howe]

My Lords, the funding formula is made up of a number of components, including capitation, deprivation, age, the number of young people not staying in education and the number of people over 60 claiming pension credit. I have a long list in front of me. However, ACRA, the independent body that I mentioned, is composed of a group of independent-minded people who are keen to take into account every relevant factor that bears on this question. If my noble friend wishes, I will write to her with a more detailed list of the factors that historically have been in the formula.

[Lord Foster of Bishop Auckland]

My Lords, because the Minister has said that he will work very hard for more equality around the regions, we believe it—but that is not true of the Government as a whole. We are terribly worried, for example, that in the first round of local government negotiations the county of Durham lost £171 million, whereas the county of Surrey gained £60 million. If what we hear is true, the same kind of negotiation will go on in the next round. Will the Minister have words with his colleagues to say that people expect the same kind of equality in local government as he is trying to achieve in health?

[Earl Howe]

My Lords, I can go further than that. As the noble Lord knows, public health at a local level will become the responsibility of local authorities. Public health grants in 2013-14 will not fall below the 2012-13 estimates, other than in exceptional circumstances where responsibilities shift or where there has been a gross error in the calculation. ACRA proposes a public health formula driven mainly by a measure of mortality, which is strongly correlated with deprivation, and we are actively seeking views on these proposals.

NHS: Definition of Exceptional Case

Earl Howe Excerpts

Monday 2nd July 2012 Lords Chamber

[Baroness Masham of Ilton]

To ask Her Majesty’s Government what is the definition of an exceptional case needing surgical and medical care through the National Health Service, and who makes the decision.

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

My Lords, the department has not issued definitive guidance on this difficult issue. Indeed, there is a paradox in the whole concept of defining an exception. However, good practice in the NHS suggests that a patient can be considered for treatment which is not normally provided locally if the patient has exceptional clinical need or is likely to derive exceptional clinical benefit. The decision is made by the local commissioner.

[Baroness Masham of Ilton]

My Lords, I thank the noble Earl for that reply. However, is he aware that there is a young doctor in Northallerton, North Yorkshire, whose PCT has denied her a vital operation for a genetic pancreatic condition? If she does not have this operation, she will remain in excruciating pain all the time, she will not be able to work, and there will be a risk of cancer.

[Earl Howe]

My Lords, I hasten to reassure the noble Baroness that I have every sympathy with the individual in question, and I was aware of this particular case. The chief executive of the NHS will shortly be writing to her clinical tutor to suggest a possible way forward. However, I should put on record my view that the commissioner is acting reasonably in insisting that its decision on exceptionality should depend solely on the clinical need of the patient, and not on any broader social factors. If there is now good clinical evidence to support the use of this particular treatment, commissioners should be considering whether to make it available to all patients with similar clinical needs, and not just to a few individuals.

[Lord Ribeiro]

Is my noble friend aware that the pancreatic unit at Leicester is not able to do any islet cell transplantation operations because the PCT refuses to fund them? The excuses used to justify not funding these operations are that these may be “procedures of limited value” and “experimental surgery”. There are, in fact, four clinical units throughout the UK doing islet cell transplantation, with good records and good outcomes. I want to know whether the PCTs are not funding these operations in order to present a clean sheet to the incoming CCGs in April 2013, or whether there is another reason.

[Earl Howe]

My Lords, no, that is not the reason. My noble friend is quite right that this treatment has been around for a little while. However, it is not yet in mainstream practice. It is expensive, it is not routinely available in the NHS, and indeed NICE has published interventional procedure guidance which concludes that it,

“shows some short term efficacy, although most patients require insulin therapy in the long term”.

That does not seem to me to be a resounding endorsement of this treatment.

[Lord Winston]

My Lords, will the Minister be kind enough to help us by defining what is meant by exceptional clinical needs?

[Earl Howe]

There is no clear-cut answer to that question. A patient might be suffering unusually severe symptoms from a given condition, or they might suffer from some comorbidity, with the result that in the absence of treatment his or her quality of life would be unusually severely affected. The underlying principle should be that the patient has some exceptional characteristic which would justify more favourable treatment being given to them than to the average patient with that condition.

[Baroness O'Loan]

Given the vulnerability of the patients, the exceptional nature of the illness in such cases, and the consequential problems in terms of access and capacity to appeal, will the Minister tell the House what arrangements exist to scrutinise the fairness and consistency of decisions by PCTs and by their exceptional cases review processes?

[Earl Howe]

My Lords, under the NHS Constitution, all patients have the right to an individual review of a decision not to fund a particular treatment if they and their doctor believe that it would be appropriate. They also have the right to an explanation of the basis of the decision. The commissioner must in turn have a process to enable such individual funding requests to be considered, so the watchwords here are transparency and publishing an explanation.

[Baroness Gardner of Parkes]

Does the Minister agree that there are other decision-making bodies? I refer in particular to the UK National Screening Committee. Is he aware that, probably correctly, it makes its decisions only on research results? Why does it claim that it does not have the money to spend on research into Streptococcus B infections, when international research shows a clear choice for screening as opposed to risk assessment? That change that has been made in other countries has resulted in reductions of strep B infections in children of 80% in the USA, 60% in Spain, 82% in Australia and 71% in France. The screening of pregnant mothers could prevent that very serious condition, which can be fatal, being passed to a small number of babies.

[Earl Howe]

My Lords, the UK National Screening Committee advises Ministers and the National Health Service in all four UK countries on all aspects of screening policy, including for group B Streptococcus carriage in pregnancy. The committee is currently reviewing the evidence for screening for that condition in pregnancy against its criteria. It will take into account the international evidence and a public consultation on the screening review will be opening shortly.

[Lord Collins of Highbury]

My Lords, the Minister said that this treatment is not routinely carried out. The doctor concerned, who works in the NHS, is aware that pancreatectomy is carried out in other PCTs. Can the noble Earl explain where it is being carried out so that we can understand what is routine and what is not?

