NHS: Health and Social Care Act 2012

Lord Hunt of Kings Heath Excerpts

Thursday 8th September 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, as this is such a general debate, I remind the House of my interests as president of GS1 UK, the Health Care Supply Association, the Royal Society of Public Health and the British Fluoridation Society, as a trustee of the Royal College of Ophthalmologists and as a consultant and trainer with Cumberlege Eden.

I am very pleased that my noble friend Lord Hanworth opened this debate today with an extensive, and indeed passionate, analysis of the NHS. He thinks that it is in a critical position, and I agree with him. Whether it is down to the overt privatisation of the NHS encapsulated in the 2012 Act or whether it is essentially down to underfunding is, I think, a matter for some debate. On the matter of privatisation, I should say that I have no problem whatever with the involvement of the private sector in the NHS; indeed, I think that there is much to be gained from partnership with the private sector. The noble Lord will know that, as a Minister, I was responsible for some of the contracts that were put in place to enable us to reduce waiting times, which I think was an excellent thing to do.

I agree with my noble friend that the NHS seems to have been forced to tender out services willy-nilly, at great expense and, frankly, with very poor outcomes. I know that the noble Lord, Lord Lansley, said that it was not his intention that clinical commissioning groups should be forced to do that; it was going to be down to them. Indeed, when he introduced the Bill and talked about it, the emphasis was very much on local GPs making the decisions. The problem is that CCGs themselves—and certainly NHS England—misunderstood those messages, and CCGs felt under pressure to put some services out to tender. I do not think that the outcome has been very satisfactory at all.

I say also to my noble friend that I disagree with him about the NHS foundation trusts. I believe that the local governance that they have, making them much more accountable to members locally, is something to be treasured and supported.

I will just address PFI. Yes, there were some schemes that were expensive and not well-managed contractually, but the fact is that, as a result of PFI, we were able to invest huge amounts of money in the infrastructure. If you want to look at PFI, I would look no further than my own local district general university hospital, Birmingham QE, which is a magnificent example of a PFI scheme, delivering fantastic services and which, overall, is affordable. It is worth saying that unpublished figures to the Health Select Committee from the Health Foundation, which look at expenditure on PFI in 2013-14, showed that it accounted for 1% of providers’ total expenditure. It is not PFI that is breaking the bank.

We need to be more dispassionate about the kind of health service we want and how we want to see it organised in the future. What happened in the 2012 Act is a salutary lesson to us all. I, too, was surprised at the Government’s decision to go for wholesale reorganisation. After all, it had a pretty good inheritance: there had been investment; waiting times had been reduced; and the infrastructure had been invested in. I tempt fate to try to persuade the noble Lord, Lord Lansley, to say at some point, but I never understood why he simply did not get PCTs to do what they should have done, which was to delegate much more decision-making with budgetary responsibility to GPs, rather than going for the wholesale reorganisation that we saw. I accept that the health and well-being boards—the potential integration of health and social care—were a very important and supportable part of that Bill. The problem is that the rest of it has produced a chaotic system in the field.

My noble friend Lord Lipsey mentioned Sir Muir Gray. He said that no reorganisation has ever produced anything of any use. I have some sympathy with that, although I suppose I must own responsibility for two or three of them. The fact is that this reorganisation produced great confusion and fragmentation at local level and, above all, a sense that no one was in charge.

My reading of sustainability and transformation plans is, essentially, that they have been established by NHS England to replace strategic health authorities because they have to have some kind of local plan and leadership. The problem is that they lack legitimacy; I am afraid they lack openness and I hear that, in many parts of the country, they have not involved local government at the start. That is a great pity.

More worrying, I hear too that STPs have come up, in the main, with tired, old solutions. So they are going for heroic reductions in acute sector capacity. They say that they are going to have fantastic, demand management approaches to reduce the intake, but the reality is that there will be no leverage over GPs, primary care or local government to make it happen. It was fascinating listening to the comments of the noble Lord, Lord Kakkar, about the Netherlands and the way in which it should be done. I am afraid that, so far, there is very little evidence that STPs are going down that route.

In July, the chief executive of NHS Improvement said that the NHS is “in a mess”. That was putting it kindly. We have huge deficits; performance has gone completely south, and I doubt that the Government are going to get back to any of those targets in any substantial way over the next four years. No one else in the health service believes that the targets are going to be recovered. At heart, we have this issue of an increase in demand for services, coupled with demographic changes, and the growth rate in resources is less than the health service has ever had in the past. We know that, historically, up to 2015, average real terms growth was 4% a year; it is now down to about 1%. It is abundantly clear that it simply cannot be done.

