Brexit: Counterfeit Medicines

Lord Clark of Windermere Excerpts

Thursday 7th February 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her Question. As stated in the response to the MHRA’s recent no-deal consultation, it is expected that stakeholders would no longer be able to comply with the requirement to verify and authenticate medicines, so legal obligations related to this would be removed. In this scenario, we have committed to evaluate options for a future falsified medicines regulatory framework, taking into account investment made by stakeholders. It is important to note that the majority of the FMD was already implemented in 2013, and also that the MHRA has 30 years of experience as a world-leading regulator of more than 3,500 medicines. We expect that patients will remain safe and that there will be continuity of supply so that we can have confidence in medicines and safety for patients.

[Lord Clark of Windermere (Lab)]

My Lords, I congratulate the noble Baroness on her appointment. As she knows, the European medicines verification system becomes effective this Saturday, I believe. Is she confident that we have sufficient personnel and procedures to implement it immediately? Will she also say whether, if the Commons were to approve the Prime Minister’s preferred agreement, this protection would be included?

[Baroness Blackwood of North Oxford]

I thank the noble Lord for his question. We are committed to meeting the 9 February deadline for the launch of FMD safety measures. We expect all stakeholders in the UK’s supply chain to be aiming to comply with the requirements. We know that much of the supply chain is already prepared, but it is a complex chain, setting up medicine supply across the EU. The main challenges concern error messages; several member states—including Denmark, Portugal, the Netherlands and Ireland—have noted, unrelated to Brexit, that there will be challenges in implementation. The MHRA has notified the supply chain that we will be taking a pragmatic approach to implementation. This is appropriate, to ensure patient safety and a continuation of dispensing.

NHS: Specialist Services in Remote Areas

Lord Clark of Windermere Excerpts

Tuesday 11th December 2018 Lords Chamber

[Lord O'Shaughnessy]

There are a number of schemes, as the noble Baroness points out. As well as the travel costs scheme, there is the low-income scheme. They are designed to help people with those kinds of costs. I do not have the specific numbers about take-up, but I shall certainly write to her with those.

[Lord Clark of Windermere (Lab)]

The Minister is correct to highlight the building of new hospitals, but these are no good if you cannot attract staff to them. Can he comment on the pilot scheme in west Cumbria which is training senior nurses to undertake the work of some junior doctors? How successful has that been, and how many students will take part in the second year of the course, which starts in January? What plans do the Government have to increase the number of staff right across the health service?

[Lord O'Shaughnessy]

I shall look at the scheme the noble Lord mentions and would be delighted to follow up with him directly on that. We need more staff; we have more NHS staff than we did in 2010, but nevertheless we need more GPs and nurses. Of course, we also need to diversify the workforce in new ways. One of the most exciting innovations in the workforce sphere recently is the creation of several thousand nursing associate posts to support nurses and doctors in a range of settings.

Domestic Abuse: General Practitioner Charges

Lord Clark of Windermere Excerpts

Thursday 15th November 2018 Lords Chamber

[Lord O’Shaughnessy]

I join the noble Baroness in condemning this type of crime, and it is disturbing that violence against older victims has risen. That is precisely the reason the Government have asked the Law Commission to look at the issue and bring forward suggestions on how to give the authorities greater powers to clamp down on those who perpetrate such crimes.

[Lord Clark of Windermere (Lab)]

My Lords, is the Minister concerned that the treatment of these abuse issues is under serious threat, given that many surgeries in the north of England no longer have a single permanent doctor?

[Lord O’Shaughnessy]

I do not think that it is an issue of staffing per se, because it is not only doctors but other healthcare professionals who are able to provide letters of this kind. The evidence that has been gathered through consultation and indeed through the progress of the secure tenancies Bill is that the charges for these letters act as a barrier. That is the issue we are trying to address.

NHS: Staff

Lord Clark of Windermere Excerpts

Tuesday 13th November 2018 Lords Chamber

Asked by

[Lord Clark of Windermere]

To ask Her Majesty's Government what plans they have to ensure that British citizens are recruited and trained to staff the National Health Service.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the Department of Health and Social Care is working with a range of partners to improve the recruitment and retention of staff required to deliver safe and effective NHS services. In England, we are increasing domestic doctor training places by 25%, there are now more than 52,000 nurses in training, and we have made more funding available to universities. Furthermore, we are increasing midwifery training places by 3,000 over the next four years.