[Earl Howe]

My Lords, I hope that my earlier answers gave a clear indication of the definition of exceptionality, which should demonstrate to the House that something that is exceptional is not routine. Our advice is that that treatment is not routinely available in the NHS. There is a handful of centres in England with doctors who are trained to carry out the operation, but although the technique has been in use since 1977, it is available only in a few centres worldwide, which does not suggest to me that other countries are ahead of us in this area.

Dementia

Earl Howe Excerpts

Thursday 28th June 2012 Lords Chamber

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

My Lords, I begin by congratulating the noble Lord, Lord Touhig, on securing this debate and thank him for his compelling speech. As all noble Lords have emphasised, dementia is one of the most important health and social care issues that we face as a society. The statistics are staggering. The 670,000 people with dementia in England will double over the next 30 years, and the current £19 billion cost will inevitably spiral.

Dementia affects not only health and social care but all of society, and the speeches today have brought that dimension graphically to life. We need to be better prepared. Dementia is a priority for this Government, and we are working to ensure that it becomes a priority for every part of our society—communities, banks, supermarkets and transport. All need to become dementia-aware and dementia-friendly. That is why, on 26 March, the Prime Minister set out the Government’s challenge on dementia, to go further and faster in implementing the national dementia strategy in three key areas: driving improvements in health and care, creating dementia-friendly communities and improving research into dementia.

I was grateful to my noble friend Lady Barker for what she said about the challenge. We do mean business in this important area. Nationally, three champion groups are driving delivery. The first meetings of the three groups have already taken place and work is well under way to make progress on the challenge. The champion groups will report their progress in September 2012 and again in March 2013.

People with dementia, their families and carers have told us what is important to them and what will help them to live well with dementia. They want to receive an early diagnosis and timely, good-quality information that will help them to make informed choices about their care. I listened with dismay to the story the noble Lord, Lord Wills, told us about his own mother in that context. They want the treatment and support they receive to be the best for their dementia and their life, regardless of whether they are cared for at home, in hospital or in a care home. They want the care they receive at the end of their life to be compassionate and appropriate and to support their exercise of choice.

Early identification of those who care for people with dementia is crucial so that they can be directed to the information, advice and support that will help them in their caring role. The NHS operating framework requires the NHS to work more closely than ever before with local carers’ organisations and councils to agree plans, pool their resources and make sure that carers get the support and breaks they deserve.

However, there are other reasons why change is so important. The challenging economic context, as noble Lords have emphasised, makes it even more important for new and more efficient models of service delivery. That is why we have launched an innovation challenge prize of £1 million for NHS organisations to develop ideas for transforming dementia care. Through the dementia care and support compact, the social care sector is committing to leading initiatives to improve the quality of care for people with dementia. That includes work to ensure that people with dementia are clear about what they have a right to expect of care services.

The noble Lord, Lord Wills, asked about the funding for all this. The Government have already made increased funding available to the NHS and many of the aims of the challenge should deliver savings. For example, the CQUIN goal of improving the recognition of dementia in hospital should lead to people with dementia spending less time in hospital, and ensuring that people with dementia are diagnosed early should stop them going into crisis. The Prime Minister’s challenge is about the NHS and social care making better use of the resources already available to them.

The noble Lord, Lord Touhig, asked about the eligibility criteria for care. The imminent White Paper on care and support—I stress that it is imminent—will set out our plans to transform the care and support system for everyone, including people with dementia. The noble Baronesses, Lady Pitkeathley and Lady Wheeler, asked me for further and better particulars on our plans for publishing the White Paper and indeed for reforming the funding of social care. The care and support White Paper and the progress report on funding reform for social care will be published simultaneously and, I hope, very shortly. I believe that I can go no further than I did the other day in responding to the noble Baroness, Lady Wheeler, but I can reaffirm the Government’s intention to legislate on both funding reform and the reform of the law on social care as early as possible in this Parliament. Clearly, following the publication of the White Paper and the draft Bill that will go with it, we will wish to hear from all sides of the House and indeed from all sectors of the community about the direction of travel and the detail of our ideas.

The noble Baroness, Lady Pitkeathley, asked about the role of GPs. As part of the Prime Minister’s challenge, we are actively working with the royal colleges to identify how best to improve early diagnosis through awareness, education and training at GP level. Early and accurate diagnosis is, as the noble Baroness and others emphasised, very important in ensuring that people with dementia can access the support and information that everyone needs when they receive the dismaying news of this dreadful condition.

My noble friend Lady Barker spoke about adaptations for those with multiple disabilities. I agree with what she said. It is important that designers think about people with dementia when designing products for older people. The department provided funding to the Design Council to run a project to encourage design for people with dementia. There were 185 entries, which shows that designers take this seriously and that the design community is very definitely rising to the challenge.

The noble Lord, Lord Wills, spoke about the Swindon project and innovation. I can tell him that we very much want to see good, innovative practice spread out across the NHS and social care. That is why we have launched the innovation challenge prize for dementia, to which I referred. We are very much looking at innovation as part of the implementation of the Prime Minister’s challenge. Incidentally, the dementia challenge is to achieve a dramatic reduction in the proportion of people who have undiagnosed dementia, with evidence of a step-change in the diagnosis rate and a strong service response. The challenges in this and other areas will be open for a minimum of three years, which should encourage health communities and organisations to confirm their intention to apply for a prize.

The noble Lord, Lord Wills, also referred to human rights. We very much welcomed the publication of the report of the EHRC inquiry into human rights in home care for older people. The report found evidence of mixed practice. While we should be positive about those who deliver good-quality care services—and there are many—there is no excuse for bad practice. We believe that the report performed a valuable service by shining a light on the care and support provided in that most private of spaces—people’s own homes. We cannot tolerate poor quality in any of our care services. I completely agreed with what the noble Baroness, Lady Greengross, said about training. Care and support that respects human rights must be the foundation on which we build to make a reality of our vision of better health and well-being and better care for all. We will continue to work with the EHRC, the Care Quality Commission, local authorities and care providers to ensure that poor practice is rooted out.