When you look at the OECD comparisons, they are pretty shocking. There are 29 countries which have more CT scanners per capita than we do. There are 28 with more MRI units and 25 have more hospital beds per capita. That gives the lie to those who think that the acute sector in this country is overinvested. Thirteen have more doctors per capita; 18 have more health expenditure; 18 have more nurses. On comparative terms, I agree with my noble friend Lord Lipsey, it is almost a miracle that it achieves what it does with the kind of resources that it is given.

My noble friends Lady Armstrong and Lady Pitkeathley spoke eloquently about the issues in social care and the funding squeeze. The noble Lord, Lord Lansley, was right about the disappointment over the implementation of the Dilnot report. It is very difficult to see where we are going overall in health and social care, except into a long-term decline. It feels like we are going back to the days when you had long waiting lists and disintegration between different parts of the service. The rhetoric is there. Ministers talk about integration, as do the STPs, but, from talking to anyone in the field who has either to do it or is a patient or a client experiencing the service, things just seem to be getting worse and worse and worse.

I do not have the time to talk about Brexit but, at the same time, there are issues to do with staffing. My major concern is about long-term investment in the life sciences in this country. The research issue to which the noble Lord, Lord Kakkar, referred is very serious.

We have the Select Committee, two members of which spoke in the debate today. It has a very important task ahead of it. It could come up with a soft report, looking at all the options one way or the other and then ducking out of a hard recommendation. I urge it to go in hard. As my noble friend Lord Lipsey said, we face fundamental questions about what sort of health and social care system we have, what we are trying to do and about the demographics and how we are going to afford it. It would be all too easy to shy away from making the kind of hard decisions that have to be made. I very much hope that our Lordships’ House and its Select Committee will help us do that; I do not think the Government will.

Junior Doctors: Industrial Action

Lord Hunt of Kings Heath Excerpts

Monday 5th September 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Lord for making the Statement.

Clearly the prospect of a series of five-day strikes is very worrying, coming after the protracted negotiations, agreement between the negotiators and then the subsequent ballot rejection. The promised action, though now delayed, would have a damaging impact on patients, the NHS and the junior doctors themselves. However, the Secretary of State and the Government cannot escape their own responsibility for the threatening catastrophe.

At the heart of this dispute is a complete absence of trust by the junior doctors in the Government and, specifically, the Secretary of State. It is not hard to see why. Towards the end of the Statement the noble Lord mentioned a seven-day service. It is the conflation of the seven-day service issue with the junior doctors’ contract which has exacerbated an already difficult situation, particularly as it is the junior doctors on whom the service is so dependent for out-of-hours working.

The Minister did not mention the advice received from officials but he knows that the documents obtained by the media outlining the risks detailed by officials on the seven-day NHS were clear in their assessment that the NHS was likely to have too few staff and too little money to deliver a truly seven-day NHS. Moreover, it gives the lie to the last sentence of the Statement where the Secretary of State comes out with all that blah about making the NHS the safest, highest-quality service in the world when everyone knows that it is crumbling through a lack of resources, a lack of staff and a lack of leadership. We have a Secretary of State who is in his own world, one that is occupied by no one else. He is charging ahead with implementing the seven-day working week without the resources, staff and support needed to do it.

Let me be clear: no one more than I would like to see a truly seven-day working NHS, but that is dependent on the resources being available to ensure its proper implementation. What I deplore—and this is a core reason for the disenchantment among junior doctors—is the Secretary of State’s distortion of the statistics in relation to weekend mortality figures to justify the imposition of the contract.

I would like to ask the Minister a number of questions. First, he referred to the contingency plans being put in place by the NHS, but clearly with the postponement or cancellation of the first proposed action there is now time for the NHS to give more consideration to those contingency plans. I wonder if he can tell the House a little more about them. Secondly, the chief executive of NHS Providers has warned that with little notice the unprecedented action,

“will cause major disruption and risk patient safety”.

What discussions have taken place between Mr Hopson and Ministers to discuss his concerns? Thirdly, where elective operations and clinics may be cancelled as a result of the promised late action, what assurances can the public be given that new dates will be scheduled as quickly as possible?

Can the noble Lord say what discussions have taken place between the Department of Health and junior doctors? In its statement today announcing the postponement of the action, the BMA has said that it will call off further action if the Secretary of State stops his imposition of the contract, listens to the concerns of junior doctors and works with the BMA to negotiate a contract based on fresh agreed principles that have the confidence of junior doctors. What is the Minister’s response to that statement by the BMA? It has been reported in the media that the Secretary of State has refused to engage with the junior doctors. Can he confirm whether that is the case, and if so, why is that the position?