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for his Answer, which is a little disappointing. I remind him that there are currently 100,000 vacancies in the National Health Service. There is a shortage of doctors, nurses, physiotherapists and radiographers, and I could go on. There is a shortage throughout the service, and it is no good the Government telling us what their aspirations are. In the light of the Chancellor’s Budget Statement, in which he concealed that there is to be a £1 billion cut for the NHS in the year beginning in 2019, will the Minister explain how the cut in funding for the training of nurses, doctors and other members of staff coincides with the aspirations he has told us about? And please, do not give any excuses whatever about the pension miscalculation.

[Lord O'Shaughnessy]

We agree that there is a need for more staff, and indeed there are more NHS staff than ever. I can tell the noble Lord that we are increasing doctor, nurse and midwife training places, and more GPs than ever started training in the NHS this year. With an ageing and growing population, we absolutely recognise the need for more doctors, nurses, midwives and many other professions. The Budget made no changes to health spending.

Health: Flu Vaccines

Lord Clark of Windermere Excerpts

Tuesday 23rd October 2018 Lords Chamber

[Lord O’Shaughnessy]

I take my noble friend’s point very seriously. It is worth stating that the reason for moving to this new vaccine is precisely because it is more effective. Unfortunately, the response rates for the vaccine that was used in the over-65s last year were not as high as hoped. Indeed, there were quite a number of admissions to intensive care units of that age group. That is the reason for moving to the vaccine, but because it is the first year it has been available, it has been necessary, because of global demand, to stagger the delivery, as I said. GPs and pharmacies were informed of this staggering of deliveries at the beginning of the year. I can tell my noble friend that 8.2 million doses have already been ordered for this age group, of which 4.9 million have already been delivered, against around 7.6 million used last year. So there is adequate supply, and it will be delivered to all GPs and pharmacies as necessary to meet the demand by the end of November, so that by the beginning of December anybody who wants that vaccination should be able to access it.

[Lord Clark of Windermere (Lab)]

My Lords, does the Minister appreciate that by delaying the availability of a vaccine for the over-65s, the Department of Health is increasing the risk of that group of people contracting flu? Can he explain to the House why it has taken the decision not to have it available until early December?

[Lord O’Shaughnessy]

I am very happy to tell the House: it was on the advice of the Joint Committee on Vaccination and Immunisation, which is precisely where we get expert advice on how to act. The reason for moving to this new vaccine is the one I set out. The reason that the delivery is staggered, but to be completed by the end of November, is because it is from December into January that we have the peak of influenza in this country. The Deputy Chief Medical Officer said:

“Based on many years of surveillance in the UK it is highly unusual for widespread community flu activity to become significant or substantial before the start of September”.


It is on that clinical advice that this decision has been taken.

NHS: Staffing

Lord Clark of Windermere Excerpts

Wednesday 10th October 2018 Lords Chamber

Asked by

[Lord Clark of Windermere]

To ask Her Majesty’s Government what plans they have to ensure that the National Health Service has sufficient staff following Brexit.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, my department is working with Health Education England, NHS England, the royal colleges and others to make sure that the NHS is able to recruit and retain the staff it needs. Furthermore, we are working with NHS and social care employers to make sure that the 167,000 EU nationals working in health and care can access the EU settlement scheme, which will safeguard their rights to live and work in the United Kingdom.

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for his Answer. Earlier this year he pleased the House by announcing that NHS staff who had worked in the NHS for more than five years would be allowed to remain in Britain under the settled case arrangements. Can he advise the House whether, following the Prime Minister’s statement on immigration at the Tory party conference, that remains the case?

[Lord O'Shaughnessy]

Yes, it is absolutely the case that anybody from the EU who is living and working in this country, not just in NHS and social care, before exit day—or December 2020, the end of the withdrawal period—will be able to apply for settled status. Indeed, if they have not lived here for five years, they will be able to apply for what is called pre-settlement status and then apply after five years.

NHS and Social Care Services: Parity of Esteem

Lord Clark of Windermere Excerpts

Thursday 5th July 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is right to point out that there are differences between the two workforces: clearly the NHS has a largely publicly employed workforce and social care has a largely privately employed one, so there will inevitably be some differences in form. We need to make sure that those workforces work together and are as attractive as one another, which is why finding a sustainable funding solution is so important so that those private contractors have the ability to pay what is necessary to attract the right staff.