The noble Baroness referred, quite rightly, to workforce issues and training. We know that two-thirds of people in care homes have dementia, so it is vital that the workforce is trained in dementia care. Indeed, 10 leading care home and home care providers have already signed the dementia care and support compact to which I referred, and we aim to have 50 organisations signed up by September this year. The compact sets out the organisation’s commitment to deliver high-quality, relationship-based care and support for people with dementia. I think that that statement of intent gets the process off to the right start.

The noble Baroness, Lady Pitkeathley, rightly reminded us of the vital contribution that carers make to society, a theme taken up, very perceptively, if I may say so, by the noble Baroness, Lady Wheeler. The Government have taken strong action to support carers. We set out our priorities in Recognised, Valued and Supported: Next Steps for the Carers Strategy, published in November 2010, and we are providing additional funding of £400 million to the NHS between 2011 and 2015 for carers’ breaks. As we set out in Innovation Health and Wealth, published last December, from April 2013 access to all CQUIN rewards will be dependent on commissioning support for carers in line with NICE and SCIE guidelines.

Furthermore, the 2012-13 NHS operating framework requires the NHS to work more closely than ever before with local carers’ organisations and councils to agree plans, pool their resources and make sure that carers get the support and break that they deserve. I very much hope and believe that that will have a positive effect on the thousands of carers of people with dementia in England.

Although dementia can be a crushing condition, we must not lose sight of the fact that people do live well with it. We need a profound shift in culture and behaviour if we are to reduce the stigma of dementia. All too often dementia is ignored, and the work of carers and other professionals goes unrecognised. Business and civic organisations are part of the solution. They can help to create dementia-friendly communities where people with dementia and their carers can remain and do the things that we all take for granted, such as travelling around and shopping. As so often, my noble friend Lady Barker was completely right in what she said on this theme. We need to create communities in which people are not ashamed of or embarrassed by dementia.

As we have a few minutes in hand, with the leave of the House I will continue a little longer. We need to create communities that show a high level of public awareness and understanding about dementia, communities where people with dementia and their carers are encouraged to seek help and where people know enough about dementia to be able to help someone with the condition. By 2015, there will be at least 20 places recognised as working towards being a dementia-friendly community. Places and organisations that meet the criteria being developed as part of the Prime Minister’s challenge will be awarded dementia-friendly status. I can say to my noble friend Lady Barker that, as part of the dementia-friendly communities strand of the challenge, we are working with banks to ensure that they and their staff understand the needs of people with dementia and that staff are dementia-aware.

The noble Baroness, Lady Greengross, mentioned an important part of the Prime Minister’s challenge, dementia research, spanning basic research through to living well with dementia and increasing capacity and capability across the entire research system. It commits the National Institute for Health Research, the Medical Research Council and the Economic and Social Research Council to increasing funding for research into dementia from £26.6 million in 2009-10 to an estimated £66.3 million in 2014-15.

Over the next three years, the NIHR will support the four new NIHR biomedical research units for dementia, projects resulting from the recent NIHR-themed call for research on dementia, and additional work depending on the volume of high-quality applications received. In addition to the increase in funding for dementia, the MRC will spend over £3 million to support the UK brain banks network. This connects all the UK brain banks for the benefit of donors, researchers and future patients. This money includes £500,000 a year to improve the process for donating brain tissue by meeting the costs of collection through the NHS. The ESRC is making £5 million of additional funding available to fund research into the prevention of dementia and interventions to maximise the quality of life for people with the condition.

There is much that the Government are doing and much more yet to be done. To address the challenges of dementia, we need a response not only from the NHS but from society as a whole.

[Lord Wills]

My Lords, as there is a little time—this is not my intervention—I want to place on record how enormously heartening I found the Minister’s response to the debate. I feel inspired by much of what he said and I want to put on record my thanks to him for his response.

My question is this: are there any milestones in place to measure progress in meeting the Prime Minister’s challenge and, if so, what are they?

[Earl Howe]

My Lords, if the noble Lord will allow me, I shall write to him on that. The answer, broadly, is yes, we want to see progress made by certain steps of time. However, time does not permit me to spell that out now.

There are already significant signs of progress up and down the country. The Prime Minister’s challenge is about mobilising not only the NHS and local authorities but all the resources that our communities have to offer. A great deal of good work is already going on and is beginning to lead to a steady increase in diagnosis rates, which is promising. The result of that will, of course, be that many more people will get the treatment and care that they need and that their loved ones deserve. Long may this continue.

House adjourned at 6.06 pm.

Care Homes

Earl Howe Excerpts

Wednesday 27th June 2012 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they will take in the light of the finding of the Care Quality Commission’s recent unannounced inspections of care homes and treatment centres for people with learning disabilities, that around half of those inspected were not meeting essential standards of care.

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

My Lords, the CQC’s findings show unacceptable levels of care. On Monday a Department of Health report set out 14 national actions to improve care and support for people with learning disabilities or autism and behaviours that challenge. All parts of the health and care system have a role to play in driving up standards, stopping abuse and transforming local services.

[Baroness Wheeler]

My Lords, in its inspection of care homes and assessment centres in the light of the serious abuse and appalling standards of care at Winterbourne View hospital for people with learning disabilities, the CQC found that of the 150 inspections it carried out, independent healthcare providers were twice as likely to fail to meet the required standards as NHS providers. How does the Minister account for that? Can he say specifically what steps he will be taking to ensure that clinical commissioning groups tackle the problems the commission found over lengths of stay in services, failure to review care plans so that residents can be moved on to community-based services, and the very worrying overuse of restraint of patients?