Finally, what are the Government’s plans to restore junior doctors’ trust in the National Health Service? There is a clear risk that the morale of a whole generation of doctors is being destroyed as we speak. When that is put alongside the implications of Brexit and the potential loss of experienced staff through the decision by many junior doctors to leave the profession or to go abroad, this is a worrying position. I have met a number of junior doctors over the past few months. They are clever, articulate and passionate about the NHS, but they have told me about the pressures that they are under, of the risky gaps that we now have in rotas which have developed over the past few years, of locums not always being available, of existing staff having to cover gaps at short notice, and of being hugely dependent on the good will of many staff, including junior doctors. The Statement of the Secretary of State is full of warm words about junior doctors’ working conditions, but as the Minister knows, the fact is that they do not have confidence in them. Frankly, I also do not think they have confidence in local management to implement the proposed contract in a way that is sensitive to their working conditions.

At the annual meeting of the Royal College of Physicians, its chairman pointed to the need for junior doctors to be valued, supported and motivated. Some months ago the RCP wrote to the Secretary of State outlining recommendations for improving conditions in training, including protected time for training and the promotion and support of flexible working, publishing rotas earlier and prioritising handover sessions. What progress has been made in responding to the sensible suggestions made by the Royal College of Physicians, and above all what are the Government going to do to endeavour to get back the confidence of junior doctors in the NHS and thus seek an end to this action?

[Lord Prior of Brampton]

My Lords, the noble Lord has raised many questions in his response to our Statement. He may well have read the article published earlier this week in the Times by Sir Simon Wessely, the president of the Royal College of Psychiatrists, which goes to the heart of what I would call the non-contractual issues that have bedevilled, coloured and provided the context for this dispute:

“Changes to the way that doctors are trained means that juniors face switching not just jobs but addresses every few months without much say about where they end up and when. Many seem condemned to spending years rootlessly shuffling from one place to another like lost luggage. Without any familiar faces, long hours are endured in relative isolation and managers who change all the time provide little or no recognition, let alone reward”.

This in a sense is what lies behind much of the dispute. The fact is that we had a contract that was wholeheartedly welcomed by Dr Ellen McCourt, now the president of the BMA, and by the association itself. The issues of difference in the contract were pretty small.

We have been discussing this contract for three years now and the Government have made 103 concessions. The Secretary of State’s door has been open throughout that time. The new contract is due to be introduced in October and at some point we really have to get on and introduce it. There is provision within it to review aspects as it goes forward. We have committed to looking at the gender pay issues that have been raised by the BMA and today HEE has published the work that it is doing on non-contractual issues with the BMA when the association is prepared to talk to it. The Government are bending over backwards to meet the BMA, but there comes a point where we just have to bite the bullet and go ahead with the contract that has been agreed, and that is the place we are in now.

The noble Lord referred to a lack of trust in local management and in the Secretary of State, but we now have the guardians of safe working hours built into the contract. They have a contractual commitment to report every quarter to the boards of trusts and to the GMC and the CQC every year. Plenty of independent safeguards have been built into the new contract. So while of course I understand many of the issues raised by the noble Lord, the Government have gone the extra yard every time they have been asked to do so and now we must get on and introduce this contract.

Health: HIV

Lord Hunt of Kings Heath Excerpts

Monday 5th September 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I too very much welcome the debate and the thrust of the argument put forward by the noble Lord, Lord Black, for the elimination of HIV. Like many other noble Lords, I echo the tribute that he made to organisations such as the National AIDS Trust and the Terrence Higgins Trust, as well as, of course, to the noble Lord, Lord Fowler, whom it is marvellous to see in the Speaker’s chair tonight. The noble Baroness, Lady Bottomley, mentioned Sir Donald Acheson, who was the powerful, dynamic Chief Medical Officer at the time, and it is right that we remember the role that Chief Medical Officers have played in this story over many years.

In opening his debate, the noble Lord reminded us that HIV is a global issue. The UK has played a proud role in global efforts but HIV remains a major challenge in this country. The noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley, referred to some of the statistics but, for me, the two most striking are the 2014 statistic showing that more than 6,000 new people in the UK were diagnosed with HIV and that in the same year an estimated 18,000 people were living with HIV but were unaware of their infection. The argument that the noble Lord put forward for testing, and for publicity about testing, is very important, and I hope that the Minister will be able to respond positively in that regard.

That then leads us to the wider issue of tackling stigma. I very much commend the argument that the noble Lord, Lord Black, made for a public information campaign. However, I would link it, as the noble Baroness, Lady Walmsley, did, with sex and relationship education. That is vital but the statistics are frightening. We know that only 40% of secondary schools in the state maintained sector have proper sex and relationship education on the curriculum and that primary schools, academies and free schools do not need to teach SRE. I do not think that that is right. I hope the noble Lord’s department is in earnest discussions with the Department for Education about a proper change in policy in this area.

