Elderly People: Powers of Attorney and Living Wills
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I am very grateful to the noble Baroness, Lady Bakewell, for bringing this important issue to the House. At a time traditionally associated with making resolutions it feels like a particularly appropriate moment to be considering how we plan for later life together with our families and loved ones. I hope she will agree with me that the contributions from all speakers this evening have combined to make for an excellent debate.
I am sure all noble Lords would agree with the basic premise that all citizens should be cared for and treated in a manner that they themselves would choose, at a time in their life when they may no longer be able to make decisions themselves. The Mental Capacity Act 2005—the MCA—provides the legislative framework for how caregivers should support individuals who may lack the mental capacity to make decisions themselves. The Act and its associated code of practice emphasise the importance of treating each person as an individual and of seeking out their particular wishes and preferences, to ensure that any decision made is in the best interests of that person.
Noble Lords will, I am sure, be aware of the excellent work of the Select Committee of this House which scrutinised the implementation of the MCA last year. Its report, published in March 2014, highlighted that awareness of the Act was poor and that as a result many individuals were not aware of or taking up their legal rights. The Government embraced this finding and set out a programme of work in our response, which was entitled Valuing every voice, respecting every right. The response sets out the great challenge we face—essentially that of bringing about a change in culture whereby individuals are comfortable talking openly with friends and families about their wishes for later life and where wider society treats those who lack capacity with the same respect as those who have capacity.
The noble Baroness asked specifically about lasting powers of attorney—LPAs, to use the abbreviation—and living wills. An LPA allows someone with mental capacity to appoint an attorney to look after their affairs in the event that they lose capacity at some point in the future. As well as the traditional property and finance LPAs, the MCA legislated for health and welfare LPAs, which, I believe, are the focus of the noble Baroness’s question. There are currently more than 1.3 million LPAs registered, and applications are increasing at a rate of 20% year on year. This is good news, but we do not intend to rest on our laurels, especially when we look into the statistics and see that for every three finance and property LPAs registered, only one health and welfare LPA is recorded. The Office of the Public Guardian, which has responsibility in Government for registering LPAs, is using all available opportunities to raise awareness of LPAs through conference events, media engagements and work with multiple partners across finance, legal, health and care settings.
A number of noble Lords voiced concerns that executing an LPA is difficult and complicated. A good example of recent success is the LPA digital tool. This tool allows applicants to enter all the required information step by step on a personal computer and then simply print it out, add the relevant signatures, and send it to the OPG. This online service was the first so-called “government digital exemplar” to pass the Government Digital Service’s stringent new 26-point test. We believe and hope that this user-friendly service will help drive further increases in LPA registrations.
In 2015, the Department of Health and the OPG will continue to work closely to raise awareness of health and welfare LPAs. The department is in the final stages of production of a statement of rights which will inform the public about their rights under the MCA, including their right to make an LPA. In addition, the OPG is looking at how LPAs are used and will look to include use within the NHS as part of this project. This should lead to potential new guidance for the health system on LPAs.
Noble Lords will I am sure be aware that overall policy responsibility for the Mental Capacity Act lies with the Ministry of Justice. This was referred to by the noble Baroness, Lady Bakewell. I can inform the House today that the Ministry of Justice plans to run a campaign to raise public awareness of the options for planning for the future and encourage members of the public to think about what would happen in the event of their death or if they lost their mental capacity and needed someone to make decisions for them.
As for living wills, an issue which was mentioned by a number of noble Lords, the House will be aware that this term has no strict legal meaning but in common usage can be taken to describe an individual’s wishes and views about any future medical treatment or indeed any other care, support or lifestyle preferences. An advance decision to refuse treatment however does have a specific legal meaning under the Mental Capacity Act. End-of-life decisions are intensely personal matters. As individuals, our views on how we would like to be cared for can change over time, even when we still have full mental capacity. The Government’s policy is to seek to ensure that individuals are aware of their rights under the law—to make them aware that they have the choice to make a living will or advance decision to refuse treatment—but fundamentally to allow the individual to decide if they want to exercise this right. Our awareness raising efforts here are tied closely to our work to raise understanding of the wider provisions of the MCA. This work is multi-faceted: professional training, which I will mention again in a moment; revising our national governance structures; and ensuring that the MCA is a key line of inquiry in the Care Quality Commission’s new inspection model for care homes and hospitals.
The noble Baroness, Lady Bakewell, cited various obstacles which she felt can deter people from registering an LPA. One of these was the cost factor, which was also mentioned by the noble Baroness, Lady Wheeler. The OPG appreciates that the cost of making an LPA may be an important factor for those who wish to plan ahead. The cost of an LPA is £110. LPA forms, however, have been designed so that they can be completed without a solicitor. However, if a person chooses to seek advice from a solicitor they will have to pay the solicitor’s fees, which may vary and, of course, are a consideration. Another obstacle cited by the noble Baronesses, Lady Bakewell and Lady Flather, was that of complexity. We need to look at the balance of the arguments here. On the one hand, as I have mentioned, there are more than 1.3 million current instruments registered and LPA applications are increasing at quite a rate. Nevertheless, the OPG recognises that it is important to ensure that the LPA process is as straightforward as possible and acknowledges that some people find the existing LPA forms too complex to complete without legal assistance. It continually reviews its forms to make sure that they are easily understood. The OPG is also rewriting and restructuring its guidance and correspondence on LPAs so that it is clear, consistent and accessible to all.
The noble Baroness, Lady Bakewell, asked whether Scottish powers of attorney were recognised in England and Wales. We are aware of the important question of cross-border recognition of powers of attorney, and are considering how best to address it. We are in frequent communication with our colleagues in the devolved Administrations—for example, in Northern Ireland, where that Administration is consulting on new mental capacity legislation based on our Mental Capacity Act. Clearly, raising awareness of issues surrounding mental capacity is a UK-wide concern. My officials intend to share learning with colleagues in the devolved Administrations as part of our upcoming work programme. I will be happy to write to the noble Baroness with the precise legal response in terms of the validity of Scottish lasting powers of attorney in England.
I agree with the noble Baroness that raising awareness is important. We recognise that awareness among the general public of what an LPA is and the benefits of having one is low. We are working to increase this level of awareness, as I described. Having said that, we would not seek to tell adults that they should have an LPA; ultimately we believe that this is a matter of personal choice. My noble friend Lord Hodgson asked whether someone could use a power of attorney to make decisions about legacies. There are exceptions to the decisions that an attorney may make. I would be happy to write setting out these exceptions in more detail.
I take the point made by the noble Baroness, Lady Flather, that it is important for people to know if someone has an LPA in place. Good practice is always changing, but we should not forget that lasting powers of attorney are registered by the Office of the Public Guardian, which maintains a register. Those who wish to know whether an LPA is in place may apply to the OPG to search the register. The noble Baroness, Lady Greengross, stressed the importance of carers. I absolutely agree that carers do a fantastic job supporting those who lack capacity. I am pleased to say that my department has worked closely with the Standing Commission on Carers—
Baroness Flather
Yes, I will be quick. The Office of the Public Guardian charges a lot of money to give the information.
Earl Howe
I will write to the noble Baroness about that. The Standing Commission on Carers, which represents the needs of carers to the government policy-making process, is a body we are working closely with. It will help us channel our new statement of rights directly to carers, providing them with an understanding of the rights of the person they care for under the law.
The noble Baroness, Lady Wheeler, spoke about the need for professional training. I agree that that is vital. Health and social care professionals need to learn the basics of the MCA through their initial training and to keep updated on this through continuing professional development. Health Education England provides national leadership for planning and developing the whole healthcare workforce. The mandate set for it by the Department of Health specifically states that Health Education England should,
“work with … partners … to improve skills and capability to respond … to the needs of people who may lack capacity as well as maximise the opportunities for people to be involved in decisions about their care”.
The noble Lord, Lord Joffe, indicated that he felt that there was a lack of government leadership in this area. I would defend, in fact, our leadership record. We do not want to shy away in the least from our responsibilities when it comes to supporting better implementation of the Act. The legislation underpinning the MCA has been widely praised. Indeed, only a few months ago, we were visited by a delegation from the Swedish Government, who are looking to learn from our legislation as they draft their own. The problem is not the framework. The problem is a lack of understanding at the local level on the ground. It is the Government’s belief that the primary drivers of better implementation of the MCA are local organisations—hospitals, care homes, local banks and solicitors. That is why we intend to make the new national mental capacity forum, which we are setting up, predominantly outward looking. Its emphasis will be on forging collaborations, but then taking these out into the country and putting actions in place at the local level. I would be happy to write further on that, when I do write, as I shall, after this debate.
I have overshot my time but, in conclusion, I emphasise that planning for a time in later life where we are unable to make our own decisions is something that we are all likely to benefit from and which can ease the burden on our loved ones. Unfortunately, as the noble Baroness, Lady Flather, reminded us, I know many people find this type of conversation uncomfortable—even morbid, perhaps. That is to an extent understandable: no one wants to dwell on the possibility of a serious debilitating disease or, indeed, on death itself.
Ultimately, however, planning for the future can be greatly empowering. It can provide a degree of comfort as we approach a vulnerable period in our lives, it can allow us to determine how we are treated—which itself can improve our well-being and health outcomes—and it can provide comfort to our friends and family. The Government are determined to support our citizens in this regard, and the thoughts and expert advice of noble Lords are, as always, most welcome.
