Junior Doctors Contract

Lord Fowler Excerpts

Friday 20th November 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the noble Lord said that this was a serious concern. It is a tragedy that we are in this situation. Of course I want a settlement, as does the Secretary of State. The last thing we want is a strike. We want the junior doctors to come back to the negotiating table and not to go on strike. The only people who will suffer from a strike are patients. I cannot believe that there are many junior doctors who want to go on strike, so it is in all our interests to find a settlement, and the Secretary of State, myself and others are very keen that we do so. The Secretary of State has made it absolutely clear that there are no preconditions, save that we settle this issue within the existing pay envelope. The door is open to the BMA to come back for talks at any time.

[Lord Fowler (Con)]

My Lords, is my noble friend aware that in 1982, when I was Health Secretary, there was lengthy industrial action not involving doctors. When I went to St Thomas’ Hospital over the river, I was met by a deputation of doctors protesting at the damage that was being done to the health service. It is the successors of those very doctors who are now threatening industrial action. Should we not all, quite irrespective of party, condemn industrial action, which will damage patient care? Should we not also recognise that this action is not just against the Government? It also involves the rejection of the independent doctors’ and dentists’ remuneration review body, which is valued and respected throughout the health service and which doctors over the years have pressed to have. Surely we are faced with a failure of BMA leadership in this case, and the obvious course is to go back to the negotiating table very quickly.

National Health Service: Sustainability

Lord Fowler Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Fowler (Con)]

My Lords, first, I congratulate most sincerely the noble Lord, Lord Patel, on his speech and on the debate. He talked about exactly the kind of issues that we should be talking about, and which the public generally should be talking about. As he might imagine, what he said about a commission was music to my ears. We should take note of what he also said about the financial problems in the NHS, which are endemic.

It is spending not just today about which we should be concerned—although I congratulate the Chancellor of the Exchequer on the resources he has made available—but spending in the future. For far too long, there has been a political preoccupation with structures and organisations to the extent that today there cannot be one person in 100 who could say how the National Health Service is actually organised. That includes quite a number of people working in the health service.

I hope that the debate can now change and tackle the obvious problems that we face. The principal one is clear. We all want a health service free at the point of delivery so that people are not denied healthcare because of a lack of income. That is basic. However, we also know that the costs of the health service are increasing because of medical advance, rising expectations and an increasing elderly population. The question is: how can we finance this increasing demand? That is an appropriate question on the day after the Budget. It is also appropriate because it seems to me that the dangers are clear. We are funding health through general taxation but what is crystal clear is the pressure on public spending. That pressure will continue. At the same time we find that large areas of public spending are exempt from economies and reductions. Health, of course, is one of those and 60% of social security spending is another.

The Government are forced to look at the areas not protected for reductions, such as the 40% of the social security budget. It is for such reasons that they are driven into eccentric policies, such as putting the costs of the over-75s television licence fee on to the BBC. I say “eccentric” although I could put it rather higher than that—I might on Tuesday when we debate this issue. The fact that the Government are driven to such policies shows just how uncertain the position is. It raises the question of whether public spending will be sufficient to meet the emerging needs in the long term, and whether we can keep going on the same basis and keep going back to the same departments to make economies.

I raised that issue in the Queen’s speech debate, but received what I term a dusty ministerial reply from the first Conservative Government for nearly 20 years, which was that Derek Wanless had gone into all these issues a few years ago. I find it slightly odd that the Government should rely on a report commissioned by Gordon Brown, published in 2002 and prepared by Derek Wanless and the health trends review team of Her Majesty’s Treasury. It is particularly odd when you consider that the report looked at the resources required, but said quite explicitly:

“Its remit was not to look at how those resources should be financed”.

It also said that there should be further and regular reviews.

To my mind—and I very much echo what the noble Lord, Lord Patel, said—what is required at the start of the new Parliament is a thorough, independent and authoritative review of the financial pressures that the health service will come under, and at the same time to set out the options for financing healthcare. We may find that funding it out of general taxation is the best and most cost-effective method—I certainly argued that it was a cost-effective service when I was Secretary of State—but we cannot have a sensible debate on the way forward without examining the other issues. We could have a ring-fenced health tax, or look at a potential system of health insurance. We should explore the part that charges could play: I always found it extraordinary that, for example, prescription charges caused so much upset, given that about 70% were prescribed absolutely free. We should look at economies that can be made in the drugs bill and a whole range of other things.