The noble Lord mentioned that the last government advice around these areas was produced 16 years ago, and it is the same in relation to sex and relationship education and guidance. There is a need for new guidance. A lot of water has flowed under the bridge in those 16 years—not least the introduction of same-sex marriage, the mass use of mobile phones, the internet, and all the issues in social media that that brings in relation to sex and relationships. The Government need to look at these issues very carefully.

I cannot add much in relation to PrEP because noble Lords have covered the subject adequately. The argument for its use is overwhelming, as is the economic case if we look at it in the round rather than from a narrow departmental point of view. It has never been explained why NHS England has taken this perverse point of view. It is equally puzzling why it is carrying on with the case having been comprehensively shown, in the judgment, the error of its ways. I am also puzzled why Ministers have simply not called in the chairman of NHS England and told him to sort his body out. We have had no cohesive explanation as to what this is about.

I completely put aside the argument that this should be for local government. It is a nonsensical argument which no one in the field believes is true. Clearly it is a device for NHS England to avoid committing itself to the expenditure of this money. If it is, it should come clean on it. If you look beneath the emotive language, essentially that is what the press release to which the noble Lord, Lord Scriven, referred is saying. I agree that many of the organisations involved in specialist services feel that blackmail is being undertaken by NHS England at the moment. It is a hard word to use, but when a senior medical official talks about making comparisons between people who indulge in high-risk sex and children with cystic fibrosis, I find it a disgraceful use of words. I am surprised that Ministers have not called that official to account.

We all know that in the current climate hard choices are being made. However, I cannot believe that Ministers do not think that PrEP should be funded. The noble Lord may quote the 2012 Act in terms of the relationship between Ministers and the NHS Executive, but he knows only too well that Ministers are accountable to Parliament and that they should discharge that accountability.

On public health budgets, the noble Lord, Lord Lexden, pointed out one of the problems with the 2012 Act—the fragmentation of effort in this area. There are two issues here: one is that there is fragmentation between local government and the health service; the second is that some local authorities are not taking their responsibilities and that others, particularly those in the big city areas, are having greater pressure put on them because individual patients are going to them because their own local services are not available. This needs review. We should probably work in partnership with the Local Government Association to see whether we can iron out the inconsistencies.

Another problem is the issue of public health budgets, which have taken more than their fair share of reductions as a result of the financial stringency. It makes it difficult to make sense of the overall five-year forward plan of NHS England, which promotes public health and prevention, yet in the budgeting decisions seems to detract from the ability of services to play their full part.

This has been an excellent debate and I endorse the points put forward by all noble Lords. It would be nice if the Minister were to say that it is the Government’s intention and aim to subscribe to the thrust of the noble Lord’s Question and, above all, to sort out some of these problems, particularly the issue of PrEP and the integration of services between health and local government.

NHS and Social Care: Impact of Brexit

Lord Hunt of Kings Heath Excerpts

Thursday 21st July 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, we all look forward to hearing the answer of the noble Lord, Lord Prior, to that question. I, too, thank the noble Baroness, Lady Watkins, for an excellent speech and introduction to this crucial debate. The noble Lord, Lord Shinkwin, also made a very moving speech and it was very good to hear his contribution.

There is obviously a lot of concern about the impact of Brexit on NHS staffing but we have a crisis today. We cannot fill posts. The Department of Health has, in my view, tried to deal with the issue of agency costs but it has not gone upstream to deal with the real issue, which is that we are not actually training enough doctors, nurses, care workers and other staff and we are certainly not retaining them. The antics of the current Secretary of State in relation to the junior doctors, and the impact that this has had on the medical profession, threatens to ensure that we have even fewer staff in the future. It is also becoming clearly apparent from the posturing of the various regulatory agencies and NHS England that the emphasis on safety and staffing since the Francis inquiry has gone and that the pressure on the NHS is on money. We have a double whammy of a shortage of staffing and pressure, undoubtedly from the centre, for staffing ratios to be reduced, not increased.

The noble Baroness, Lady Tyler, is right; clearly this £350 million is a fantasy—but the Government’s approach to NHS funding is a fantasy. They were exposed yesterday by the Health Select Committee. They claimed £8 billion but then it went up to £10 billion because they added an extra year. As the Health Select Committee has shown, over half of that has been retained by the department because it nicked other budget heads. The actual money is pathetic. It is a less than 1% real-terms increase. The health service has never had such a parsimonious amount over such a long time. The regulators and NHS England have this fantasy that somehow the NHS can provide better services on less money. We are facing a crisis. The care sector, as the noble Baronesses, Lady Howarth and Lady Tyler, said, is even worse. The Brexit decision comes on top of a very serious situation for our health and care system.