Alcohol: Addiction
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Lord Avebury
To ask Her Majesty’s Government what are Public Health England’s plans for combatting alcohol addiction.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, Public Health England recognises that the harmful use of alcohol is a major health risk. The harm from alcohol is preventable; alcohol is one of seven key priorities that PHE is focusing on. It is implementing a programme to support national and local government, the NHS and partners to implement evidence-based policies and interventions. Included in this work is the reduction of alcohol addiction.
Lord Avebury (LD)
Considering that three years ago, there were 1.1 million alcohol addicts in England and that abuse of alcohol was costing the nation £21 billion—and probably much more than that today—how can the Minister reconcile the fact that we spend only one-tenth as much on treating alcohol addiction as we do on patients suffering from drug addiction? Why is it taking until 2016 to update the guidance on access to mutual aid fellowships such as Alcoholics Anonymous, when the ACMD has shown that there are effective ways of combatting the addiction?
Earl Howe
My Lords, my noble friend was kind enough to give me advance warning of those questions. I have to say to him that we do not recognise the figures he quotes; nor do we think that the comparison he makes is like for like. In 2007, an estimated 1.6 million people had some degree of alcohol dependence, including those with a slight dependence. Of those, some 250,000 were believed to be moderately or severely dependent. The specialist treatment centre system continues to work well for many people. Many of the trends in terms of treatment are positive. As regards supportive relationships, I fully agree with what he said; they are a vital element in helping individuals build their own recovery. In October 2013, Public Health England produced a strategic action plan for supporting the treatment sector to strengthen its links with mutual aid organisations to ensure that everyone in treatment can benefit from that support.
Lord Hunt of Kings Heath (Lab)
My Lords, how many meetings have been held between Ministers and representatives of the alcohol industry since the last election? Why are the Government delaying the publication of the Chief Medical Officer’s review of safe drinking levels until after the election? Are the two connected?
Earl Howe
No, my Lords, they are not. The Government have regular dialogue with the industry, but the industry does not formulate policy and never will do. There has been a delay on the new guidelines; the consultation on them had been planned for December last year but will not now happen until shortly after the general election. That is simply due to problems with Public Health England commissioning expert advice on guideline methodologies, which took longer than intended. The academic body that PHE wanted to do the work decided that it did not have the capacity to do so. A tender exercise was therefore necessary and the work is being carried out by a team from Sheffield University.
Baroness Howarth of Breckland (CB)
My Lords, the Minister is well aware of the effect of alcohol on unborn children. What are the Government doing for young mothers who are either addicted to drink or unaware of the difficulties that alcohol creates for their children in terms of education both through the health service and the education system?
Lord McColl of Dulwich (Con)
My Lords, does the Minister accept that although alcohol was until recently the commonest cause of liver disease, the commonest cause is now the obesity epidemic, which is killing millions of people? Some 13 million people in this country are suffering from obesity—far more than are suffering from alcohol problems.
Lord Brooke of Alverthorpe (Lab)
Will the Minister explain to the House why, when his Government came to power, they tore up the draft strategy on liver disease that had been prepared by the previous Government? What are they going to do to put one in place and, given the complaints we have heard, make sure that the growth in the number of deaths is reversed?
Earl Howe
My Lords, Public Health England has a programme of work to ensure that all the bases are covered. It is producing a report for government that will be published later this year. Over the next 18 months, there will be a longer programme of work on such things as a framework for liver disease, setting out the evidence base for the introduction of a minimum unit price for alcohol and using alcohol as the trail-blazer for a new whole-system approach that establishes what works and is clear on the return on investment, to enable government to take action based on evidence.
Baroness Hollins (CB)
My Lords, the Board of Science at the BMA, which I chair, believes that the availability of cheap alcohol, such as white cider, is one of the main causes of the rise in addiction. We believe that the sale of cheap alcohol needs to be tackled through the introduction of a minimum unit price and that prevention really is better—and cheaper—than cure. What does the Minister think about that?
Earl Howe
Minimum unit pricing remains under consideration while additional evidence becomes available. We are not taking it forward at the moment. We need to give careful consideration to any possible unintended consequences of minimum unit pricing, such as the potential impact on the cost of living, the economic impact of the policy and increases in illicit alcohol sales. It is, and has only ever been, part of the Government’s alcohol strategy—although, as I mentioned a moment ago, Public Health England will be assembling the evidence base for the introduction of a minimum unit price for alcohol to advise the next Government.
Lord Garel-Jones (Con)
Does the Minister agree with me that alcohol is properly defined as a habit-forming, hallucinatory drug, and is it not about time that Governments began to treat the use and abuse of this particular drug with the same seriousness as they do the abuse of other drugs?
Earl Howe
My noble friend makes a very good point. Alcohol in moderation is something that we can all enjoy, but people who binge drink or drink drive cause problems for accident and emergency departments. They are the people we have to bear down upon. I believe that we do now have effective systems of regulation and enforcement, which are proving their worth.
National Health Service
Earl Howe Excerpts(10 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I start by congratulating the noble Lord, Lord Turnberg, on securing this debate and thanking those noble Lords who have contributed to it.
As noble Lords will know, having covered the health portfolio continuously since 1997, I still find myself continuously in awe of the NHS and the principles that underpin it, as well as of the people within our health service who live out these principles, not least at the moment.
The NHS is currently facing challenges that it has never faced before. Even though the Government have protected the NHS with real-terms funding increases, we do not underestimate how challenging it has been to continue to deliver high-quality care in the current climate. Demand for healthcare is rising and changing as the population ages and different diseases come to the fore. We are faced with an ageing population, as has been said, and one where increasing numbers of people are living with multiple chronic conditions. The big issues that the NHS must deal with now, such as dementia and lifestyle conditions such as obesity, cannot be addressed by the traditional model of a healthcare system which is focused on the acute sector.
I want to spend most of my speech considering the future of the NHS following the recent publication of the Five Year Forward View. This document, which was published jointly by NHS England and five other arm’s-length bodies, sets out a vision for how our health system will evolve over the next five years. It is a vision which the Government share. The Secretary of State and I have previously set out the four pillars of our response, which are worth recapping.
The first pillar is to ensure that we have an economy that is able to pay for the growing costs of our NHS and social care system. A strong NHS needs a strong economy. The success of our economy means that we were able to provide additional funding in the Autumn Statement, including £1.7 billion to support and modernise the delivery of front-line care, and £1 billion of funding over four years for investment in new primary care infrastructure. In all, NHS funding will be about £3 billion more next year compared with this year, and all that extra funding will be baselined for future years.
The NHS itself contributes to that strong economy in a number of ways, and we want to help it to develop its role. It is helping people with mental health conditions to get back to work by offering talking therapies to 100,000 more people every year than four years ago. The NHS can also attract jobs to the UK by playing a pivotal role in our emerging life sciences industries. In the past three years, we have attracted £3.5 billion of investment and 11,000 jobs. This Government have set out our ambition to be the first country in the world to decode 100,000 research-ready whole genomes.
The second pillar of our plan is to change the models of care to be more suited for an ageing population. As I said earlier, we need to accommodate growing numbers of vulnerable older people who need support to live better at home with long-term conditions such as dementia, diabetes and arthritis. To do that, we need a greater focus on prevention, which will help people to stay healthy and not allow illnesses to deteriorate to the point where they need expensive hospital treatment.
This Government have already made good progress in improving out-of-hospital care. Last year, all those aged 75 and over were given a named GP responsible for their care—something that was abolished by the previous Government. From April, everyone will have a named GP. Already 3.5 million people benefit from our introduction of evening and weekend GP appointments, which will progressively become available to the whole population by 2020. The better care fund is integrating the health and social care systems to provide joined-up care for our most vulnerable patients. Alongside that, the Government have legislated, for the first time ever, on parity of esteem between physical and mental health.
However, I recognise that there is more to do. NHS England has already invited applications from local areas for the £200 million of funding which has been made available to pilot the new models of care set out in the Five Year Forward View. To deliver these new models, we will need to support the new clinical commissioning groups in taking responsibility, with their local partners, for the entire health and care needs of people in their area.
A strong economy and a focus on prevention are the first two pillars of our plan. The third pillar is to be much better at embracing innovation and eliminating waste. Previously, the NHS has often been too slow to adopt and spread innovation. Sometimes this has been because the people buying healthcare have not had the information to see how much smart purchasing can contain costs. From this year, CCGs will have access to improved financial information, including per-patient costings. The best way to encourage investment in innovation is a stable financial environment. Following the next spending review, local authorities and CCGs will receive multi-year budgets. The NHS also needs to be better at controlling costs in areas such as procurement and agency staff as well as reducing litigation and other costs associated with poor care. We are working with NHS England and partner organisations to agree the level of savings in each area, which will allow more resources to be directed to patient care.
The final pillar of our plan is to continue to develop a culture of care in all parts of the NHS. We have made good progress since the Francis report. We have introduced a greater focus on patient care. There are 5,000 more nurses on our wards and 4.2 million NHS patients have been asked, for the first time, if they would recommend to others the care they received. We plan to go further over the next few months. We will set out how we will improve training and safety for new doctors and nurses, launch a national campaign to reduce sepsis, and, responding to recommendations made in the follow-up Francis report, tackle issues of whistleblowing and the ability to speak out easily about poor care.