[Lord Clark of Windermere (Lab)]

My Lords, the NHS proves that, with determined leadership, democracy can deliver long-lasting benefits to society. Will the Minister join me in paying tribute to those parliamentarians—in spite of them all being Labour—who, over 70 years ago, time and again traipsed through the Lobbies to bring about the National Health Service?

[Lord O'Shaughnessy]

Well, they say that success has many parents and we should pay tribute to the Liberal MP William Beveridge, the Conservative Health Minister Henry Willink, and the Labour Health Minister Nye Bevan in the founding of the NHS. It is important to point out that the Conservative Party has been in power for 43 of the NHS’s 70 years and it has thrived under our leadership.

Nursing and Midwifery (Amendment) Order 2018

Lord Clark of Windermere Excerpts

Monday 25th June 2018 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I support the Minister and the Motion to approve the Nursing and Midwifery (Amendment) Order 2018. I acknowledge the challenges that the noble Baroness, Lady Thornton, has raised, in particular those that the Royal College of Nursing is concerned about, but believe that they are capable of resolution. I believe that the registered nurses who stand today will ensure that substitution does not happen for the roles that they really must undertake themselves.

I qualified as a nurse in 1976, when we still had enrolled nurses. For some time, I led a team that included enrolled nurses, but I was very clear, both as a district nursing sister and as a ward sister, that I was accountable for the elements that I delegated. That did not mean that enrolled nurses were not able to undertake routine care by themselves unsupervised, but rather that they were very aware of how to get help when they needed it. I believe that, if we get the nursing associate role right, a similar structure will occur.

I applaud the fact that nursing associates will have a clear ladder—probably through the apprenticeship route, as the noble Lord has just raised—to enable those who want to and who are capable to get university-level associated registration as a nurse. I do, however, regret that we have not called this new role a “healthcare associate”, because I believe that some of the work they will do will be undertaken in social care as well as in routine nursing care. We may need to reflect on that in years to come.

I also want to make it clear that this route should enable people to come relatively young into an adjunct profession that is associated, without them necessarily having A-levels on entry. That is important, because we know that a lot of young people would like to go into nursing or associated healthcare roles but are not able at that point to enter a three-year degree course. This is why I am so supportive of the structure.

The order makes provision for the new role of nursing associate to be subject to professional regulation by the Nursing and Midwifery Council. As has been explained, the first cohort should qualify in January 2019 and it is important for this legislation to be approved in sufficient time for the Nursing and Midwifery Council to open the register and put in place safe and effective standards and requirements for new staff entering the workforce. By regulating the role, the Nursing and Midwifery Council will contribute to the protection of the public by ensuring that nursing associates have high standards of education, will be required to keep their skills and knowledge up to date, and will be held accountable to a code of conduct.

As others have said, this new role has been rapidly developed as the result of successful work between employers and educational providers, with leadership from the CNO for England, Professor Jane Cummings, and the lead nurse at Health Education England, Professor Lisa Bayliss-Pratt, both of whom should be commended for their tenacity and work to achieve this end despite reluctance in some areas of the profession.

To reiterate an issue recently raised by the noble Lord, Lord Willis, many overseas applicants will want their qualifications recognised in relation to the nursing associate qualification, particularly licensed vocational nurses from a variety of Commonwealth countries. I urge the Government to ensure that proper funding is made available to map similar qualifications across the world so that we can make sure that we protect our own public if we allow overseas registrants to apply for this kind of qualification. It may be that they will need some kind of top-up, depending on the final standards that are agreed for nursing associates here.

I am aware that there have been challenges at the NMC recently but I echo the point of the noble Lord, Lord Willis, and acknowledge the commitment of the Chief Executive and Registrar, Jackie Smith, which has ensured that nursing associates will be registered at the NMC in order not only to protect the public but to achieve a proper career route for nursing associates if they wish to proceed to study for registration as a nurse in the future. In the longer term, I hope the nursing associate route may provide a successful apprenticeship approach for some members of the public to become registered nurses, without necessarily having to enter graduate-level study at a time that is not suitable for all.