Before I come on to Brexit, in relation to the point made by the noble Baroness, Lady Emerton, about nursing associates, it would be helpful if Health Education England agreed to come and speak to noble Lords on this issue. I am worried that it is making a decision that properly ought to be made by Parliament in creating essentially a second-tier professional nursing grade. It may be right, it may be wrong, but it should not do it itself. This needs to be shared through a parliamentary process.

I also very much agree with the noble Baroness, Lady Watkins, that the Department of Health needs a lot of advice from professional advisory people. The decision to do away with the nursing, midwifery and allied health professions policy unit has been a very big mistake and I hope it will now be put into reverse.

The noble Lord, Lord Bilimoria, asked the Minister a series of questions which, again, we look forward to hearing the answers to. The question I want to ask is: what preparation did his department make for the result being in favour of Brexit? I suspect the answer is none. This morning the Foreign Affairs Select Committee of the other place said:

“The previous Government’s considered view not to instruct key Departments including the FCO to plan for the possibility that the electorate would vote to leave the EU amounted to gross negligence”.

Anyone who has read the Chilcot report, or the summary, will know that one of its key points was that the then Government refused to let the military plan for the intervention, and the consequences were very serious indeed. When we had the Statement on Chilcot, we were told that the lessons were going to be learned, but this Government went through exactly the same process. On the day after the referendum it was clear that neither the people leading the leave campaign nor the Government had a clue what to do. In fact, were it not for the much-maligned Governor of the Bank of England, I hate to think what would have happened on that day.

My main question for the Minister is: what work is now being undertaken by the department? Obviously, the fundamental issue is the trade-off between free movement of labour and open access to the EU market, as well as the need to protect workers’ rights. But what about the important issues in relation to health? Is the department now going through a process of working through the issues where we need to reach a decision? What needs to be negotiated and what will be the advantages of coming out of EU legislation? Will the department be consulting with the public and with Parliament on that matter?

Other issues go more widely than staffing. The noble Lord, Lord Crisp, raised the question of our participation in EU-wide research projects. Is an emergency task force being established to try to get this right so it is accepted that British universities should be part of collaboration in the future, or are we going to go into a three- or four-year downturn in research, which would devastate our universities?

The second is the life sciences sector, which is a huge asset to this country. What are we doing to ensure that that sector will be able to contribute to our economy and that the innovation it introduces will be enhanced in the future? The failure of the NHS to invest in innovation is one of the most depressing sights that I have seen in the last few years. If we are to enhance the life sciences and pharmaceutical sectors—I am proud of the research-based pharmaceutical sector and I applaud people who work in it; they have contributed a huge amount to this country—we have no chance of retaining R&D in the pharmaceutical sector unless the NHS starts to adopt innovative new medicines. The problem is that a huge amount of rationing is taking place. My concern is that the pharmaceutical industry, and the life sciences sector as a whole, will conclude that the combination of Brexit and the failure of the NHS to invest will lead to a deinvestment. We have to try to sort this through in the next few months.

My final point before I come on to staffing is on the position of the MHRA and clinical trials. I founded the MHRA, in the sense of naming it from its old form, and I am very proud of its work. But its situation is at huge risk unless we can reach an agreement that the relationship it has with the European agency will continue in future. Will that be the Government’s intention? Clinical trials is another area, however.

As far as staffing is concerned, I do not have time to raise many issues but, first, the big ask is for a commitment that staff from other EU countries who work in the NHS and social care will be afforded indefinite leave to remain in the UK. Secondly, will the NHS be instructed to take action against members of the public who abuse staff in the way that we have heard about? We need action; it is no good just tut-tutting. I would like to see whether it is possible to prosecute people. I suspect that it is in certain cases but we have to be very tough on patients. If they expect to be treated in our hospitals, then we can expect our staff to be entitled to respect from them.

The GMC produced a very interesting and detailed note on the impact on the medical profession. Will the Minister assure me that the Government are in discussions with the GMC and the other bodies that are concerned about staffing levels?

Finally, there is a big question. Because the Government have decided that immigration controls are more important than anything else, should we lose a lot of mutual recognition and full access to the free market then one implication is that we will have to train—and retain—more of our own health service staff in future. Is the Minister’s department working on a strategy to do that?

Bread and Flour Regulations (Folic Acid) Bill [HL]

Lord Hunt of Kings Heath Excerpts

Friday 8th July 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to wind up for the Opposition and to congratulate my noble friend Lord Rooker on bringing this Bill here. As the noble Baroness, Lady Hayman, said, my noble friend is not giving up. I am delighted about that; I hope that he will carry on with force to press the case.