Noble Lords have raised a number of other important issues in this debate. I shall endeavour to respond to as many as I have time to do. First, I shall talk about funding, a subject covered very thoughtfully by the noble Lord, Lord Turnberg, my noble friends Lord Horam and Lord Cormack, and the noble Lord, Lord Liddle, among others. The Five Year Forward View argued that a combination of growing demand and no further efficiencies would bring about a funding gap for the NHS of nearly £30 billion by 2020-21 against a flat real baseline. A 2% efficiency growth, rising to 3% over time, produces a remaining gap of £8 billion. But if the NHS can achieve 3% efficiency gains, the remaining challenge would reduce to around £4.4 billion in 2020-21. I will talk about the scope for efficiencies in a moment, but this is broadly the same real-terms funding increase that the Government have committed to the NHS over this Parliament.
The funding announced in the Autumn Statement fully delivers the investment required to make the Five Year Forward View a reality in 2015-16 and provides funding to start delivering the changes required by the Five Year Forward View to deliver a sustainable NHS in future years. As I have said, this new funding will be baselined for future years. As has happened over this Parliament, real increases in funding will be required to complete this transformation and ensure a sustainable NHS in the future but the NHS will also be required to make significant efficiencies. Of course, I cannot go further than that at the moment because the detailed funding package for 2016-17 onwards will be announced at the next spending review, whichever party is in government. It is worth pointing out that all the £1.5 billion of investment in NHS front-line patient care in 2015, stemming from the Autumn Statement, will go to improving local NHS services and will help the NHS to meet rising demand. On top of that, we are introducing a £200 million transformation fund. The fund will kick-start the work needed to develop new ways of caring for patients which do a better job of joining up GPs, community services and hospitals.
In part of her speech, the noble Baroness, Lady Jay, focused on competition. I am sure she will remember that greater competition in the NHS was introduced through deliberate policies from 2003, such as the independent sector treatment centres and choice of any willing provider. Rules were put in place in 2007 to manage this competition. We as a government continued that approach of managed competition, overseen, however, by an expert health regulator in the shape of Monitor. I would just say that this has hardly led to a giant expansion of private provision. Commissioner spending on healthcare from private sector providers equates to about 6.1% of total NHS revenue expenditure, which is only 1.2% more of the NHS budget than in 2010. Much of the increase is accounted for by social enterprises and charities, which I know the party opposite supports.
The key here is that it is not politicians who take these commissioning decisions but clinicians. As the noble Baroness conceded, there has not been a change in the Secretary of State’s core duty. He is responsible for promoting a comprehensive health service. This remains consistent with the wording of the original 1946 Act. At the same time, what the Act also did was right. The Health and Social Care Act puts clinicians in charge of decision-making about patients rather than politicians or administrators. That involves a strengthening of local accountability and decision-making through clinical commissioning groups and local health and well-being boards. Local authorities are once again responsible for public health, as my noble friend Lady Barker reminded us. We have also restored a culture of care to the health service so that doctors are primarily accountable to their patients, not top-down- targets or bureaucrats. I simply say to the noble Baroness, Lady Jay, and the noble Lords, Lord Morris and Lord Hunt, that any future Government would reverse those measures at their peril.
The noble Lord, Lord Turnberg, said that the NHS should become a much more preventive service and we fully agree with that. Action is needed to address the common risk factors for the big killer diseases. To give one example, the NHS health check provides an opportunity to review an individual’s health against some of the risk factors that he listed. Last year, more people than ever before received a free NHS health check. Since it was introduced, 7.5 million offers have been made and more than 3.7 million NHS health checks have been received, offering a real opportunity to reduce avoidable deaths and disability and to tackle health inequalities.
My noble friend Lord Balfe spoke about GPs and, in particular, GP access. We are introducing a number of measures to ensure that people who need to see a GP do so at a time to suit them. We have invested through the Prime Minister’s Challenge Fund £50 million this year to help more than 1,100 practices to develop new ways of improving GP access. We have committed to invest another £100 million into the scheme next year and we will extend seven-day opening to every patient in the country by 2020. From January, practices will also be allowed to register people outside their local area, making it easier for hard-working people to register near their place of work or somewhere else that is convenient to them. Despite a decrease in head count, there has been a 1.2% increase in full-time equivalent GPs since 2012 and the number of practice nurses and other practice staff has also grown, representing in total a real capacity increase.
The noble Lord, Lord Rea, focused on alcohol, an important issue. We are committed to reducing alcohol-related harm and have already banned alcohol sales below the level of duty plus VAT, meaning that it will no longer be legal to sell a can of ordinary lager for less than around 40p. Alcohol consumption per head has fallen, I am pleased to say, in recent years. Reduced affordability of alcohol, influenced by tax rises up to 2013, has been a factor in this. Alcohol minimum unit pricing is still being considered as a possible way forward but no decision has been taken.
The noble Baronesses, Lady Masham and Lady Wilkins, turned our attention to spinal injury services. The NHS England spinal cord injuries service specification clearly sets out what providers must have in place to offer evidence-based safe and effective services. It sets a core requirement that each specialised SCI centre can demonstrate that it has a minimum of 20 beds dedicated exclusively for the treatment and rehabilitation of SCI patients. The overall bed complement for England is being reviewed through a demand and capacity project led by the Spinal Cord Injury Clinical Reference Group. That group aims to produce a report in 2015-16.
The noble Baroness, Lady Wilkins, argued for a strategic view of spinal injury services. As she knows, NHS England commissions specialised rehabilitation services as defined by the service specification, which sets out what providers must have in place to offer safe and effective specialised rehabilitation services. The clinical reference group is currently completing a review of those services. It will involve establishing nationally what the current demand is for rehabilitation services, which must be the first point of reference.
My noble friend Lord Horam spoke about bed blocking and asked whether some of the delayed discharges could be resolved by discharge to mental health trusts or housing associations, and whether local areas could do more than they are doing. I would simply say to him that these things have to be dealt with locally; we cannot hope to do it centrally. The Health and Social Care Act 2012 gives local clinicians more power and responsibility to develop the right solutions for their local areas. Hospital trusts are already forming effective partnerships to ensure that patients get the support they need to be discharged from hospital quickly, and I can tell him that NHS England and others are supporting them to do this.
My noble friend Lady Barker focused part of her speech on mental health. I fully agree with her that public services should reflect the importance of mental health, putting it on a par with physical health, as we have argued so often. Parity of esteem between mental and physical health is now enshrined in legislation. For the first time, we have introduced waiting time standards for mental health, ensuring that NHS England and local partners properly prioritise access to mental health services, and we have made mental health part of the new national measure of well-being so that it is more likely to be taken into account when government departments are developing and implementing policy.
The noble Lord, Lord Kakkar, in his wide-ranging speech, covered a number of key issues. I turn first to efficiency savings. There is no doubt that the NHS needs to be better at controlling costs in areas such as the procurement of medicines and clinical equipment, and indeed non-clinical equipment, energy and fuel, agency staff, the collection of fees from international visitors, and reducing litigation and other costs associated with poor care. Gains can also be made in ways of working, such as by getting paramedic teams to treat more patients at home rather than bringing them to hospital; creating more regional centres of excellence for specialist treatments such as stroke and heart disease; bringing more services out of hospital and into the community by, for instance, having specialist consultants in GP surgeries; offering more patients better access to GPs, including evening and weekend appointments and Skype consultations; and joining up health and social care services such as through the Better Care Fund. Working with NHS England, the department has announced plans in all these areas. We will agree the precise level of savings to be achieved through consultation with NHS partner organisations over the next six months. That will lead to a compact signed up to by the department, its arm’s-length bodies and local NHS organisations with agreed plans to eliminate waste, thus allowing more resources to be directed to patient care.
The noble Lord, Lord Hunt, asked me about the cancer drugs fund. Of course, the policy behind this is to give patients access to the drugs they need, but I would qualify that by saying that those drugs need to be clinically effective. That is the reason why NHS England is doing the sifting process that is currently in train. The payments from industry that he referred to were never going to be hypothecated; they form part of NHS England’s general budget. Having said that, NHS England does have the freedom to apply the money as it sees fit, whether that is for drugs, radiotherapy, or indeed any other investment that it deems to be clinically effective.
Moving back to the noble Lord, Lord Kakkar, who asked me about innovation, the appropriate use of technology-enabled care services such as telehealth and telecare can support patients in managing their long-term conditions more effectively and enable people with social care needs to live independently for longer. We are making progress in this area, and I will be happy to bring him up to date by letter on that. As regards the new NHS Innovation Accelerator programme announced yesterday, I agree with him that that is very good news. It invites leading healthcare pioneers from around the world to bring their tried and tested innovations to the NHS. Again, I can expand on that by letter.
Where are we with the personalised medicine agenda, informatics and the UK Biobank? I can say to him, as I can to my noble friend Lady Thomas, that we are determined to make Britain the best place in the world to discover and develop 21st century medicines. By harnessing the UK’s unique strengths in research, the NHS, medical charities and a vibrant life sciences cluster of innovative companies, we are sure that we can accelerate access to new treatments and attract major new investment and growth.
I will need to leave the other questions to the letter that I have promised to send round to all noble Lords who have spoken. However, suffice it to say for now that in recognising that the NHS faces some definite challenges as we strive to increase both the efficiency and quality of care, we also have a clear plan for how we are going to tackle this. The progress that we want to make will only be made possible by people: those who work in the NHS and those who rely on it. We need to free people up to make decisions about the NHS, creating models of care that suit local needs while upholding a world-class standard. I am confident that we can do that together.