[Earl Howe]

My Lords, it is true that CQC inspectors found that for the kind of services they inspected, there was more non-compliance in services run by the private sector. But the information the CQC gathered for its report does not enable it to analyse the reasons for that. I would simply say that all providers of services, whether in the independent sector or the NHS, need to ensure that they comply with essential standards. The noble Baroness summarised a number of the areas where the CQC found failings and I endorse her view that there is a fundamental failing across the system, not just in providers but in terms of commissioning as well. The examples of poor care show up a fundamental need for commissioners to review commissioning plans and care plans, and make sure not just that the providers are capable of offering and providing care to the right standards but that they are actually doing so at the right level for the patients and service users they look after.

[Lord Patel]

My Lords—

[Baroness Campbell of Surbiton]

My Lords, in 2008 the Joint Committee on Human Rights produced a shocking report which highlighted some of the most degrading experiences endured by adults with learning disabilities in health and residential care settings. Four years on we are debating the same human rights abuses—this time highlighted by the CQC report, which shows excessive use of restraint and seclusion in assessment and treatment facilities. Will the Minister assure us that he will return to the JCHR and CQC reports and tell us what measures the Government will take now to protect the liberties and safety of this highly vulnerable group so that we do not sit here again in four years debating how we have failed for a third time?

[Earl Howe]

The noble Baroness’s remarks will resonate with many noble Lords. We have been here before. One of the emerging issues from the review is around poor practice on the use of restraint, as she rightly mentioned. CQC inspectors found that only 73% of locations met requirements on physical intervention or restraint. There was ineffective monitoring of restraint data and learning from incidents. Staff were not always trained and restraint was not always delivered in line with the care plan. There are real lessons to be learnt by providers about the use of restraint. We have flagged this up as one of the actions that we will take in the department to work with the Department for Education, the Care Quality Commission and others to drive up standards and promote best practice in the use of positive behavioural support and ensure that physical restraint is only ever used as a last resort. The report published on Monday is an interim report and we will be publishing a final report later in the year.

[Baroness Barker]

My Lords, does the Minister agree that this report calls into question the role of local safeguarding adult bodies? What are they doing now while people are being mistreated in a way that the CQC has uncovered? Does the Minister think that it is time to revisit the legal bases of those organisations?

[Earl Howe]

My Lords, my noble friend is right to call that matter into question. My department will be working with the NHS Commissioning Board Authority to agree by January next year how best to embed quality of health principles in the system using NHS contracting and guidance. Those principles will set out the expectations of service users in relation to their experience. We are taking a range of other action—the 14 national actions to which I referred in my initial Answer—which I would suggest my noble friend looks at. We are clear that there is a need not just for providers but for everybody in the system to focus on their responsibilities and to work together to drive up standards in the way that we all wish to see.

[Baroness Browning]

My Lords, given the number of years that have passed since we saw the Mencap report Death by Indifference, and the fact that these reports show an inadequate level of improvement, I find myself in the strange position of asking my noble friend if he would please reconsider a proper register, professionally supervised by those working in the care industry?

[Earl Howe]

My Lords, as my noble friend knows, we committed in the Health and Social Care Act to facilitate a voluntary register for care workers and health workers. We believe that the system should be tried before we think about any statutory regulation. However, I understand the urgency and strength of feeling around this issue and it is a matter that we will keep under regular review.

NHS: Dental Care

Earl Howe Excerpts

Tuesday 26th June 2012 Lords Chamber

[Baroness Gardner of Parkes]

To ask Her Majesty’s Government how many dentists are now providing NHS dental care under the general dental services contract introduced in 2006; and what is the annual cost of the care provided and the amount generated in patient charge revenues towards funding this care.

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

My Lords, the latest figures published by the NHS information centre show that 22,799 dentists provided NHS primary dental care in 2010-11. The net allocation for primary dental care in 2010-11, the latest year for which figures are available, was £2,200 million. Patient charge revenue for 2010-11 was £617 million.

[Baroness Gardner of Parkes]

It is good to have the updated figures, but is the Minister aware that the two major concerns for patients now are transparency and availability? Availability is something that we look to the health service to provide. However, the transparency issue has become very important, not only to patients but to other dentists, who are very dissatisfied that dentists are able to put up notices saying, “National Health Service treatment available”, yet after a patient goes to them it emerges that the treatment is very limited. Does the Minister not think that, in the interests of warning the consumer, the present NHS fee charts should show that conditions may apply?

[Earl Howe]

My Lords, I absolutely agree with my noble friend about the importance of transparency of information for NHS patients. NHS Choices, which is the department’s public-facing website, already displays a lot of information about fees, the treatment that should be received and how to make a complaint about NHS dentistry, but more work is being done in this area to improve information on patients’ ratings of different practices, and we are updating the patient leaflet as well. What a dentist should not do is mislead a patient or induce a patient to access the surgery and then not provide the treatment that the patient thought they were going to get. If they cannot provide NHS treatment for whatever reason, they should point the patient in the direction of a practice that can, or else refer him or her to the primary care trust helpline.

[Lord Hunt of Kings Heath]

My Lords, I refer the House to my health interests in the register. Following on from the noble Baroness’s Question, can the Minister refer specifically to the OFT report, which showed that thousands of patients, after being told by their dentist that they could not have a certain treatment on the NHS, were persuaded to go private? That is and was inaccurate information. Are the Government going to take action in this area?

[Earl Howe]

My Lords, the OFT report on the dental market was published last month and we very much welcome that study. We note that it found that the vast majority of patients were happy with their dental treatment and that the vast majority of dentists behave ethically. There should be, and are, clear penalties for the small minority who mislead patients, but the noble Lord is right to draw attention to that aspect of the OFT report. It is an area that we are taking extremely seriously and we are looking at what more we can do.