These are difficult questions, particularly given how health is exploited as a political issue—any change is alleged to mean the destruction of the health service as we know it—but they are options that should be explored. That is why I believe that a royal commission, made up of independent members and working quite openly, would be the way forward. It would look at the resources needed to deliver a high-quality health service that is free at the point of delivery, but also examine how those resources should be financed. I am sure that many will say that this cannot be done and that it is politically too difficult. Frankly, however, we have an exceptional opportunity, at the beginning of a Parliament, to mount a thorough and open investigation into the financial pressures that the health service is and will be under and how they can be met. That would be supported by those who are concerned about not just the state of the health service today, but its future over the coming years. I very much hope that this is a challenge the Government will not duck.

NHS: Immigration Rules

Lord Fowler Excerpts

Wednesday 24th June 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the Royal College of Nursing figure I saw was closer to 3,000 than 7,000, but in a sense that is not what is important. What is important is that over the long run we train our own nurses in this country. Although we recruit some exceptionally wonderful nurses from places such as the Philippines, it does not seem a good long-term strategy to rely on recruiting nurses, often from third-world, quite poor countries, so I am very pleased that we are going to train 23,000 new nurses over the next five years. That is the right answer to any short-term, temporary shortage.

[Lord Fowler (Con)]

My Lords, surely the central point is that we should review the policy of recruiting nurses from overseas, as I think my noble friend is indicating. Should we not in a bipartisan way now concentrate on training our own nurses in this country rather than permanently taking them from other countries, for example, in Africa, which often desperately need their care?

[Lord Prior of Brampton]

My Lords, I agree with my noble friend; it cannot be right for a rich country such as ours to recruit nurses from much poorer countries. I will just say that the Philippines, for example, produces more nurses on a deliberate basis than it needs for itself, so that they can go overseas, usually for temporary periods, not permanently. Interestingly, over the last five years, the number of non-EU overseas nurses working in this country has reduced by 41%.

Penrose Inquiry

Lord Fowler Excerpts

Thursday 26th March 2015 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Lord, Lord Hunt, for his comments and questions. There is no doubt that Lord Penrose has done a very thorough job in examining the facts. It is worth understanding that he has considered the evidence from England as well as Scotland.

I pay tribute to those who showed tremendous courage in telling the inquiry about the impact of infection on their lives and the lives of their families. The report has systematically examined the facts and set them out. As well as other inquires, such as the Archer inquiry, with which the noble Lord is familiar, this report has now given us a detailed account of what happened, which is extremely valuable. I agree that there will be a need to reach a formal view on Penrose’s conclusions once my department and the next Government have had an opportunity properly to consider the conclusions that he reached.

As for Lord Penrose’s recommendation to offer a hepatitis C test to everyone who had a blood transfusion before 1991, the department conducted a look-back exercise in 1995 to try to identify everyone who might have received infected blood prior to 1991. We will consider whether anything more can be done on this in England, although obviously Lord Penrose’s recommendation relates specifically to the Scottish Government taking steps along these lines. We have already done an exercise to identify anyone who could have been affected, and we will consider whether anything more should be done on this.

The noble Lord asked about the Skipton Fund, which, as noble Lords will remember, is there to make non-discretionary payments to patients infected with hepatitis C. To date, over 5,100 individuals in the UK have received the stage one payment and around 1,500 have received a stage two lump sum in the UK, with around 700 receiving annual payments in the UK.

[Lord Fowler (Con)]

My Lords, I am very glad to hear the Government’s pledge to give all possible help to those who have been harmed through no fault of their own. However, with respect that pledge has been given before. It is very important this time that it is properly, and above all generously, followed through.

Does my noble friend agree that we should take note of Lord Penrose’s statement, following his very detailed and long inquiry, when he said yesterday:

“Much of the comment made over the years on the topics discussed in the Final Report has reflected strongly-held beliefs. Some commentators believe that more could have been done to prevent infection in particular groups of patients. Careful consideration of the evidence has, however, revealed few respects in which matters could or”—

more importantly—

“should have been handled differently”.

Will my noble friend endorse that conclusion?