NHS: Accident and Emergency Services
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I shall now repeat as a Statement the Answer to an Urgent Question given in another place by my right honourable friend the Secretary of State for Health on major incidents and A&E performance in hospitals. The Statement is as follows.
“Mr Speaker, I welcome this opportunity to come to the House and make a Statement on accident and emergency services.
First, we must recognise the context. The NHS always faces significant pressures during the winter months, but with an ageing population we now have 350,000 more over-75s than four years ago. As a result, we are seeing more people turning up at our A&Es, with 279,000 more attendances in quarter 3 of this year compared to last and a greater level of sickness among those who arrive, leading to an increase in emergency admissions of nearly 6% on last year. This picture is reflected across the home nations, with A&Es in Wales, Scotland and Northern Ireland all missing key performance standards as a result.
A number of hospitals have declared major incidents over the past few days in what is traditionally a particularly busy time in A&E. A major incident is part of the established escalation process for the NHS and has been since 2005. This enables trusts to deal with significant demands, putting in place a command and control structure to allow them to bring in additional staff and increase capacity. It is a temporary measure taken to ensure that the most urgent and serious cases get the safe, high-quality care they need.
The decision to declare a major incident is taken locally, and there is no national definition. We must trust the managers and clinicians in our local NHS to make these decisions and support them in doing so by making sure that there is sufficient financial support available to help deal with additional pressures. I chaired my first meeting to discuss that support on 17 March last year. On 13 June, we gave the NHS an additional £400 million for winter pressures, topped up in the autumn by £300 million to a record total of £700 million, ensuring that local services had the certainty of additional money and time to plan how it should best be used. The NHS started this winter with 1,900 more doctors and 4,800 more hospital nurses than a year ago. This planning and funding has been widely welcomed by experts in the system, including NHS England, NHS providers, the College of Emergency Medicine and the NHS Confederation.
The funding that the Government have put in, which is on top of the year-on-year real-terms increases in funding, is made possible by a strong economy and will pay for the equivalent of 1,000 more doctors, 2,000 more nurses and 2,000 other NHS and care staff, including physiotherapists and social workers. It will fund up to 2,500 additional beds in both the acute and community sectors and provide £50 million to support ambulance services.
However, the NHS also needs longer term solutions to these pressures. We are providing £150 million through the Prime Minister’s Challenge Fund to make evening and weekend GP appointments available for 10 million people, with over 4 million already benefiting from this. Our better care programme integrates, for the first time ever, health and social care services in 151 local authority areas, with plans starting in April to reduce emergency admissions to hospitals on average by 3%. We have funded the NHS’s own plan to deal with these pressures, the five-year forward view, with an additional £1.7 billion for the NHS in 2015-16 and £1 billion of capital over the next four years to improve primary care facilities.
Let me finish by thanking hard-working NHS staff across the country for the outstanding care that they continue to deliver under a great deal of operational pressure”.
That concludes the Statement.
Lord Hunt of Kings Heath (Lab)
My Lords, I join the Minister in paying tribute to the staff of the NHS who are facing such a pressurised situation at the moment. Does he accept that, for all the actions that he has listed today, the fact is that too many vulnerable people are currently being exposed to too much risk in the NHS as a result of the crisis in A&E? How many hospitals have declared major incidents in the past two weeks? Does he agree that the crisis has been caused principally by the savage cuts in social care and the chaos caused by NHS reorganisation? Why have the Government overseen the closure of dozens of NHS walk-in centres? Why did the Government oversee the replacement of qualified NHS nurses in NHS Direct by unqualified call-centre staff in NHS 111, who have computers programmed to encourage people to go to A&E? When will the Government get a grip?
Earl Howe
My Lords, the noble Lord will understand that I am under instructions to keep my answers brief, in the nature of Urgent Questions. To cover his main points, though, we have made social care a priority at the same time as protecting the NHS budget and reducing the deficit. Since 2010 we have allocated additional funding from the NHS each year to support social care worth £1.1 billion in the current year and £2 billion next year. With regard to walk-in centres, there is no evidence that the closure of those centres, where that has occurred, has resulted in additional A&E attendances. A Monitor report in 2013 found that closures were often part of reconfigurations to replace walk-in centres with urgent care centres co-located with A&Es. On NHS reorganisation, I simply point out to the noble Lord that the pressures that we are seeing in the English health service are replicated just as strongly in the NHS in Wales, Scotland and Northern Ireland. Our A&E departments are in fact coping even better than those in the devolved Administrations.
Lord Tebbit (Con)
My Lords, I wonder whether my noble friend will give consideration to helping those people who could not get appointments to see their general practitioners, some of whose surgeries were closed for five days over Christmas, by allowing or encouraging hospitals to set up general practices alongside their A&E departments, which would be open seven days a week, 24 hours a day, for people who registered at the hospital general practice. That would mean more funds for the hospital and less funds for the general practices that chose to close up in that manner.
Earl Howe
My noble friend has made an extremely important point. I have visited hospitals where that very model has been in place, for example, in Luton, where I went not so long ago. More and more hospitals are adopting this suggestion so that when people turn up at A&E they can be triaged immediately into urgent and less urgent cases, often to be channelled through to the GP service.
Lord Kinnock (Lab)
I endorse the sentiments just expressed by the noble Lord, Lord Tebbit, unusual though that may be. I ask the Minister to commend those hospitals and health authorities that have introduced GP services as part of their A&E emergency response. I also draw his attention, if he has not seen them already, to the statements of the Royal College of Nursing and the College of Emergency Medicine. Both said emphatically that a substantial part of the reason for the present pressures is the effect of the reduction of local authority funding which means, in the words of one of the college leaders, that there is no community care. That has meant that people have to be accommodated in hospitals who would otherwise be in either their own homes or local authority homes. Is it not the case that the savage cuts imposed on local authorities, which have had a direct impact on commitment to care for the elderly especially, are to blame for a substantial part of this crisis? Will the Government consider, in addition to NHS funding, reversing at least some of those cuts?
Earl Howe
My Lords, I thank the noble Lord for his endorsement of the model which my noble friend proposed for GP presence in or alongside A&E departments. I fully agree with him on that. It works well. As regards local authority funding, social care expenditure, in particular, has decreased over the past three years. Obviously that has had an effect on the NHS. It would be idle to pretend that it has not. However he will know the very constrained funding environment in which we stand, and I understand that the party opposite has not undertaken to reverse the reductions in funding to local authorities for understandable reasons. That means that we have got to think clever, and one of the initiatives that we are launching next year is the better care fund which will bring together the NHS and social services in a meaningful way. By far the lion’s share of the funding in the better care fund will go to social services.
Baroness Barker (LD)
Since 2010 there has been an average decrease in social care funding in local government of 26%. Are the Government tracking the coincidence of reductions in budgets for things such as continuing care beds and increased attendance at A&E?
Baroness Finlay of Llandaff (CB)
Can the Government confirm that they are working with the College of Emergency Medicine—and I declare an interest as a fellow of that college—to manage their STEP programme? It requires sustainable staffing levels within emergency medicine departments, renegotiation of the tariff to make sure that they are adequately funded and dealing urgently with exit block. The college has calculated it would free 20,000 bed days if delayed discharges from the rest of the system were able to happen on time. The “P” of course is for primary care co-location which has already been addressed. Does the Minister recognise that these departments are working incredibly hard? Although people are waiting longer, by and large they are managing to protect outcomes for individuals who are severely ill and who are seen.
Earl Howe
I am grateful to the noble Baroness. It is worth observing that while the standard is that 95% of people arriving at A&E should be seen and treated within four hours, that standard has not been met in recent weeks. Nevertheless, on average, hospitals are seeing and treating around 90% of patients. The department is working closely with the College of Emergency Medicine. Indeed, I have the college’s paper in front of me. I am well aware of the issues that it has identified, but it is worth noting that the college says that the latest figures show that in England hospitals and their staff have coped extraordinarily well.
Baroness McIntosh of Hudnall (Lab)
My Lords, can the Minister confirm that staffing, particularly of emergency medicine doctors, is acute in the sense that probably enough are being recruited but not enough are being retained in emergency medicine and that there is a significant loss of those qualified practitioners overseas? What is being done to address that?
Earl Howe
I recognise that issue. Having said that, we currently have a record number of A&E doctors in the NHS, which is good, and across the system we have 1,800 more doctors and 4,700 more hospital nurses than we had a year ago. However, being an A&E doctor is a stressful occupation, and doctors are sometimes tempted to go overseas. We are concerned about the loss of any A&E doctor, and that is being looked at in conjunction with the royal colleges and the BMA.
Baroness Knight of Collingtree (Con)
My Lords, there can be no doubt that the figures which we have been given by the Minister need to be looked at very carefully. It would be a miracle if this enormous demand could be faced with no financial troubles at all. However, does he recognise that there is quite a bone of contention, and that the argument is building up that those who bear the heat and the burden of the day working in A&E departments seem to get a fairly small salary compared to the enormous sums that are paid out to managers within the health service? I do not know whether it would be possible to rein that back a little, but if that is the case, it seems very unfair.
Earl Howe
I am grateful to my noble friend. Of course, rates of pay are a sensitive matter, and it is true that the constraints on pay rises over recent years have had an effect on the attractiveness of particular careers in the health service. We can do little about that in the short term, but there are ways and means of improving the work-life balance and working lives of those who work in the health service, even if we cannot increase their pay at the current time.