[Lord Clark of Windermere (Lab)]

My Lords, I too welcome the order; I am struck by the knowledge of the noble Lord, Lord Willis, obviously, and of the noble Baroness, Lady Watkins, from her own practical experience. It is right and proper that we have this debate because a number of questions ought to be raised. To be fair to the Government, they have not been able to answer all the questions beforehand because, as we all know, this order is somewhat rushed. I understand the reason why and I concur with it.

As the Minister mentioned, the order was laid on 17 May; that is absolutely right, but it was first laid on 11 May and had to be withdrawn because it was inaccurate. That is an example of how the legislation has been rushed. It is therefore important that we, as a legislature, challenge the Executive on a number of issues. As has been indicated—the Minister understands this—the Government have consulted widely to try to get the feeling that, if the report by the noble Lord, Lord Willis, was implemented, it would be done in a sensible and correct manner. However, there has been a problem in that a number of the consultees have a vested interest. For example, the local commissioning trusts have an interest about who is going to pay for this. Will the funding come from the centre or from them? I shall come back to that point in a moment. Obviously the providers—the universities—have an interest because they need the income from running these courses. But of course I now see, and this is slightly worrying, that it is not only higher education institutions which are involved—further education institutions are too. The noble Lord, Lord Willis, possibly referred to this point when he said that he was “slightly concerned”—I emphasise the word “slightly”—that there could be some downgrading of the teaching input.

However, one group has not really been represented in these consultations: the nurses themselves. People will refer immediately to the Royal College of Nursing and its equivalent for midwives. But the trouble is that that organisation, in terms of this area, also has a vested interest. It is a registration body for nurses, yet at the same time it is a member organisation and there can be a conflict of views which I have come across quite often. I have no problem with the RCN registering nurses because it is both right and sensible, but we must recognise that there is a potential difficulty. I have talked to a number of nurses who are concerned about nursing associates. However, they can be reassured by this order. As the noble Baroness, Lady Watkins, and the noble Lord, Lord Willis, have both said, nurses are professionals. Indeed, the noble Lord, Lord Willis, made a very wise point. The pivotal role of caring in hospitals ought to rest with registered nurses. That is where we ought to begin because they are professional people.

Even so, nurses are concerned that their views have not always been represented in this consultation. I am therefore pleased to note that paragraph 7.20 of the draft Explanatory Memorandum makes that clear. I shall repeat that because it is important that it is on the record and nurses can see what the position is. The Government say, quite rightly:

“Nursing Associates are identified as a separate profession with different qualifications and education and training to nurses and midwives”.


Nursing associates are not nurses. They are not fully qualified and registered so in that sense they do not represent a challenge to nurses. That point must be rung out aloud because we need to ensure that a profession which is under pressure and suffering from low morale is reassured.

Paragraph 7.9 provides even more reassurance when it makes it clear that nursing associates will not be capable of,

“providing, supplying and administering medicines”.

That too needs to be shouted out. Moreover, I assume—perhaps the Minister can confirm this—that this includes giving injections. I should think it does because it refers to “administering medicines”, but we need clarification. The point is reinforced where the draft memorandum talks about situations of national emergency, when nurses and midwives can be empowered to prescribe. A flu pandemic is cited as an example. That is very sensible because we need the hands and brains of these people to do the job. Nurses help doctors, but it is made quite clear that the education and training of nursing associates is not of the same high standard as that of registered nurses. They will not be allowed to prescribe medicines in a national emergency situation or even a hospital emergency situation. I have spoken at some length, more than I would normally, but this House perhaps needs to help the Government to reassure qualified nurses that their status is not under threat.

I will deal with one or two other points. Paragraphs 7.14 to 7.16 talk about the two-year pilot courses. We understand why they were brought in, and I hope that we have learned a lot from them. Perhaps I might press the Minister on the number of people pursuing nursing associate courses at the moment. The Health Education England plan is for 5,000 nursing associates in training this year. I recollect a debate not long ago in this House in which the number of nurse associates in training was given not as 5,000 but 30—not 30,000 but 30. The Minister said, “I’m pretty sure those figures are wrong—they are too low—but the figure is disappointing”. I wonder whether he has up-to-date figures for the number of students expected to be on NA courses this year, because the projection is important in planning ahead for the workforce.