[Earl Howe]

My Lords, if my noble friend will forgive me, I do not want to be drawn too closely on Lord Penrose’s comments, as we should reflect on them carefully. However, it is clear that, as knowledge of these viruses began to emerge in the 1970s and early 1980s, no tests were available to screen blood donations and no means existed to inactivate the virus in blood or blood products. By 1985, a screening test for HIV was available, and heat-treated plasma products that inactivated the virus had been developed. It was not until 1990 that an effective screening test for hepatitis C was available. It is important to put that into context, because Lord Penrose found that clinicians acted in accordance with the technical facilities that they had available to them and in accordance with the ethical frameworks that were in place during the 1970s and 1980s. The ethical frameworks in which clinicians operate today are of course very different from those that were in place then.

HIV/AIDS

Lord Fowler Excerpts

Thursday 5th March 2015 Grand Committee

Asked by

[Lord Fowler]

To ask Her Majesty’s Government what steps they are taking to meet the continuing challenge of HIV and AIDS.

[Lord Fowler (Con)]

My Lords, we are nearing the end of a Parliament, which is, perhaps, a good time to assess what progress has been made in this important area, where we are and where we want to be. I start by congratulating the Government on two measures of immense importance. The first was their decision to enable equal marriage, which did a vast amount not only to encourage equality but at the same time to fight prejudice against gay people, which stands against progress in fighting HIV and AIDS literally around the world. The second was to double their contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which brings invaluable help to areas where the death toll has been immense. AIDS alone has been responsible for 35 million deaths around the world since the epidemic began. Frankly, the criticism of the National Audit Office that this was an example of a last-minute decision was about as far from the mark as it was possible to get. It was first promised not by the current Secretary of State but by her predecessor, Andrew Mitchell, and it was, as I say, extraordinarily welcome.

However, in this short debate I want to concentrate on this country and ask whether we are making the progress that we should. In bare statistics, last year there were almost 6,500 new HIV diagnoses. I have just come back from Russia, where I looked at the position there. Indeed, they were kind enough to present me with a medal for 25 years service. It is a damn sight more than I ever get from the Department of Health, I can tell noble Lords, but I fear that it makes me no more sympathetic to their policies, which last year resulted in 85,000 new HIV diagnoses. The figure goes up remorselessly each year.

The temptation is, against that background, to say about Britain, with fewer than 6,500 new HIV diagnoses, what are you worried about and what is the problem? The problem, basically, is that today in Britain there are 100,000 men, women and children living with HIV. That is almost double the number accessing care a decade ago. The National Health Service now spends £860 million a year on treatment and care: almost £1 billion a year. Worst of all, of those 100,000 with HIV, about a quarter are undiagnosed. They do not know that they have the virus and, of course, other things being equal, they spread HIV further. In other words we have, in my view, an undoubted public health crisis and, although we now have antiretroviral drugs which prolong life, we still face the situation which we faced, frankly, in the 1980s, with no cure and no vaccine.

Against such figures, what can we do and what are we doing? The obvious step is to put the maximum effort into prevention. We save £320,000 in lifetime costs for every infection which is prevented. Top of the list in prevention policy is to persuade ever more people to be tested. We are not going to win when we have around 25,000 people untested and undiagnosed in the community. Second to that is that we also need to persuade people to continue with their treatment once they are on it. Too many drop off. The point to recognise, generally, here is that persuasion can work, provided that sufficient imagination is put into the messages and it is backed by sufficient resources. We established that back in 1986-87 with the promotion of condom use and the warnings against shared needles.

The Select Committee that I chaired in 2011—I am glad to see that one of its members, my noble friend Lord Gardiner, is sitting very near me—raised this point with the Government. We said that publicity was inadequate and should be increased, so what did the department do? It cut it further. Today, the department spends about £2.4 million a year nationally on promoting prevention. I repeat that the cost of treatment and care is £860 million a year. It is, frankly, a ludicrous position. We spend hundreds of millions on treating the casualties but next to nothing on trying to prevent those casualties coming about. The defence for this is that, in addition to the national campaign, another £10 million or £11 million is spent by local authorities, although the figures suggest that some of the most affected local authorities are spending next to nothing, if anything at all.

Frankly, making every allowance in the book, the amount we spend on trying to prevent infection is seriously inadequate. Prevention is simply not being given the priority that it deserves. If it were not for the NGOs and the volunteers, our overall national policy would, in my view, be not only in trouble but in tatters.