NHS: Medical Competence and Skill
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, in thanking the noble Lord, Lord Parekh, for bringing this topic to the House and for his very constructive and thoughtful speech, I would like to begin on the subject of medical education.
I am sure all noble Lords will agree that medical education in this country is of the highest quality. Indeed, our medical schools rank in the top 10 in the world. But it is not just formal education at university that contributes to maintaining and improving the skill of clinicians in the NHS, as the noble Lord, Lord Turnberg, reminded us. High-quality postgraduate education, continuing professional development, appropriate regulation, the development and dissemination of best practice, the uptake of innovation, and, as the noble Lord, Lord Parekh, emphasised, transparency in the performance of clinicians all contribute to delivering high-quality patient care.
With regard to regulation, the General Medical Council—GMC—is required to evaluate the fitness to practise of all doctors holding a licence to practise medicine in the UK. Medical revalidation, which was raised by the noble Lord, Lord Hunt, commenced on 3 December 2012 and is the process by which the GMC will make an evaluation to renew a doctor’s licence. Doctors are required to revalidate every five years by participation in local schemes of appraisals which are based on the GMC’s core guidance for the medical profession, Good Medical Practice. Areas of concern will be discussed at appraisal and plans agreed to undertake further development to tackle those concerns. These remedial activities are overseen by a senior doctor to ensure an effective outcome.
Revalidation provides the reassurance that all doctors, including locums and doctors in private practice, are engaged in a process of structured appraisal and professional development that will provide the framework for continuously improving the quality of their practice. Medical revalidation will help doctors keep up to the standard expected of them by ensuring that they stay up to date with the latest techniques, technologies and research. The regular feedback from patients and colleagues will highlight areas for improvement and help a doctor to tackle any concerns about important skills such as bedside manner and maintaining trust with patients. Where concerns about doctors are more serious or attempts to tackle them are not successful, as the noble Lord, Lord Turnberg, alluded to, a doctor may be referred to the GMC fitness-to-practise process, where a full investigation will be made that may result in sanctions or removal from the medical register.
I was very struck by the phrase used by the noble Countess, Lady Mar, about the notice that she saw: “One complaint at a time”. In this context, the noble Lord, Lord Hunt, mentioned the Shape of Training report. One of the key themes of Professor Sir David Greenaway’s report was the balance between specialists and generalists in the medical workforce. I can say at this point that the four UK Health Ministers will consider the draft policy proposals early this year.
The noble Lord, Lord Turnberg, mentioned doctors from the EEA. We welcome the agreement to modernise the professional qualifications directive. The revised directive will now make it easier for professionals to work anywhere in the EU but we have pushed hard for more transparency in regulated professions across member states to ease the requirements on skilled professionals finding jobs in the EU. We also have a duty to play our part as a department in the furthering of the UK’s wider aims in Europe, such as freedom of movement. To that end, we are also keen to ensure that highly skilled professionals do not face unnecessary or disproportionate barriers when moving to the UK.
My noble friend Lord Bridgeman focused on language skills, which, as he said, are also a key part of ensuring that doctors in the NHS are able to care properly for and communicate with patients. That is why we made changes to the Medical Act in 2014 which allow the GMC to refuse a licence to practise in circumstances where a medical practitioner from within the EU is unable to demonstrate the necessary knowledge of English. Furthermore, an additional fitness-to-practise category of impairment was created relating to language competence. These powers help to ensure patient safety and strengthen the GMC’s ability to take fitness-to-practise action where concerns are identified. Doctors from outside the EU are already subject to systematic language checks prior to registration with the GMC. These powers ensure that only doctors with the necessary language competence are given a licence to practise in the UK.
My noble friend referred to other healthcare professionals. As he mentioned, the department has consulted on proposals to give powers to the Nursing and Midwifery Council, the General Pharmaceutical Council, the Pharmaceutical Society of Northern Ireland and the General Dental Council to carry out proportionate language controls for EEA applicants similar to those given to the GMC. The consultation ended on 15 December 2014 and a government response will be published shortly.
The content and standard of formal medical education and training are the responsibility of the GMC, which has the general function of promoting high standards of education and ensuring that medical students and newly qualified doctors are equipped with the knowledge, skills and attitudes essential for professional practice. Medical schools also play a key role in medical education and training. They design curricula for undergraduate medical education, including the type of placements students may undertake during the course. The royal colleges also play a vital role in postgraduate specialty training. They develop postgraduate curricula, provide advice to postgraduate deaneries on the quality management of training as part of the GMC’s quality framework, and provide continuing professional development opportunities for their members.
The department set up Health Education England to deliver a better health and healthcare workforce for England. HEE does this in a number of ways: by commissioning training places to ensure delivery of the right number of medical staff for the future; working to influence the royal colleges and other professional bodies responsible for developing and approving formal training curricula to ensure they are appropriate; and ensuring professional and personal development does not end when formal training stops.
The creation of HEE and its local education and training boards has given employers a stronger voice in workforce planning so that the education and training HEE commissions better reflect their needs and, therefore, the care they deliver to patients. The noble Countess, Lady Mar, will be interested to know that in 2014 we asked HEE, through its mandate, to work with the professional bodies and regulators to seek to include specific training in curricula where needed. Examples of this training include perinatal mental health training to support the health and well-being of women and their children during pregnancy and following the birth; compulsory work-based training modules in child health in GP training; care of young people with long-term conditions; and dementia education across a number of specialty areas.
We also asked HEE to provide leadership and to work with the local education and training boards and healthcare providers to ensure that professional and personal development continues beyond the end of formal training. For example, HEE will work with other organisations to develop a bespoke training programme to allow GPs to develop a special interest in the care of young people with long-term conditions by September 2015.
Clear outcomes and guidance also provide a focus for action and improvement for clinicians. Since 2010, the Department of Health has published outcomes frameworks for public health, adult social care and the NHS, which include the main outcomes that represent the issues across health and care that matter most. Combined with this, quality standards produced by the National Institute for Health and Care Excellence provide a clear description of what high-quality health and social care services look like, so that organisations can improve quality and achieve excellence.
As my noble friend Lord Selsdon rightly said, and as the noble Lord, Lord Hunt, also pointed out, innovation within the NHS is also an important driver of improving the skills and knowledge of staff. We are working with key stakeholders to remove barriers and put in place incentives to accelerate the adoption of innovation at all levels in this complex system. In 2013, England became the first country in the world to implement a universal system of academic health science networks which act as system integrators to link all parts of the healthcare landscape with industry and academia. Through this network, innovations and best practice can be spread and disseminated.
The noble Lord, Lord Hunt, referred to the use of technology in particular. The development of supportive tools for clinicians is an example of how innovation can be used to deliver improved patient care. The noble Lord mentioned others and I will get back to him on the specific examples that he gave if I can get further information on them. Macmillan Cancer Support, which is part-funded by the Department of Health, has developed an electronic cancer decision tool which is currently installed in over 1,000 GP practices across the UK, with plans to make it available to all GPs as part of their standard software. In answer to the noble Lord, Lord Parekh, we recognise the hard work and the vital job that GPs do, and we are doing our best to free them from excessive box-ticking so they have more time to devote to patient care.
Finally, to address one particular point made by the noble Lord, Lord Parekh, the Government’s commitment to transparency has seen, among other things, consultant-level outcomes data published for 11 specialties on the My NHS website. It has also seen the Care Quality Commission publish the findings from its first comprehensive inspection of NHS GP out-of-hours services. More generally, transparency in public services and access to open data are key government policies, and I would be happy to expand on that in writing to the noble Lord.
The Government’s response to Robert Francis’s public inquiry into Mid Staffordshire NHS Foundation Trust also set out our commitment to creating a culture of openness, candour, learning and accountability in an NHS which puts compassion at its heart. As noble Lords can see, the Government are undertaking a great many things to ensure that the medical competence of staff in the NHS is not only maintained, but is improved where needed.
NHS: Dermatology Services
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Lord Kennedy of Southwark
To ask Her Majesty’s Government what action they are taking to improve dermatology services in the National Health Service.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we want all patients with dermatological conditions to have access to high-quality, patient-centred services wherever they live. NHS England has set national standards to ensure that the needs of patients with the rarest skin conditions are met, the National Institute for Health and Care Excellence has published clinical guidance and quality standards to drive improvement for common conditions, and we are currently investing more than £9 million in dermatology research.
Lord Kennedy of Southwark (Lab)
My Lords, does the noble Earl believe that we have the balance right between the training that doctors and other healthcare professionals receive and the people they have to deal with, who have conditions ranging from minor skin complaints to serious skin cancers? If we do not have the balance right, what appropriate changes have to be made to make sure that patients are provided with the best possible care?
Earl Howe
My Lords, the Government have mandated Health Education England to provide national leadership on education, training and workforce development. Dermatology is currently a key part of the generalist undergraduate medical curriculum and a component of GP training. The General Medical Council requires that the undergraduate medical curriculum should provide enough structured clinical placements to enable students to demonstrate the outcomes for graduates across a range of clinical specialties, including dermatology.
Baroness Gardner of Parkes (Con)
My Lords, with my typical Australian fair skin and the strong sunlight there, I had a skin cancer some years ago. I have to go back and be checked and I consider that I am being looked after very well. However, the one thing that the consultant always says when he sees me on this annual basis is that there is a lot of unhappiness about the research money. When people apply for research funding, it tends not to go to those who are actually doing the work, but to someone who carries the name of being the research officer in the department. The money is spent on administration rather than on actual research. Can my noble friend tell me whether that has improved since I last raised this point, which must be about two years ago?