The argument is overwhelming. It is not just a matter of regret in relation to the women and babies who have been so affected by the failure to implement an entirely rational decision. What is striking is that it was British research, led by that brilliant scientist Sir Nick Wald, which found the link and recommended as a result of the MRC work that flour be fortified—in 1991. This Government have an accelerated access review and have adopted a number of initiatives to speed up the introduction in the National Health Service of proven new technologies and medicines. Yet here we have a brilliant piece of British research that this country—unlike many other countries—has ignored. I think that is a matter of great regret.

The Government have clearly been prevaricating for a number of years. When the noble Earl, Lord Howe, was the Minister a few years ago, there was a clear indication that the Government were prepared to go with it. Then there was a step back and prevarication by referral to any number of scientific bodies. Finally, the noble Lord, Lord Prior, made it clear in one debate that the Government had decided not to go ahead.

That was followed up in his letter of 7 June 2016—I am very grateful for a copy of it—confirming that decision. In it, the noble Lord, Lord Prior of Brampton, said that,

“whilst we will continue to consider emerging evidence, the Government currently has no plans to take forward the mandatory fortification of white flour with folic acid in England”.

So, essentially, the Government have made their decision, Like the noble Baroness, Lady Walmsley, and my noble friend Lord Hughes, I hope that the Minister will say exactly why they have done so. What happened to change the Government’s view? Is it to do with the nanny state argument? What is it to do with?

If it is to do with the nanny state argument, I remind him of our debate earlier this week on the recommended number of units of alcohol. The Government took the CMO’s advice to reduce the level—I am not sure it is right to call it the “recommended” level, but the Minister will understand me—from 18 units to 14 units per week for men. As I told him earlier in the week, I looked at the department’s website to find out what the change in risk would be of keeping it at 18 units per week—but the website simply talks about risk.

I also went back to the main research in relation to cancer on which the decision was based and looked at the lay summary. Again, there is no quantification of the change in risk. Going through the paper, I encountered a lot of scientific terminology that, as a layman, I could not work out. My suspicion is that the actual change in risk is quite small. Yet the Government are quite prepared to accept that they should take action in that area. That is why I find it so puzzling that the Government will not take action in relation to folic acid in white flour. It is beyond comprehension.

Finally, I will mention the other issue raised in the Minister’s letter. He is very gracious in agreeing to meet organisations that noble Lords ask him to meet, and he should know how grateful we are to him for that. But my noble friend Lord Rooker asked whether the Minister for Public Health, Jane Ellison, would meet Sir Nicholas Wald, and obviously she has turned down that request. I must say that it is outrageous for a Minister to turn down a meeting with Sir Nicholas Wald. He has huge scientific advances to his credit, and he was the leader of the research in 1991. Given that the Government have decided not to go ahead with fortification, it is really a bit much that the Minister concerned is not even prepared to tell Sir Nick to his face why they are not going ahead with it.

We know that the noble Lord, Lord Prior of Brampton, is a great servant of this House. I hope that at the end of this debate he might at least be able to open the door to some further dialogue on this matter.

NHS: Junior Doctors’ Contract

Lord Hunt of Kings Heath Excerpts

Wednesday 6th July 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they propose to take in view of the decision by junior doctors to reject the terms negotiated on the proposed new contract.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask a Question of which I have given private notice.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, in May after nearly three years of talks, several days of damaging strike action and following conciliation through ACAS, the Government, NHS employers and BMA leaders reached agreement on a new, safer contract for junior doctors. The Government decided that to help deliver their manifesto commitment for a seven-day NHS, they will now proceed with the phased introduction of the new, safer contract, which is supported by the BMA leadership.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the Minister for that statement. It is clearly a matter of great regret that the issue of the new contract for junior doctors has not been resolved satisfactorily and that the Government are intent on imposing the contract. What legal power do the Government have to impose that contract? Can he tell me whether the Government have any plans to resume discussions with the junior doctors? At the heart of the dispute is a lack of trust in the Government on the part of those junior doctors. What plans do the Government have to restore that trust and the trust of patients in the NHS?

[Lord Prior of Brampton]

My Lords, it is certainly a matter of regret on all sides that this dispute has not been resolved in an amicable, satisfactory way; I agree with the noble Lord on that. The Secretary of State plans to introduce the new contract with NHS employers in a phased way beginning in November. He has said that in terms of how the contract is implemented and any extra-contractual issues that arise, his door is always open; he is willing to talk to the BMA and junior doctors.

Public Health England: Alcohol

Lord Hunt of Kings Heath Excerpts

Tuesday 5th July 2016 Lords Chamber

[Lord Prior of Brampton]

I cannot plead that I did not hear the question again, but I am going to have to say that I do not know the answer, so I shall write to the right reverend Prelate later.