Therefore, I say to the Government that we need a new campaign to encourage testing, which is the obvious glaring gap in our policy. A few weeks ago, I proposed to the Minister on the Floor of the House that a task force should be set up to explore how to take that forward. The Minister, as is his custom, was courteous—even encouraging—but, frankly, I have heard no more, doubtless because he was planning the detail of the campaign that I set out. Perhaps this afternoon he might come forward with those proposals.

I would like to make two further points. The first is on drugs and harm reduction policy generally. We introduced clean needles and then methadone as a policy back in the 1980s. Methadone is not injected and therefore has an obvious use in reducing transmission. It has been demonstrably successful as a policy. For the last 25 years the number contracting HIV in this country through shared needles has been around 1% of the total—almost imperceptible. Therefore, it is vastly important that that policy is maintained and that there is no lurching away from it. Why do I say, “lurching away from it”? In recent weeks there has been a suggestion that policy is changing. There has been a hint that drug users should be forced into taking treatment—taken not only off injecting drugs but off methadone as well. I say to the Minister that my only advice on this is to go very cautiously indeed.

Of course, we all want to see as many people as possible living a drug-free life, but we should not underestimate the difficulties, which are not going to be reconciled by a speedy review of a few weeks. If you want to see the alternative, again, go to Russia: see the treatment centres there and the attempt at rehabilitation, and look at the figures. They show that after 12 months of treatment and rehabilitation 80% or 90% go back to injecting drugs, and after five years virtually everyone does.

Given that drug users have never really been able to be forced off drugs in the way that seems to be imagined, I think we might also remember that methadone can lead to a recovered life. I remember visiting a clinic in Ukraine, where the doctor in charge basically said just that—that, although some of them had been on methadone for six, seven or eight years, they had at least been restored to society: they held down jobs and were relating to their families again. Basically, I would like an assurance that there is no intention on the part of the Government to turn their back on sensible harm reduction policies.

My last point I make in précis. The latest research shows that the drug Truvada can very substantially cut HIV for men who have sex with men. It prevents HIV infection. Given that men who have sex with men are the group most affected by HIV in this country, it seems obvious that we should develop that policy as quickly as we can. Of course, there are costs to the policy, but there are even greater costs in doing nothing.

My conclusion is this. On a number of issues, such as the increased contribution to the Global Fund, this country has been among the leaders in the world, but I fear that nationally, inside Britain, there are too many gaps in our policy to say that we lead the world. What we can say is that we have some of the finest and most devoted clinicians, NGOs, voluntary organisations and officials. If I had one word of advice for the Government, it would be that Ministers should raise their general policy game to the level of those doctors and volunteers who work so tirelessly in this country to eliminate HIV and AIDS.

HIV

Lord Fowler Excerpts

Thursday 15th January 2015 Lords Chamber

Asked by

[Lord Fowler]

To ask Her Majesty’s Government what estimate they have made of the proportion of people living with HIV who are undiagnosed.

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

My Lords, Public Health England estimates that in 2013 107,800 people were living with HIV in the United Kingdom. Of these, 24%, some 26,100, down from 25% in 2012, were undiagnosed and unaware of their infection. Early diagnosis is important to ensure people can get early treatment and to prevent them infecting others.

[Lord Fowler (Con)]

My Lords, surely we cannot ever eradicate HIV in Britain, which currently is costing the health service something like £650 million a year, when there are at any one time, as my noble friend has just said, 26,000 people who have contracted HIV but are undiagnosed and untested and can obviously spread the infection further. Will my noble friend consider setting up a working party to report on how testing in this country can be improved, which would be of benefit to those people affected and also to the benefit of the public generally?

[Earl Howe]

I will gladly take that suggestion from my noble friend away and give it consideration and I am grateful to him for it. The position on testing is, however, quite encouraging. We have seen more than 1 million HIV tests in sexual health clinics in 2013, which is up 5% from the previous year, and that is only in sexual health clinics. As my noble friend knows, there are other routes to testing through GP surgeries, self-sampling kits and so on. Additional testing is vital if we are going to make sufficient inroads into diagnosing this condition.

NHS: Medical Staff

Lord Fowler Excerpts

Monday 15th December 2014 Lords Chamber

Asked by

[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.