Earl Howe
My Lords, the National Institute for Health Research’s clinical research network is currently recruiting patients to more than 60 studies in dermatology. Specifically, it funds a wide range of research on skin cancer. It has awarded £1 million for research on GP and patient interventions to improve early diagnosis of malignant melanoma in primary care. Another NIHR award is on understanding the experiences and support needs of patients with melanoma and their carers, and patients are being recruited to 18 melanoma studies. I will take away my noble friend’s point about administrative costs but clearly any research project carries such costs, which must be covered somehow. Unless the balance is wholly wrong, I do not think we should be worried that some funding goes towards administration.
Lord Walton of Detchant
My Lords, it is a truism in medicine that one of the greatest stimuli towards the recruitment of doctors into a particular specialty is the example that they respect from their teachers. Many years ago when I was dean of medicine in Newcastle, the standard of dermatological services in the area was relatively poor. The appointment of a new professor who had a stimulating effect on teaching and recruitment made an immense difference. What are the Government doing to encourage Universities UK to recruit new professors in dermatology?
Earl Howe
My Lords, I will have to write to the noble Lord on that issue. I know that there is not an issue in relation to the number of dermatologists serving in the health service. We believe that number to be satisfactory. But as regards the emergence of leaders in the sense that he has described, I shall have to take advice and let him know.
Baroness Barker (LD)
My Lords, NHS England has set the objective of all patients receiving a timely and accurate diagnosis within three months of referral. Is that objective being met?
Lord Bradley (Lab)
My Lords, I am sure the Minister is aware that the psychological and social impact of skin disease, such as psoriasis, can be devastating. But is he aware of the 2011 survey by Dr Anthony Bewley, which found that of 127 hospitals across the UK only one had a dedicated dermatology psychiatric clinic, only seven had a psychodermatology service, and only one had a children and adolescent psychodermatology service? What action will the Government take significantly to improve psychodermatology services across the country?
Earl Howe
I was not aware of that survey but the noble Lord’s point is well made. Guidance for the management of both common and complex skin conditions set out by NICE and NHS England makes it very clear that access to psychological services for patients should be considered where appropriate. Through the IAPT—Improving Access to Psychological Therapies —programme, NHS England is looking at how best to support people with psychological problems arising from their physical problems, including, very significantly, skin conditions.
Alcohol-related Disease
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what action they are taking to address the increase in alcohol-related disease.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we have set out the Government’s approach to reducing the incidence of alcohol-related disease in the Government’s alcohol strategy. Our ambition is to radically reshape the approach to alcohol and reduce the number of people drinking to excess. We are seeing encouraging signs of change, with the first significant fall for some years in alcohol-related deaths in England in 2012.
Lord Hunt of Kings Heath (Lab)
My Lords, I am sure the whole House would wish me to congratulate the noble Earl on being nominated by Health Service Journal as the 29th most powerful person in the National Health Service.
Lord Hunt of Kings Heath
Coming in at 95, I look on with admiration, but from some way behind. Did the noble Earl notice that a Mr Lynton Crosby came 50th in that list? Does he think that that reflects the rather close relationship between the Conservative Party and the drinks industry—and does that explain the outrageous delay in the publication of the Chief Medical Officer’s review of what safe levels of drinking should be?
Earl Howe
My Lords, I am sure the noble Lord would not expect me to agree with him on the position of Mr Crosby in relation to the drinks industry. We feel it right to engage with the industry because it is in a position of influence over consumers, and we have seen, through the responsibility deals, some real progress, which it has instigated at our prompting. I recognise the issue that the noble Lord raises on price. That, of course, is only one aspect of the issue of alcohol consumption and its prevention.
Lord Kakkar (CB)
My Lords, I declare my interest as professor of surgery at University College London. A recent Lancet commission on liver disease in the UK has identified alcoholic liver disease as an increasing cause of mortality in our country. What measures do Her Majesty’s Government propose to take to improve both expertise and facilities for the early detection and treatment of liver disease in primary care?
Earl Howe
My Lords, increasingly, GPs are being made aware of the need to upskill in this area. Of course, it is not just GPs but local authorities who have responsibilities in the arena of public health to make sure that excessive drinking is discouraged. I can write to the noble Lord with the precise details of the GP training that I am aware of.
Lord Ribeiro (Con)
My Lords, does my noble friend agree with Professor Roger Williams, author of the Lancet commission report on liver disease, that with more than 1 million admissions per year due to alcohol-related conditions, and the developing tsunami of obesity cases, many of whom will present with non-alcoholic fatty liver disease, services will be seriously stretched in the future? What efforts are going to be made to try to stem this tide?
Earl Howe
My noble friend is right. I am afraid that the figures for hospital admissions over the past 12 years make gloomy reading. Admissions relating to alcohol-related illness have more than doubled. We welcome the recent falls in alcohol consumption that we are witnessing, and the falls in alcohol-related deaths, but we should not be complacent—and we are not. Harms such as liver disease, as well as social impacts such as crime and domestic violence linked to alcohol, remain much too high, and Public Health England is giving priority to alcohol issues from this year, particularly through support to local authorities.
Lord Patel of Bradford (Lab)
My Lords, on the point the noble Earl made earlier about Public Health England and dissemination of funds to local authorities, he will remember that that before Public Health England was set up, £800 million that was ring-fenced for drug use and drug treatment was given to the new body to disseminate to local authorities. Can he say how much of that funding is now diverted from the essential treatment that drug users need to people misusing alcohol, thus probably raising drug-related deaths, acquisitive crime and drug use generally across the country?
Earl Howe
The noble Lord was kind enough to give me prior notice of that question just before we came in. I have taken advice on it, and the advice I have received is that there is no wholesale evidence of a shift of funding from drug treatment to alcohol treatment. There may be the odd example of that, but I can tell the noble Lord that Public Health England is monitoring this issue in local areas, to make sure that that shift does not take place in a disproportionate way in relation to the need in those areas.
Lord Avebury (LD)
My Lords, the BMA states that the misuse of alcohol is costing the UK £25 billion a year and imposing immense burdens on our overloaded health and criminal justice systems. Is not the answer to increase alcohol duty, starting with the alcohol duty escalator, which was withdrawn by the Chancellor, forfeiting £1 billion in revenue over the next five years, thereby also making it more difficult for us to meet our fiscal commitments? Increases in alcohol duties are the answer, as everybody who has studied the matter agrees.
Earl Howe
My Lords, we have acted on alcohol pricing. We have to look at this in the round and in relation to what is happening. Alcohol consumption per head has fallen in recent years. Reduced affordability of alcohol—influenced, I may say, by tax rises above the RPI each year to 2013—has certainly been one factor in that, we believe. We are committed to reducing alcohol-related harm. We have already banned alcohol sales below the level of duty plus VAT, meaning that it will no longer be legal to sell a can of ordinary lager for less than about 40p.
Lord Brooke of Alverthorpe (Lab)
My Lords, I declare an interest as a patron of the British Liver Trust, which was associated with the Lancet commission report. I am sure that the Minister will agree that deaths from liver damage related to alcohol are increasing, not decreasing. Although the Government have made changes to pricing, why is Public Health England stating that there needs to be significant movement on pricing and easy access to alcohol before there will be any effect not just on deaths but the wider problems that arise from alcohol harm?
Earl Howe
My Lords, I take it that the noble Lord is referring to minimum unit pricing, among other things. The long-term trend in alcohol-related deaths is indeed upwards, although there has been a dip over the past four years. Minimum unit pricing is a policy that is still under consideration. It has only ever been one part of the Government’s alcohol strategy, which includes a range of national and local actions, including partnership with industry, as I said, and increased powers for local communities to tackle harm. There are various ways in which we can address the problem, which the noble Lord rightly highlights.
Abortion (Sex-Selection) Bill
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Baroness Knight of Collingtree
To ask Her Majesty’s Government what action they intend to take following the First Reading of the Abortion (Sex-Selection) Bill in the House of Commons on 4 November.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, abortion is traditionally an area where there is a free vote on Private Members’ Bills. We have made it clear on numerous occasions that abortion on the grounds of gender alone is illegal. We take this issue very seriously and will continue to monitor birth ratios and consider any evidence that comes to light.
Baroness Knight of Collingtree (Con)
My Lords, did my noble friend note that at the end of the First Reading debate on the Bill 181 MPs voted for it and only one voted against it and the tellers counting the vote against insisted that their votes be counted in favour of the Bill? Does he consider that this indicates acceptance of the evidence that abortion for gender reasons is going on and is causing very grave concern? Even a Minister saying in this House that this is illegal does not make it so: only a parliamentary Bill can do that. If gender equality means anything at all, surely the protection of the lives of baby girls is a matter of urgency.
Earl Howe
My Lords, the legal position is not in doubt. It is illegal to abort a foetus based solely on its gender. The Abortion Act states that two practitioners have to be,
“of the opinion formed in good faith”,
that the woman had grounds for an abortion. It is for doctors, in line with any guidance from their professional bodies, to satisfy themselves that they are in a position to give the opinion and to defend it if challenged. We refreshed the guidance in May of this year to make the position crystal clear.