--- Later in debate ---

[Lord Willis of Knaresborough]

Perhaps I might help. Some of the thinking behind the funding model, in particular for apprenticeships, relates to the levy. It will not apply to very small trusts, but most large trusts have a 0.5% employment levy, and to apply that through the apprenticeship route seems very logical. Whether it will work is a different matter, but that is the logic.

[Lord Clark of Windermere]

I am very grateful for that—and I understand that many trusts contribute to the levy. Perhaps the Minister could give us an indication of what the breakdown will be between the conventional course and the apprenticeship course for nurse associates. That would be helpful, because one has to bear in mind that the cost to a registered nurse undergraduate is £9,000 a year. That is what they have to pay—which means that they will pay £27,000 to get their qualification.

We need to continue at a high level. As the Minister said, we have increased the number of nurses in training; I found that very encouraging. He is absolutely correct. But why should somebody who wants to become a registered nurse spend £27,000 over three years when they could do a conventional NA qualification for two years at no cost, then do another year to become a fully qualified registered nurse? It just does not make sense. The Government have to look at the funding of nurse support training as a whole. I hope that they do so.

I felt that it was right and proper to raise these difficulties as they have not been raised elsewhere because, as I said, many of the consultees have other interests in putting forward their points of view.

[The Earl of Listowel (CB)]

My Lords, the noble Baroness, Lady Thornton, and the noble Lord, Lord Willis, asked about the impact of this new profession on the wider healthcare workforce. I wonder whether it is helpful to ask the Minister at this point a little about possible impact, if any, on health visitors. There is real concern about the decline of health visitors; they had a resurgence in recent years but are in serious decline now. I do not wish to detain the House for too long if this seems a bit beyond the main business.

I am a patron of the charity Best Beginnings, which provides mental health and perinatal support for parents. I spoke with the chief executive last week. We recognise that health visitors are very important, as healthcare professionals working in the vital perinatal period to ensure the best attachment between parent and child. I recently spoke with the president of the Institute of Health Visiting, Dr Cheryll Adams. Again, she expressed concern about the decline of the number of health visitors. As we establish a new healthcare profession, do we not need also to think about this other, declining profession under the healthcare umbrella?

I imagine that there is no plan to replace health visitors with these new healthcare professionals, but sometimes there is a misunderstanding that health visitors are just there to weigh the baby, when anyone could do that. In fact, when family-nurse partnerships were introduced to support vulnerable parents, the outcome was significantly better when higher qualified practitioners worked with the families. This job is challenging, because people are often working with vulnerable families in poor housing and poor conditions. It is a demoralising profession, unless one has a good professional foundation.

I emphasis the importance of the vital early years. As Graham Allen and Mr Field MP have established, the first 2,000 days in a child’s life are the most important. We need to ensure that the best professionals are available to them. Two or three years ago, health visitor funding went from the Department of Health to local authorities. We all know that local authorities have very little money to spend, so it is not surprising that there has been a significant decline in the number of health visitors. Does the Minister recognise concerns about that decline? Will he assure the House that he is keeping in mind the health visiting profession and what can be done to sustain it and ensure its continued health?

I have a final question. This particular new brand of healthcare professional gives rise to the problem of professionals from the developing world being pulled in to fill the niche. I am sure that the Minister can assure us that we will not poach healthcare professionals from Nigeria, Ghana and elsewhere, but the possible risk of that certainly comes to my mind. I welcome the order and I look forward to the Minister’s response.

--- Later in debate ---

The noble Baroness, Lady Jolly, made a very interesting point about this being particularly attractive in areas where it is hard to recruit. In one way it solves one problem, but it serves only to highlight another: if these are not substitutes, which they are not, that does not mean that we have necessarily solved the nursing shortage in rural areas. It is important that we keep those issues distinct.

[Lord Clark of Windermere]

May I press the Minister a little further on the training costs? Is he saying that all students on the nursing associate courses will be apprentices and that no student on the nursing associate course will pay towards the cost of that course?

[Lord O’Shaughnessy]

I thank the noble Lord for that question. My understanding is that the nursing associate is a two-year apprenticeship that provides a level 5 qualification. Therefore, there is currently a consultation about the nature of the role—the balance between work and training and so on—but obviously if it counts as an apprenticeship any organisation providing it can draw down on the apprenticeship levy fund to pay for those training costs. Whether it is in theory possible to train through an alternative route that would involve the paying of fees is something I will need to investigate and write to the noble Lord about. Of course, I will put that letter in the Library. The funding is there and the NHS is paying it. It is not necessarily drawing it down at the moment; this is an opportunity for us, with a course that is tailor-made for apprenticeships, to take advantage of that money to fund the courses.