HIV: Stigma

Lord Fowler Excerpts

Monday 1st December 2014 Lords Chamber

[Earl Howe]

My Lords, there is certainly still too much stigma, although I believe opinion has moved in the right direction generally. The campaigns in the 1980s played a key part in providing information to the general public about AIDS and later HIV, but for some years it has, I think, been widely accepted that campaigns targeting groups at increased risk of HIV are more effective. That is why, for many years, my department has funded the Terrence Higgins Trust for targeted HIV prevention. HIV Prevention England, the unit set up by the Terrence Higgins Trust, is leading that, and is delivering innovative social marketing campaigns, including some mainstream advertising, on things like condom use and testing. There is also a DH-funded national programme, which has been successfully piloted with Public Health England.

[Lord Fowler (Con)]

My Lords, do we not need to fight stigma and discrimination overseas as well as at home? Around the world, some 18 million people have HIV and are untested, many because of their fear of discrimination. Given that many of them are in Commonwealth countries, should we not use all our influence to persuade such countries to follow policies of equal and fair treatment for all minorities?

[Earl Howe]

My noble friend, with his immense knowledge of this subject, is of course absolutely right. The 2011 UN Political Declaration on HIV and AIDS specifically includes a goal to eliminate by 2015 stigma and discrimination against people living with and affected by HIV through the promotion of laws and policies which ensure that human rights and fundamental freedoms are protected. Progress towards universal access cannot be made unless stigma and discrimination are tackled. They are a particular barrier with regard to the criminalisation of gay men and women, transgender people and sex workers. DfID is a constant champion of these groups internationally.

NHS: Five Year Forward View

Lord Fowler Excerpts

Thursday 23rd October 2014 Lords Chamber

[Lord Fowler (Con)]

My Lords, the strategy seems to be very sensible, but I hope that not only the Government but also all the parties will do what the chief executive of the National Health Service said on the radio this morning and recognise that there is no appetite inside the health service for any further top-down reorganisation. Will they also recognise that we need to put much more emphasis on preventing ill health? Pharmacists, who are highly qualified and well trained, should have a much bigger role to play, which would reduce the present burden on general practitioners.

[Earl Howe]

My noble friend is absolutely right in what he says. The report lays great emphasis on the prevention agenda, not only through the work done in the public health arena by Public Health England and local authorities, but also through secondary prevention by the NHS itself: preventing the need for people to enter hospital in the first place. I fully agree with my noble friend about the potential role of pharmacists. Actually, that role has been enlarged over the past few years in an encouraging way with such things as medicines use reviews and the Healthy Living Pharmacy agenda. We want to go further and pharmacists are keen that we should do so.

Ebola

Lord Fowler Excerpts

Monday 13th October 2014 Lords Chamber

[Earl Howe]

There is a limited amount that I can say to the noble Lord about his second question. A general answer is that we would naturally want to give as fast a passage as possible through the regulatory process to any breakthrough treatment for Ebola. It should be borne in mind, however, that safety is the paramount concern. This is why it is important that the vaccine, which is now in clinical trials, is thoroughly tested for safety as well as efficacy. If there is further news on this that I can impart to the noble Lord, I will be happy to write to him.

The noble Lord asked whether staff who volunteer will be repatriated if they contract the disease. My advice is that decisions on repatriation would be taken on a case-by-case basis, taking into account the clinical condition of the person and the benefit they may gain from repatriation. Repatriation involves a long journey that can potentially be dangerous for the patient. Once there is high-quality treatment available in Sierra Leone, it will not necessarily be in the best interests of the patient to be repatriated. That is why we are building the 12-bed unit specifically for national and international healthcare workers.

[Lord Fowler (Con)]

My Lords, I totally support the measures set out by the Minister. It is obviously sensible, as it has been in past events, for the Government to follow carefully the guidance of the Chief Medical Officer. Is not the real long-term task permanently to strengthen the inadequate and underfinanced health systems in so many parts of Africa? Would that not be to the benefit of tackling not just Ebola but other life-threatening conditions such as malaria, TB and HIV/AIDS?

[Earl Howe]

My noble friend has immense experience in this area and I completely agree with him. I attended a conference in Washington a few days ago which was called by the President of the United States at which 44 Health Ministers from around the world were present. I emphasised the very point my noble friend has made: yes, it is important to provide assistance to deal with the current emergency—everybody is agreed about that—but we must not lose sight of the need for the health systems in those poor countries to be bolstered in the way my noble friend mentioned and for there to be adequately trained clinicians and healthcare staff on the ground as well as diagnostic facilities so that in future those countries are capable of some resilience if they are hit by such an emergency again. I can tell my noble friend that DfID funding is going into that effort, as it has been systematically over the past few years.