Baroness Thornton (Lab)
My Lords, anyone who seeks an abortion on the basis of wrong gender is perpetuating a practice that is not only morally repugnant but illegal, as the noble Earl said. Sex-selection abortion is banned in the UK under the Abortion Act 1967. Does the noble Earl agree that because this practice happens in certain places in the world it may be taking place illegally in those communities in the UK? What are Her Majesty’s Government doing to identify whether this is the case?
Earl Howe
My Lords, our latest analysis of data by country of birth and ethnicity, which we have done for a second year running, found no evidence of sex selection taking place in the UK. Without exception, the wide variation in birth ratios was within the bounds expected. Any termination wilfully failing to meet the requirements of the Abortion Act will render those performing such procedures liable to prosecution under other legislation.
The Lord Bishop of St Albans
My Lords, given that many are concerned that we may not be protecting the most vulnerable in our society in this area, we need to understand the full extent of sex-selection abortion in this country, if indeed it is taking place. We need to collect and collate data. In the light of that, will the Minister tell the House what Her Majesty’s Government are doing to require the registration of the gender of foetuses using forms such as HSA4 or something similar so that we can actually have the evidence?
Lord Steel of Aikwood (LD)
Does the Minister agree that sex-selection abortion is not just illegal, as he says, but totally abhorrent? Does he further agree that, as the BMA has said that in some rare medical cases it may be necessary, it is really up to his department to issue clearer guidance as the Bill to which my noble friend referred is a 10-minute rule Bill that is not going anywhere? It is up to the department to issue guidance on this matter.
Earl Howe
My Lords, we issued guidance in May of this year. It sets out the expectations around the procedure to be adopted by the two doctors involved: certifying that an abortion meets the criteria set out in the Act by considering the individual circumstances of the woman and how they reached their decision. The guidance also reaffirms our position that abortion on the grounds of gender alone is illegal.
Lord Alton of Liverpool (CB)
My Lords, is the noble Earl aware that in China there have been 34 million abortions on the grounds of the one-child policy and that that has led to a distortion in the population of 34 million more males than females? Similar policies in India using ultrasound scanning tests have also led to the targeting of little girls. Given that some of these policies have been financed directly or indirectly through development funds from our own Department for International Development, will the noble Earl undertake to speak to his colleagues in that department to ensure that no British taxpayers’ money is used for these purposes?
Baroness Scotland of Asthal (Lab)
My Lords, is not one of the difficulties being faced by the practitioner the fact that the guidance talks about “alone”, whereas we know that the psychological issues which arise among women who are put under pressure to have only boys may count towards the rationale that produces the abortion? What, if anything, do the Government intend to do to address this issue?
Earl Howe
My Lords, coercion and violence is of course an issue that is taken very seriously. Every woman who is being seen for a possible abortion has the opportunity to speak to a healthcare professional on her own. Those healthcare professionals are trained to be alert to the signs of coercion and violence and will take appropriate action.
Lord Anderson of Swansea (Lab)
My Lords, it is clearly counterintuitive to say that there is no linkage of the practice to certain ethnic communities. As the practice is clearly illegal, can the noble Earl tell us how many prosecutions there have been, how many of them were successful, and whether he believes that any sanctions are sufficient?
Earl Howe
My Lords, to my knowledge there have not been any successful prosecutions in this area, but the decision by the Crown Prosecution Service not to prosecute two doctors involved in recent allegations led to the call for my department to reissue the guidance on this matter, which, as I have said, we did earlier this year.
NHS: Medical Staff
Earl Howe Excerpts(10 years, 2 months ago)
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Lord Fowler
To ask Her Majesty’s Government how many medical staff working in the National Health Service today, including doctors and nurses, were trained in Africa.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, in 2013, the latest year for which figures are available, there were 6,472 doctors working in the NHS—that is 4.4%—who gained their primary medical qualification in Africa and 13,969 nurses on the Nursing and Midwifery Council’s register who trained in Africa. In that same year, 12,203 professional clinically qualified staff working in the NHS—that is 1.8%—held nationality with an African country.
Lord Fowler (Con)
My Lords, I pay tribute to the job that these people do for the National Health Service, but is not the lesson of the Ebola crisis that many of the health services in Africa are seriously underresourced? Can it be justified that not only Britain but other countries in Europe and the Middle East are taking much needed doctors and nurses away from Africa? Could we look at our own training policies to see how that position can be improved?
Earl Howe
My noble friend makes a very important point. As he will know, the UK signed the World Health Organization code of practice on the international recruitment of health personnel. My department worked together with the Department for International Development to produce a definitive list of developing countries—based on economic status and the availability of healthcare professionals—that should not be targeted for recruitment. He may like to know that the WHO is planning an assessment of the implementation of that code of practice and is due to report in 2016. However, we are mindful of the point made by my noble friend. Particularly with the Ebola crisis, it is important that we are sensitive to the serious issues that pertain in Sierra Leone in particular.
Lord Hunt of Kings Heath (Lab)
My Lords, given that, and given the Health Select Committee’s recommendation that although the contribution of overseas staff to the NHS should be celebrated, we should not be dependent on significant flows of trained staff from overseas, does the noble Earl still agree with the decision in 2012 to reduce the number of medical school training places by 2%? Does that not need reviewing?
Earl Howe
My Lords, as the noble Lord is aware, we rely on Health Education England to determine the number of training places that the NHS needs going forward, looking at not just the short term but also the medium to long term, informed by the work of the local education and training boards. That is as good a system as we believe we can get. Health Education England is properly funded to do that and we must rely on its expertise.
Lord Crisp (CB)
My Lords, I understand that the NHS in recent years has made it harder to employ people coming from poorer countries in Africa and elsewhere to work here. However the NHS, as the Minister has already stated, has a large number of people working within it from those backgrounds. I have two questions. First, what are the Government doing to aid countries to train more people in their own countries? Secondly, what are the latest figures for the international medical graduate scheme for people coming from Africa training in this country?
Lord Crisp
I hope I can remember it. It was very simply: what are we doing from the UK to support the training of people in their own countries, where they will often stay longer than if they come and train here?
Earl Howe
I beg your pardon, my Lords. DfID has a number of programmes designed to support the health economies of developing countries. They have been in place for many years. They can take the form of training, not just of doctors but of all healthcare professionals. I am aware that DfID is extremely supportive of those programmes.
Baroness Brinton (LD)
My Lords, 10 years ago there were more Malawian doctors working in England than there were in Malawi and the Royal College of Surgeons, working with CBM UK, a disability charity, set up the College of Surgeons of East, Central and Southern Africa. In that time the number of African-trained surgeons has substantially increased through this joint practice. Are other royal colleges following their example in setting up similar projects?
Earl Howe
I am not aware of the answer to that question but I can tell my noble friend that the UK has been moving towards self-sufficiency for a number of years. For example, there was a 27% decrease in the number of registrations of non-European Economic Area nurses from April 2010 to March 2014, continuing a longer-term trend. The number of doctors in the NHS with a primary medical qualification from outside the EEA has remained relatively static over the last four years despite the full-time equivalent number of doctors increasing by more than 5% over the same period. I think we can take heart from those figures, mindful, of course, of the need to adhere to the World Health Organization code of practice.
Baroness Wall of New Barnet (Lab)
My Lords, I am sure the whole House will join in the sentiments expressed by the noble Lord, Lord Fowler, about the tremendous work that these nurses and doctors do in our NHS. I declare an interest as chairman of Milton Keynes Hospital NHS Foundation Trust. As I am sure the noble Earl is aware, many of the hospitals now are encouraging some of the African nurses to go back and have an opportunity to train the skilled and unskilled nurses who are already in their own countries. Despite the fact that things are obviously very challenging for us here, it is very important that they are able to do that.
Earl Howe
I agree with the noble Baroness. It is important to underline that the medical training initiative, which is the means by which we can present an offer to foreign doctors—that is, postgraduate medical specialists—to come to train here, is a fixed-term arrangement for up to two years. It seeks to promote circular migration so that participants in a scheme can return to their home country and apply the skills and knowledge developed during their time in the UK. That is very valuable for those individuals and those countries.
Baroness Chisholm of Owlpen (Con)
My Lords, during my career as a nurse, I had the privilege of working with nurses from all over the world, including the African continent. They showed enormous compassion and dedication to their work. Does my noble friend feel that it is important that, when these nurses come to England, they are given all the support and training possible so that they reach the high standards that our nurses reach in their training here?
Earl Howe
My Lords, I do. My noble friend will be aware that the Nursing and Midwifery Council has established standards which ensure that the quality of the nurses whom we get from overseas is absolutely up to that of home-trained nurses. Support for those nurses while they are in this country is of course an essential ingredient if we are to keep them here for a reasonable length of time.
Health: Lesbian, Bisexual and Trans Women
Earl Howe Excerpts(10 years, 2 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by thanking my noble friend very warmly for securing a debate—the first one, in my experience—on the important issue of the health of lesbians, bisexual and trans women. These are women who may face discrimination by the NHS because of prejudice or, as we have heard, a lack of understanding about the particular health needs that they may have.
The noble Lord, Lord Cashman, spoke eloquently about the duties and principles of a civilised society in relation to minority groups of people such as these. The NHS constitution is our way of enshrining those principles in relation to the National Health Service. It commits the NHS to providing a comprehensive service available to all, irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity, or marital or civil partnership status. The service is designed to diagnose, treat and improve both physical and mental health. It has a duty to each and every individual whom it serves and it must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.