[Lord Colwyn]

In view of the Minister’s comments on patient charge revenues and the fact that NHS dentists are not allowed to do competitive pricing, has he any idea why the recent OFT report to which he has just referred revealed that 1% of regular NHS patients chose their dentist because, they said, the practice had competitive prices? Why do his colleagues at the department still refer to the NHS as being free at the point of delivery?

[Earl Howe]

My Lords, my noble friend is correct. Treatment provided on the NHS carries only one pricing tariff, which cannot be varied. The OFT report found that only 1% of NHS patients and 2% of private patients chose a dentist on the basis of price. I stand to be corrected, but I do not believe that it made any suggestion that NHS charges were uncompetitive; they are, and always have been, a subsidised contribution to NHS costs—they are not a market price. Therefore, I imagine that the OFT report reflected the fact that patients were comparing private charges with NHS charges. Of course, the NHS is in general free at the point of use, but my noble friend is right. It is important that we are clear that some charges exist, as they have in dentistry for 60 years.

[Baroness Jolly]

My Lords, some may avoid the dentist because they cannot find one, others for fear of high costs, and others just for fear. Have the Government carried out any work to determine what proportion of the population does not attend a dentist, and the reason why?

--- Later in debate ---

[Earl Howe]

I am pleased to tell my noble friend that since May 2010 over 1.1 million more patients have been seen by an NHS dentist, which is very good news. Nevertheless, we are clear that access is a priority—56.6% of the population has seen an NHS dentist within the past two years. We wish to design the new dental contract, which is currently being piloted, in a way that encourages access.

[Baroness Knight of Collingtree]

My Lords, does my noble friend recall that last month he told the House that he was giving attention to the possibility of access online to dental prices. Has he anything to report since he said that?

[Earl Howe]

My Lords, I referred earlier to NHS Choices, the website that patients and the public can access. It contains the most up-to-date information on dental treatment costs and entitlements. The dental section of NHS Choices was updated at the end of February following suggestions and comments submitted by the public through the website itself and these changes include new pages that clearly explain dental charges and exemptions and inform patients how to get help with dental costs.

[The Countess of Mar]

My Lords, am I right in my understanding that children and young people get all NHS dental treatment free of charge? If so, what improvements have there been in dental health among this group?

[Earl Howe]

The noble Countess is quite right. The oral health of children, particularly those from disadvantaged families, is one of the biggest challenges we have and one of the main priorities in this policy area. While two-thirds of five year-olds are now caries free, the remaining one-third have an average of 3.45 decayed, missing or filled teeth. We are piloting new ways of supporting dentists to identify children at risk of tooth decay to get them the care and preventive advice they need, including engagement through schools, the wider community and local authorities.

Care Quality Commission (Registration and Membership) (Amendment) Regulations 2012

Earl Howe Excerpts

Monday 25th June 2012 Grand Committee

[Earl Howe]

My Lords, I am most grateful to noble Lords who have spoken and shall endeavour to cover the questions and points they have raised in a moment. However, before I do so, perhaps I may briefly take the Committee through the purpose of this instrument.

The regulations before us today make changes to two areas of the legislation that affect the operation of the CQC. The first component of this statutory instrument makes two small amendments to the Care Quality Commission (Registration) Regulations 2009 to replace references to the National Patient Safety Agency, the NPSA, with references to the NHS Commissioning Board Authority. The second relates to the make-up of the commission’s board. I shall say more about the purpose of these changes in a moment but I should like to reflect on the importance of the Care Quality Commission as the independent regulator of health and adult social care services in England.

The commission plays a vital role in providing assurance that patients and service users receive the standards of care that they have a right to expect. All providers of regulated activities in England, regardless of whether they are public, private or voluntary sector organisations, are required to register with the commission. Providing a regulated activity without being registered is an offence. In order to be registered, providers have to comply with a set of registration requirements that set the essential levels of quality and safety. Where providers do not meet these essential levels, the commission has a range of enforcement powers that it can use to protect patients and service users from unsafe care, including, in the most extreme cases of poor care, closing down services. The changes to the commission effected through the Health and Social Care Act 2012 are to strengthen the CQC as the quality regulator of health and adult social care services.

I shall now explain why we need to make these changes to the regulations included in the instrument under debate. Under Regulations 16 and 18 of the CQC registration regulations, registered providers of regulated health service activities have been required to notify the CQC of unexpected deaths of service users or other serious incidents, except where such providers have already reported the death or incident to the NPSA. This exception was designed to reduce the reporting burden on providers, preventing the duplication of reporting to both the NPSA and the CQC. Notifications to the NPSA were processed through the national reporting and learning system, the NRLS, and notifications made in the circumstances described in Regulations 16 and 18 of the registration regulations were passed on to the commission by the NPSA. However, from 1 June, responsibility for oversight of the NRLS transferred from the NPSA to the NHS Commissioning Board Authority. Therefore, the amendments to which I referred were needed to reflect the changing ownership of and responsibility for the NRLS and to update the exception and allow it to continue from 1 June.

Relevant notifications to the NRLS will continue to be passed to the CQC under the new arrangements. To set this in context, as noble Lords are aware, the arm’s-length bodies review in 2010 recommended the abolition of the NPSA, and provision is made for the recommended abolition in Section 281 of the Health and Social Care Act 2012. Provision in the Act is also made for the NHS Commissioning Board to have responsibility for the patient safety functions formerly carried out by the NPSA. I shall briefly reiterate why we believe this to be entirely sensible and in the best interests of patients. Patient safety has to be the key priority for all those working in the health service. It can never be allowed to be seen as an add-on or an afterthought.