[Lord Hunt of Kings Heath (Lab)]

My Lords, my understanding is that junior doctors have rejected the Government’s final offer by 58% to 42%, which is quite a large majority. Will the noble Lord make a Statement tomorrow in your Lordships’ House on the consequences of this?

On the issue of the limit of 14 units of alcohol per week, I looked at the Department of Health’s website this morning and although it talks about the risks of alcohol, it does not actually specify the additional risks of, for instance, keeping the maximum units for men at 18 per week? The lay summary of the principal expert advice and research given to the Chief Medical Officer again does not quantify the risks. It states simply that there is a raised risk. Does the Minister accept that if we are not prepared to give the public the real facts, it is unlikely that the advice of the Chief Medical Officer will be taken seriously? I wonder if he can have a look at this.

[Lord Prior of Brampton]

On the first issue, I cannot commit to giving a Statement tomorrow—that depends on decisions elsewhere. Certainly, if there is a Statement in the House of Commons I would expect it to be repeated in this House. On the other issue, the Chief Medical Officer’s guidelines are based on real facts. The last time the CMO issued guidelines was, I think, in 1995. Between then and now the scientific link between alcohol and cancer has changed, so she feels that it is right to put the facts into the public domain. As I said, we are consulting on how we word those guidelines to the public.

Health: HIV

Lord Hunt of Kings Heath Excerpts

Monday 4th July 2016 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they will instruct NHS England to commission the use of pre-exposure prophylaxis (PrEP) for patients with HIV.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, after taking legal advice, NHS England has concluded that it has no legal power to commission pre-exposure prophylaxis. NHS England’s decision is currently subject to judicial review by the National AIDS Trust and we are therefore unable to comment further on the legal position. We will consider the options available following the outcome of the legal review.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this is a perverse decision on a ground-breaking drug that could save many people’s lives. Essentially, NHS England is hiding behind the responsibilities of local authorities in relation to sexual health services. How long must we wait before the public get the use of this drug, which is widely available in other countries? The Government should instruct NHS England to get on and make it available.

[Lord Prior of Brampton]

My Lords, the judicial review is being held next Wednesday, which is only 10 days from now, at which point we will know the exact legal position. I really cannot comment further on it today. As far as this drug being widely available as a prophylaxis, it is widely available only in some countries for very specific groups of people. If we commission it in the future, it is important that we are clear about where we can get the most benefit from it.

Tobacco and Related Products Regulations 2016

Lord Hunt of Kings Heath Excerpts

Monday 4th July 2016 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

As an amendment to the above motion, to leave out “and calls upon Her Majesty’s Government to withdraw them” and insert “and further regrets that the Regulations are not to be accompanied by a public information campaign to reassure smokers that electronic cigarettes are less harmful than normal smoking; that smoking cessation services are being cut back at the same time as the Regulations are being introduced; and that the Regulations are due for implementation before the Government have published their tobacco strategy.”

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome this debate and thank the noble Lord, Lord Callanan, for allowing us to have a further go, since we have already debated it in Grand Committee. I am sure the Minister is looking forward to winding up at the end of the debate.

I should declare an interest as president of the Royal Society for Public Health, which has pronounced on e-cigarettes. I would say to the noble Lord, Lord Callanan, who was a mite critical of the organisation, that as a Minister I established the MHRA, and I am glad to see that it is doing so well in relation to this matter. I liked his rousing endorsement of the record of Ministers in his Government on this matter. When he mentioned Edwina Currie, I thought he was going to talk about eggs—he will recall that she had a bit of a downer on egg production—but she did not quite take it to Europe in the way he suggested.

I have moved an amendment to the Motion because, although I share some of the noble Lord’s concerns about the regulations in relation to e-cigarettes, my problem with his Motion is that he calls on the Government to withdraw the entire set of regulations. The regulations cover e-cigarettes, but there are also a lot of useful measures that will discourage smoking in general. That is why I cannot support the noble Lord’s Motion, although I share some of his concerns.

It is pretty clear from the work of my own organisation, the Royal Society for Public Health, as well as from that of the Royal College of Physicians and other health bodies, that e-cigarettes can actually be an incredibly useful tool in encouraging smokers to give up smoking. The core of people who have already taken advantage of e-cigarettes are often those whom traditional public health measures have not touched. That is why I am particularly concerned about whether the regulations will have a negative impact on that group.

Equally, I know that noble Lords will quote the report of the Royal College of Physicians. It is worth reading because it says that there is a case for some regulatory provisions, and the Minister will no doubt refer to that. However, my main concern is the point, which was made by the noble Lord, Lord Callanan, that RSPH research has revealed that 90% of the public have the impression that e-cigarettes are at least as harmful as tobacco. That is not helped by the fact that some organisations have notices prohibiting not just smoking, but vaping. Because some elements in the public health field—how can I put this kindly?—perhaps got the wrong end of the stick when e-cigarettes were first produced, they have given the impression that e-cigarettes are much more harmful than they are. The problem with the regulations is that they colour the context, and the public may be confused about the positive effect that e-cigarettes can have. Therefore my amendment to the Motion—I do not intend to delay the House very long—seeks to draw attention to some of the concerns that we have about the regulations on e-cigarettes, although we wish to see the regulations introduced as a package.