I hope I have been able to answer noble Lords’ questions. This is an exciting moment in the development of the workforce. It provides an extra gear to the workforce to provide for the ever more complex care needs of our population. This is a good step forward. We are moving quickly and I look forward to working with noble Lords in the coming months to make sure we can put this course and its regulation on a statutory footing, attract many thousands of people into it and welcome a new profession into the health and care family. On that basis I commend the order to the House.

National Health Service: Assaults on Staff

Lord Clark of Windermere Excerpts

Wednesday 20th June 2018 Lords Chamber

Asked by

[Lord Clark of Windermere]

To ask Her Majesty’s Government how many attacks on NHS staff were reported in 2016-17 and 2015-16.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the Government are committed to taking action against those who abuse or attack NHS staff. In 2015-16, NHS organisations, which are responsible for protecting their staff, reported 70,555 physical assaults. Of those, 52,704 were due to patients’ conditions or treatments they were receiving. Data has not been collected for 2016-17. We are reviewing with the NHS how in future information about assaults and abuse of NHS staff can help trusts promote best practice.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer. Can I give him a little help with the updated figures? Has he seen the figures produced by the Health Service Journal and Unison which show a 10% increase in violence against NHS staff in the latest year? That is just unacceptable. Why did the Government in November 2017 abolish NHS Protect, which had the responsibility to protect NHS staff against violence? I know that it was replaced and that its staff, but not its functions, were transferred to the NHS Counter Fraud Authority, which focuses on fraud and protection of buildings. Will the Minister confirm that there is now no body responsible for the safety of NHS staff? I am drawn to the conclusion that this Government value property more than people.

Long-term Plan for the NHS

Lord Clark of Windermere Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

We have in this debate just started the lively conversation that we will be having on taxation in the next few months. Clearly there are a number of ideas; they have been voiced by Members on the Liberal Democrat and Labour Benches as well as those on my Benches and the Cross Benches. We know that there are a number of ways that this could be done; the Prime Minister has shown incredible leadership to admit that this is necessary. These are very difficult decisions: in polls, people say that they want to pay more tax but when it comes to the crunch they often feel slightly differently. True leadership is being able to take us through that situation, and that is what the Prime Minister is showing.

[Lord Clark of Windermere (Lab)]

I thank the Minister for taking the trouble to repeat the Statement made yesterday in the other place. Of course we welcome the money, but let us not get carried away. Every health trust charity believes that the increase needs to be at least 4%. Secondly, this still leaves only one country in the G7 paying less towards healthcare than we are.

May I ask the Minister three very brief questions? I saw a report saying that the training costs of doctors and nurses were not included in these figures. Is that correct? Secondly, when we pursue the Government’s concept, which is right, of bringing the NHS and social care together, hence delaying the plan, will the extra costs of social care come out of the 3.4%? Finally, when it is discovered that there is no exit bonus when we leave the EU, will the Government guarantee that that shortfall will be made up from elsewhere?

[Lord O'Shaughnessy]

The noble Lord mentions the figure of 4%. I have looked at a number of think tank reports and their assumptions on what is required. They make some very cautious assumptions of the productivity improvements that the NHS is making, based on historical performance. The improvements in productivity over the last five years are very healthy—in fact, in the last year the NHS became more productive at a rate of 1.8%. If you add that to the 3.4%, that gives an increase of more than 5% in terms of bang for your buck. It is incumbent on us during this process not only to put in more money but to make sure that we are driving those productivity gains that we have seen in the last five years. If that then gives a 5% effective increase in funding, that is what we will need to deal with the long-term pressures that the noble Lord has quite rightly highlighted.

On the three questions, there is an explicit commitment to deliver this workforce strategy that the NHS comes up with as part of its plan. On the extra costs of social care, we clearly need a social care settlement that delivers the funding for those rather than their being covered by the NHS. That is what we mean about the commitment not to create extra pressures. As I have said, the funding will come from three sources—whatever the mix, the funding will be there.