For that reason the Act puts safety at the heart of the NHS, not at arm’s length. Safety is, of course, a central part of quality and we believe that the board, as a body legally responsible for ensuring continuous quality improvement in the NHS, will be best placed to drive a powerful safety agenda throughout the NHS. Embedding safety across the health and social care system is vital. That is why oversight of the patient safety function has been conferred on the shadow body—the NHS Commissioning Board Authority—from 1 June. The NPSA did not have the authority or position to fully exploit the information gained from the NRLS. In contrast the board will have the necessary authority and, being positioned at the very heart of the system, will be better placed to lead and drive improvements. Patients rightly expect that all NHS services will be safe. We believe that by making the board responsible for safety, we are placing that responsibility at the centre of the NHS.

The second part of the regulations makes changes to the regulations setting out the composition of the Care Quality Commission’s board. These changes are in response to the recommendations of the Department of Health’s review into the performance and capability of the commission. The review recommended that the department should take steps to strengthen the board, including changing its structure to that of a unitary board, so that instead of comprising only non-executives, senior executives can also be appointed and held to account by the non-executive members. The model of a unitary board also potentially offers strength in combining the strategic views of the non-executives with the organisational knowledge of the executives. In addition, the performance and capability review recommended that the Secretary of State should strengthen the board by appointing new non-executive members to existing board vacancies. The regulations, therefore, remove the bar in the commission’s existing regulations stating that the Secretary of State cannot appoint an employee of the commission to the board, so allowing for the creation of a unitary board. The regulations also extend the number of members who can be appointed to the commission’s board so as to accommodate the senior executives. The upper limit is currently set at 10, and these regulations extend that to 12. That allows flexibility in the appointment of new executive and non-executive members to strengthen the board’s capability.

I was very grateful for the comments of the noble Lord, Lord Hunt, on the appointment of David Behan as chief executive of the commission. I am sure he will agree that David’s wealth of experience around adult social care and local government system reforms at the department as director-general for social care, local government and care partnerships will stand him in excellent stead for his new role as chief executive of the CQC. David’s previous experience as the first chief inspector of the Commission for Social Care Inspection and as president of the Association of Directors of Adult Social Services, as well as his other front-line experience, will also be a great advantage to the commission.

All noble Lords who spoke asked about resources and funding. It is important to recognise that the CQC recovers fees from providers to cover the cost of registration. In addition, it receives grant in aid to cover its other functions. Every year, the CQC agrees its business plan with the Department of Health and its financial position is kept under constant review. We have agreed that the CQC will receive additional funding for staff recruitment in 2012-13.

Allied with the question of resources was that about the CQC’s capability. We have every confidence in the CQC’s ability to provide the effective regulation of providers of health and adult social care. I welcomed what the noble Baroness, Lady Wall, had to say about that. As the noble Lord, Lord Hunt, has acknowledged, huge improvements are being made in the delivery of its core task of providing assurance that services for patients and service users are safe and of appropriate quality. The CQC leadership is now demonstrating greater confidence and challenge. The recommendations that we made in the performance and capability review are aimed at building on performance during the past 12 months to strengthen capability further and to improve accountability, including accountability with the department.

We are committed to supporting and strengthening the CQC. We are clear that the CQC should continue to focus on its core role of assessing whether providers meet the essential levels of safety and quality through its registration function. The department is assured that the CQC is delivering its core functions and learning from its implementation of the registration system, improving the way in which it carries out its core business to provide a better service. We have emphasised to the CQC the importance of ensuring that providers continue to comply with regulations and safety and quality requirements. The CQC continues to monitor closely the information on service providers that it receives and takes regulatory enforcement action if it finds the safety and quality of services to be lacking in any case.

We are committed to developing the role of the CQC as the quality regulator of health and adult social care services in England. The functions that the CQC will gain as a result of the Health and Social Care Act 2012—joint licensing with Monitor, information governance monitoring and hosting Healthwatch England—and the potential transfer of functions from the Human Fertilisation and Embryology Authority and the Human Tissue Authority, subject to consultation, are all aimed at strengthening its role in assuring the safety and quality of health and adult social care services.

I emphasise that these changes will not happen overnight. For example, the delivery of joint licensing is not expected until 2014, and any transfer of functions from the HFEA or the HTA will not happen until 2015. The CQC will have a number of years to prepare for these functions, including assessing the resources needed to carry them out. During this time, the department will work with the CQC to ensure that it is ready to take on the functions at a pace that avoids distracting the commission from its core responsibilities and placing the delivery of its current functions at risk.

The noble Lord, Lord Hunt, spoke about the CQC’s methodology and in particular the “generic model of regulation”. Professional regulation, as he knows, conducted through the GMC, the GDC and other professional regulators, focuses mainly on the competence of the individual professional. However, the way in which organisations are managed and their systems work, together with factors such as the suitability of premises, also affects the safety and quality of the services provided. CQC registration will ensure that competent individuals meet the needs of their patients without putting them at risk from potential system or premises weaknesses. It is encouraging that both the General Practitioners Committee and the Royal College of General Practitioners have issued joint statements with the CQC illustrating the profession’s acknowledgment of the need for CQC registration and the light-touch approach that the CQC is taking to bringing providers into registration.

I argue that there is a generic element to the regulation process, but that does not mean that the CQC approaches its task on a one-size-fits-all basis. I have accompanied CQC inspectors when visiting a dental practice, and I know that there are non-generic elements of its methodology that apply only to dentistry. The CQC has worked with stakeholders and trialled its processes to keep these to a minimum, but it is important that it has the capacity to take action where services do not meet essential standards.

NHS: Liverpool Care Pathway

Earl Howe Excerpts

Wednesday 20th June 2012 Lords Chamber

[Baroness Knight of Collingtree]

To ask Her Majesty’s Government whether use of the Liverpool care pathway in NHS hospitals is consistent with the outcome of parliamentary debates and votes on euthanasia.