However, despite this we recognise that discrimination still takes place. In my comments, I will highlight some of the work that we are taking forward to combat such discrimination. The Department of Health is funding a number of organisations to help tackle some of the challenges that lesbians, bisexual and trans women face when seeking to access health services. First, the department has awarded Stonewall £235,000 over three years for its Health Champions programme. This supports 20 NHS organisations a year to improve their knowledge and awareness of the health needs of lesbian, gay and bisexual people—if noble Lords do not mind, I will use the acronym LGB—and helps them to deliver a more personalised health and care service.
Secondly, the department is funding the Lesbian & Gay Foundation to carry out two projects over three-year periods. The first, with a grant of up to £140,000, focuses on the recruitment, training and empowerment of LGB community leaders, enabling them to engage with NHS structures. The second project, with a further £108,000, is its Pride in Practice project, which aims to increase LGB people’s access to appropriate healthcare.
Thirdly, the department is funding the National LGB&T Partnership with a grant of £186,000 this year. The partnership is made up of a number of organisations, and this funding enables them to work with Public Health England to ensure that LGBT people’s needs are included in their business plan priorities; with the Department of Health to produce an LGBT companion to the adult social care outcomes framework; and with NHS England on the future of gender identity services for adults.
The noble Lord, Lord Cashman, and the noble Baroness, Lady Gould, expressed concern about the classification of trans people. It is universally accepted that gender nonconformity is not a mental disorder. However, specialist services in this country are commissioned from mental health trusts, and input from psychologists and psychiatrists, among others, is essential to offer advice and assessment for people affected by concerns regarding their gender identity. Some patients will not require or wish to receive any hormonal, physical or surgical treatment, but improvement in the patient’s self-perceived psychological and emotional well-being is a key goal of treatment for all patients. I will be happy to write to noble Lords expanding on that.
I turn to my noble friend’s concerns, in particular about lesbian and bisexual women. She spoke of insensitivity by general practitioners towards lesbian and bisexual people. I am sorry to say that the experiences she recounted resonate with some of the briefing that I have received. In September this year, a study funded by the Department of Health saw experts examine data from over 2 million responses to the general practice survey of 2009-10, including 27,000 responses from people who identified themselves as gay, lesbian or bisexual. It found that lesbian, gay or bisexual people were up to 50% more likely than heterosexuals to report negative experiences with the GP services that they received. Admittedly, the figure was 1.7% of lesbian, gay and bisexual people who reported their overall experience with their GP as very poor, compared with 1.1% of heterosexual people: nevertheless, that is a statistically significant difference. All patients deserve high-quality care from their GP regardless of their sexual orientation. Patients expect their GP to offer the best care, so if ever there were an example of how important it is for GPs to use the results of the GP Patient Survey to improve the services that they offer, surely this is it.
With regard to training and asking the appropriate questions, which is clearly part of all this, we have asked Health Education England to ensure that the recruitment, education, training and development of the healthcare workforce generally results in patients, carers and the public reporting a positive experience of healthcare, consistent with the values and behaviours identified in the NHS constitution. The quality of care is as important as the quality of treatment. We also asked Health Education England to ensure that there is an increased focus on delivering safe, dignified and compassionate care in the education and training of healthcare professionals.
In response to my noble friend’s point about mental health, Public Health England recognises the increased risk of suicide and self-harm among lesbian, bisexual and trans women. As part of its response, it is developing a professional toolkit for nurses with the Royal College of Nursing on youth suicide prevention among lesbian, gay, bisexual and trans youth in order to ensure that young people get better support.
My noble friend asked about the possibility of a strategy and what we were doing to monitor data. Public Health England recognises the health inequalities affecting all three groups of women. Many of these issues were clearly set out in the lesbian, gay and bisexual and trans companion document to the public health outcomes framework, published last year by the National LGB&T Partnership. I do not have time to read out some of the key points from that, but it is worth studying because it presents a very good way forward.
Improving the quality of the data is an important aspect of this. Public Health England recognises the challenges involved in understanding at a population level the health of these women because of the lack of routine data collection. It and NHS England are working together with the National LGB&T Partnership to integrate sexual orientation monitoring alongside other demographic data collection across the NHS.
The noble Baroness, Lady Gould, spoke very powerfully, as she always does, about the position of trans people and, in particular, about waiting times. NHS England acknowledges that there are some system delays at both gender identity clinic level and surgery level. It has set up, as she mentioned, a task and finish group to look at the issue of delays and has engaged with the three surgical providers to discuss options. It is under no illusions about this. I am well aware that Healthwatch England has made its opinions very clear to NHS England, and I pay tribute to it for that.
In general in this area, NHS England has created a gender identity clinical reference group which has developed a new service specification and clinical commissioning policy. It has also established a transgender network designed to hear the views of people and to influence the strategic direction of services. It is organised and facilitated by the NHS England patient and public voice team.
The noble Baroness also mentioned the workforce. NHS England has confirmed that the number of surgeons contracted to provide feminising gender reassignment surgery is currently 1.5 whole-time equivalent. It hopes there will be an additional 0.8 whole-time equivalent available by the autumn of next year. Two surgeons are currently training to perform gender reassignment surgery and are employed by the NHS. There is another one whole-time equivalent capacity available, but this is not currently contracted by NHS England. Clearly, surgery of this kind is highly specialised. It takes at least six months’ additional training to learn these particular techniques, and trainees would normally be established consultants in neurology, gynaecology or plastic surgery.
As regards hormonal treatment, oestrogens are not authorised, licensed or regulated for the use of trans women. Consequently, GPs may refuse to prescribe them. Specialist clinics make recommendations for the prescribing and monitoring of these therapies but do not directly prescribe them or provide physical or laboratory monitoring procedures for patients. It is true that there are no preparations of oestrogen licensed for the treatment of gender dysphoria. NHS England’s specialised services circular 1417 sets out arrangements for prescribing and monitoring medications.
GPs undoubtedly have an important role in the healthcare of people with atypical gender identity development, not only around the time of their transition to a social role and physical development congruent to their gender identity but for the rest of their lives when they no longer have a need for specialised gender identity services. If I can expand on those remarks, I would be happy to write to noble Lords.
The noble Lord, Lord Cashman, asked what actions had been delivered from the actions plans. The Department of Health has delivered on all its commitments in the trans and LGB action plans. The Government Equalities Office will shortly publish a report on all the work carried out by government in this area.
Responsibility for improving the health of the nation lies with Public Health England and NHS England and I am pleased to say that both organisations are working to improve the health of these groups of women. My noble friend mentioned cervical screening. Public Health England’s NHS cervical screening and breast screening programmes are offered to all women irrespective of their sexual orientation although Public Health England is working with the Lesbian & Gay Foundation to support screening for lesbian and bisexual women. This is especially necessary in respect of the cervical screening programme, which encourages lesbians to be screened despite the common misconception that this is not necessary.
Public Health England also recognises that there are health inequalities which are common across all three groups of women, such as the significantly increased risk of mental ill health, self-harm and suicide and also issues specific to gender identity, such as the ease of access to gender identity clinics. Many of these issues have been clearly set out in the companion to the public health outcomes framework published by the National LGB&T Partnership. The partnership is also developing healthy living guides for trans people which cover a wide range of topics including sexual health, mental health and well-being, physical activity and diet. Public Health England acknowledges the challenges involved in understanding, at a population level, the health needs of these women because of the lack of routine data collection, about which I have already spoken. Therefore they are working together with stakeholders to integrate sexual orientation monitoring alongside other demographic data collected across the NHS.
As part of its response to the increased risk of suicide and self-harm among these groups, Public Health England is developing a professional toolkit for nurses with the Royal College of Nursing on youth suicide prevention among LGBT youth to ensure they get better support. That builds on previous work by the department to support young people’s mental health. In addition, Public Health England has been working in partnership with the Royal College of General Practitioners to raise awareness of sexual orientation through a new e-learning resource.
I turn briefly to the work that NHS England has been taking forward in respect of gender reassignment. Since April 2013, NHS England commissioned gender identity services, as the noble Baroness mentioned, and soon after this it established a gender identity clinical reference group, which comprises clinical staff, patients, carers and representatives of professional bodies. In June last year the group embarked on the development of a new service specification and clinical commissioning policy. A transgender network has been established to support that work, and now has more than 100 members. The network is designed to hear the views of stakeholders and to influence the strategic direction of services, and is facilitated by the NHS England patient and public voice team. In recognition of the time required to develop the new service specification, an interim gender protocol was adopted in July 2013, based on the NHS Scotland gender reassignment protocol.
Finally, I know there are concerns in the trans community about waiting times for treatment—I have covered those in my earlier remarks. However, I emphasise that once within a gender identity clinic, patients should receive appointments with the team at an interval appropriate to their need. NHS England is aware of the situation and has set up a task and finish group specifically to address issues around delays. As I have indicated, any delays before gender reassignment surgery are related to capacity problems among surgery providers. I understand that around 455 patients are waiting for surgery, at various stages of clinical readiness. The positive thing is that in future, NHS England will be in a better position to monitor that, as it will hold the data centrally.
In summary, although the legal framework is in place to make discrimination on the grounds of gender, sexual orientation and gender reassignment unlawful, and despite the fact that equality is enshrined in the NHS constitution, we acknowledge that discrimination sometimes still takes place. What we need to do now, building on the legal framework, is to strive to change hearts and minds to eradicate prejudice. However, of course, that is not just a role for government; surely we all have a role to play in that endeavour. Each one of us needs to be honest about our own prejudices, and work to establish a more equal and fairer society for all.