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

My Lords, the Liverpool care pathway is an internationally recognised framework to guide the delivery of high-quality care for people in their last hours or days of life. It is not a means of euthanasia and is therefore entirely consistent with the outcome of parliamentary debates and votes on the subject. The Liverpool care pathway helps to ensure that people die with dignity, respect and minimum distress.

[Baroness Knight of Collingtree]

My Lords, is my noble friend aware, however, that although the Liverpool care pathway is certainly not intended to be a tool for euthanasia, that is what a growing number of people now believe it to be, judging by their own experiences? Is he aware that consultants are not always informed that their patients have been put on this pathway, and that invariably neither those patients nor their relatives are told? Will he look into what is happening, since the very name “pathway” indicates that they are shortly to face induced death, as indeed they do?

[Earl Howe]

My Lords, I recognise that some people who have been on the Liverpool care pathway have received poor care. The pathway is not of itself a guarantor of best-quality care. It has been consistently made clear in the guidance for the implementation of the Liverpool care pathway that it is in no way a replacement for clinical judgment and should not be treated as a simple tick-box exercise. Rather, it should be seen as a useful framework to guide the delivery of care in a way that complements the skill and expertise of the practitioner using it.

[Lord Hunt of Kings Heath]

My Lords, I refer the House to my health interests in the register. Does the noble Earl agree that the noble Baroness, Lady Knight, has done sterling work in bringing to the attention of Parliament issues to do with the appropriate feeding and nutrition of patients in hospitals, but that on this issue she is wrong? Will he confirm that the national care of the dying audit shows that in fact the vast majority of patients on the care pathway in the last 24 hours of their life were reported to be comfortable and receiving good clinical care, and that his department will continue to recommend the care pathway as good practice?

[Earl Howe]

My Lords, we will continue to do so. The Liverpool care pathway has sometimes been accused of being a way of withholding treatment, including hydration and nutrition. That is not the case. It is used to prevent dying patients from having the distress of receiving treatment or tests that are not beneficial and that may in fact cause harm rather than good. The noble Lord was right that the recent national care of the dying audit of hospitals, run by Marie Curie in collaboration with the Royal College of Physicians, notes that in 94% of documented cases discussions explaining the use of the LCP were held with relatives or carers. That audit process gives clinicians an opportunity to feed in their views about how well, or not so well, the pathway is working in practice.

[Baroness Finlay of Llandaff]

My Lords, given that the Government have recognised that the Liverpool care pathway has been designed to bring the best of hospice care into other care settings, such as hospitals, nursing homes and patients’ own homes, and that it is a tool—and a tool is often only as good as the person using it—will the Government ensure that Health Education England includes in its remit comprehensive education around the appropriate care of dying patients?

[Earl Howe]

Yes, my Lords. To ensure that it is used properly, the Liverpool care pathway emphasises the importance of staff receiving appropriate training and support in its use as well as accessing relevant end of life training and education programmes. A range of activity has been undertaken to support staff education and training and end of life care by the national end of life care programme and others. That includes the development of an extensive package of e-learning, which is free to access for health and social care staff.

[Baroness Browning]

Will my noble friend tell the House whether there is ongoing monitoring of patients who are sedated but not hydrated? Looking at people who are dying can take a long time. My noble friend mentioned a few hours or a few days. If you are not hydrated for days on end, inevitably death will come. What analysis is there?

[Earl Howe]

My Lords, one key feature of the Liverpool care pathway is regular monitoring of the patient—every four hours at a minimum, I believe. That regular monitoring process gives clinicians and nursing staff an opportunity to reassess the patient’s condition to see whether they are in fact responding to treatment, whether they require a different form of treatment or whether the treatment they are being given is unduly burdensome. That regular monitoring should, I think, take care of the point my noble friend raises.

[The Lord Bishop of Liverpool]

My Lords, I have some contact with the Liverpool care pathway in Liverpool. Does the Minister agree that not just palliative care professionals but all healthcare professionals should receive education and training in caring for dying patients? Would he also agree that in the relationship between the two, trust is paramount?

[Earl Howe]

My Lords, the right reverend Prelate is absolutely right. Audits that have been carried out, particularly the recent audit published in December last year, provide us with important information about the current quality of care provision. The recent audit makes a series of recommendations, including mandatory training in the care of the dying for all healthcare staff involved and a seven day, nine to five, face to face palliative care service.

[Baroness Crawley]

My Lords, is the Minister aware that my own dear mother spent her last days on the Liverpool care pathway? Is he further aware that our family experience was of extraordinary care and sensitivity on the part of all the healthcare professionals involved, enabling us to be with my mother peacefully at home at her death? Confusion reigns over the title. A family friend, hearing that Mum was on the Liverpool care pathway, thought that a miraculous recovery had taken place and that she was taking a leisurely stroll in one of our great northern cities.

[Earl Howe]

My Lords, I am pleased to hear that the noble Baroness’s mother was well looked after with the benefit of the Liverpool care pathway. I take the point about the name. Indeed, the noble Baroness, Lady Finlay, can probably give us some instructive examples from Wales, where the word “pathway” has not been adopted and the process has, I believe, been refined.

[Baroness Masham of Ilton]

My Lords, is the noble Earl aware that some relatives and loved ones have to fight to stop their loved ones being on the Liverpool care programme? Can he think of anything worse than dying of thirst?

[Earl Howe]

My Lords, no one should be denied basic care at the end of life. However, that is a different question from whether artificial nutrition and hydration should be withheld. Relatives should always be consulted.

Tobacco: Control

Earl Howe Excerpts

Tuesday 19th June 2012 Lords Chamber

[Lord Naseby]

To ask Her Majesty’s Government whether they will meet representatives of non-governmental organisations, the tobacco industry and retailers to discuss tobacco control issues, publishing the minutes of such meetings, in line with both the requirements of Article 5.3 of the World Health Organisation Framework Convention on Tobacco Control and the practice of the European Commission and other member states.

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

My Lords, Health Ministers consider all meeting requests carefully. Article 5.3 of the Framework Convention on Tobacco Control requires the Government to protect the development of public health policies from the vested and commercial interests of the tobacco industry. The tobacco industry is welcome to share its views on tobacco control issues with us in writing at any time.

[Lord Naseby]

My Lords, that is a depressing Answer. How is it possible that in a country that believes in freedom of speech, a highly regulated and legitimate industry employing thousands of people and providing millions of pounds of revenue for Her Majesty's Government can be treated quite so shabbily when the Government are developing new regulations affecting plain packaging, which affects intellectual property, and are involved in consumer safety? I ask my noble friend to think again and to receive representations. The Government may not want to agree with those representations, but surely it is the legitimate right of every elector and every employer in this country to make their representations in person to Her Majesty’s Government.

[Earl Howe]

My Lords, we welcome the views of tobacco companies, retailers and all those with an interest in tobacco-related policy. Ministers in other departments may have legitimate reasons to meet the tobacco industry—I understand that, from time to time, they do—but Health Ministers and Department of Health officials would have a good reason to meet tobacco companies only if a specific matter, as opposed to general issues to do with tobacco control, demanded that. We would have to think carefully whether there was a good reason.

[Lord Hunt of Kings Heath]

My Lords, I refer the House to my health interests in the register, in particular as president of the Royal Society for Public Health. I ask the noble Earl to continue his efforts to keep those companies at some distance from him and the Department of Health. Will he confirm that it is the view of the Government, as it was of the previous Government, that the tobacco industry promotes a product that has been described by the WHO as being proven scientifically to be addictive and to cause disease and death, and that we should have very little to do with those companies?

[Earl Howe]

My Lords, I can only agree with the noble Lord, Lord Hunt, that tobacco is extremely damaging to public health. There is no safe level of smoking, and as a party to the Framework Convention on Tobacco Control, the UK has an obligation to take its undertakings very seriously—which means to develop public health policy free from influence from the vested commercial interests of a very powerful industry. However, that does not mean that we close our ears to what the tobacco industry may have to say: we are very happy to hear from it in writing. That promotes transparency, which I think assists everybody in a freedom of information context.

[Lord Stoddart of Swindon]

But is it not hypocritical of a Government—not only this one but previous Governments—to refuse to meet the tobacco industry, which is their tax-gatherer to the extent of £10.5 billion a year? If they had any honour and really believed that tobacco is such a bad commodity they would ban it. If they believe that, why do they not?

[Earl Howe]

My Lords, across government we recognise the need for Ministers or officials from other government departments to meet the tobacco industry within the parameters set under the framework convention. There may be legitimate operational reasons why such meetings might be necessary—for example, Her Majesty’s Revenue and Customs sometimes meets the tobacco industry to discuss measures to reduce the illicit trade in tobacco. So it is not as if all government departments have closed their doors, but there is a very specific issue to do with Health Ministers and health officials.

[Lord Rennard]

My Lords, I declare my interest as an unpaid director of Action on Smoking and Health. Does the Minister recognise that any dealings he has with the tobacco industry will be with an industry that is responsible for the deaths of around 300 of its own consumers every day in this country alone, and that any claims that that industry makes must be treated with very great scepticism given its knowledge over many years of the connection between smoking and lung cancer and the addictive properties of nicotine—facts which it well knew but denied for many decades?

[Earl Howe]

My Lords, my noble friend makes some very powerful points and he is right. Smoking is the biggest preventable cause of death in England. It causes more than 80,000 premature deaths every year. Tobacco use is a significant cause of health inequalities in the UK. One in two long-term smokers will die as a result of smoking. That demands that we take this issue very seriously indeed.

[Lord Faulkner of Worcester]

My Lords, is the Minister aware that his answers this afternoon will give a great deal of satisfaction to those of us who care about public health and the pernicious effect of the tobacco industry in its attempt to subvert it? As other questioners have said, this is a unique product: it is the only legal product that kills if it is used as the manufacturers intend. Does he share the views of his Secretary of State, who told the Times last month that he wanted the tobacco companies to have “no business” in the United Kingdom? If he does, he can be assured that he will certainly have the support of many Members of this House.

[Earl Howe]

My Lords, if we are successful in our strategy to reduce smoking rates significantly, an inevitable consequence will be that, over time, less and less tobacco will be sold. It is smoking that we aim to reduce, which will have consequences for the sale of tobacco products. For the good of public health we are trying to arrive at a point where there is no smoking in this country, and that would mean no retail sales of smoking tobacco. Hence I fully support the remarks of my right honourable friend the Secretary of State.

[Lord Ribeiro]

My Lords, I am grateful to my noble friend for acknowledging the harm and damage that smoking does. Can he assure the House that the Government are equally determined to ensure that smoking will not have an adverse effect on children and children’s health in the future?

[Earl Howe]

The need to reduce and, we hope, eliminate the uptake of smoking by young people is one of our top priorities. I would like to thank my noble friend for his Private Member’s Bill, which will certainly enable this issue to benefit from a wide airing. We would all like to see smoking in cars with children eradicated—the health of people can be harmed by second-hand smoke. The key question for us at the moment is what is the most appropriate and workable way of protecting children from second-hand smoking. No doubt we will debate that matter when we come to my noble friend’s Bill.

[Lord Foster of Bishop Auckland]

Does the noble Earl ever speak to one of the best Ministers of Health that his party ever had—and, indeed, probably the best leader that they were never intelligent enough to elect—namely Kenneth Clarke, who they tell me used to get £150,000 a year from British American Tobacco? Perhaps I may just add that Rothmans was one of the best employers that I ever encountered. It was good with the employees, good with the trade unions and good with the community. It was just that its product happened to kill people—like arms dealers’.

[Earl Howe]

I think that the noble Lord has answered his own question. Being a good employer is one thing, public health is another.