However, I also draw attention to the other problem that we have with the Government’s current policies on smoking cessation, which is that budgets, particularly those which go to local authorities, have been drastically reduced, and we have seen a drastic reduction in smoking cessation services. As an example, the amount of money that has been spent on smoking cessation media campaigns has been drastically reduced. Some £24.91 million was spent in 2009-10, which has become £5.3 million in 2016. Of course, I understand budgetary constraints, but I would also say that because of the risk of confusion by the public over e-cigarettes, some Department of Health-sponsored public campaigning is necessary to get the right facts across to the public.

[Lord Forsyth of Drumlean (Con)]

The noble Lord said that he could not support my noble friend’s Motion because it referred to all the regulations. Why, then, does his amendment not seek simply to delete Parts 6, 7 and 8 of the regulations? Which parts of the regulations as they stand does he not agree with?

[Lord Hunt of Kings Heath]

I thought that my amendment elegantly dealt with the broad principles rather than going into technical details such as which paragraph I do not like. I am disappointed by the noble Lord’s intervention on that matter. No doubt he is stunned by his noble friend’s remarks that in fact the EU came to the rescue of the UK. We know that if the EU had not legislated in this area, the Government would certainly have brought in legislation much earlier which would have been much more draconian than the regulations that are before the House tonight.

[Lord Forsyth of Drumlean]

We can change that.

[Lord Hunt of Kings Heath]

No doubt we will of course be able to see in the future what a Government would do in the event of Brexit. However, to be fair, at the moment we are debating these regulations, which have come into force. I have attempted to signal some of my concerns that this would have a negative impact on the use of e-cigarettes without detracting from the overall regulations. I beg to move.

[Baroness Walmsley (LD)]

My Lords, I was most interested in the speech made by the noble Lord, Lord Callanan, and in particular his gallant admiration of his colleague the Public Health Minister, who in my experience has usually been quite on top of her brief. I venture to warn the noble Lord never to make a mistake in your Lordships’ House, because I suspect that Facebook might be watching. I was also very moved by his defence—in fact it was quite tear-jerking—of the discrimination against the multi billion pound tobacco companies compared with the multi billion pound pharmaceutical companies.

I agree with much of what was said by the noble Lords, Lord Callanan and Lord Hunt of Kings Heath, about the desirability of encouraging smokers to give up smoking. There is no doubt that vaping devices have an enormous role to play in this campaign, as many former smokers have managed to give up through using them. However, the regulations are not just about vaping devices but include, as the noble Lord, Lord Hunt, pointed out, standardised packaging regulations, which are essential for ensuring the effectiveness of the health information and warnings on cigarette packs. They also help to enable the UK to meet its obligations as a party to the World Health Organization’s Framework Convention on Tobacco Control with respect to tobacco packaging and labelling, and product regulation.

There is no doubt that vaping devices have already been an enormous benefit to public health—although I fail to see why we need 25,000 different kinds of them—and have saved the NHS a great deal of money. When the directive to which these regulations give effect was first discussed in the European Parliament, as has been said, the Liberal group, which contained at that time several Liberal Democrat MEPs, worked hard to ensure that while the regulation of tobacco packaging continued to be robust, the regulations about vaping devices would be proportionate. Given that the original proposals followed the World Health Organization’s recommendation that these products should be licensed as medicines and would therefore be extremely tightly regulated, the Liberal group had some considerable success in making them a bit more proportionate, resulting in the directive as it is now. However, one of the things on which the group was not successful was the prohibition of commercial advertising of vaping products. This is the major item contained in my regret Motion.

According to the Royal College of Physicians, vaping is 95% less harmful than smoking and half of all smokers die from diseases that result from smoking. That is why it is vital that smokers can get information about these products and their benefits, and I regret very much that publicity about them is to be restricted. However, I support the noble Lord, Lord Hunt, in his call for a new public information programme to inform smokers of the benefits of switching to e-cigarettes. It may surprise your Lordships to know that half of smokers are not aware of how much safer for their health e-cigarettes are. I also agree with the noble Lord, Lord Hunt, in regretting the cutting of smoking cessation services—one of the many results of the public health funding cuts which I have condemned many times in your Lordships’ House.

I suppose that one of the reasons for the advertising ban is the fear that advertising will attract young people to vaping even though they have never smoked. This is of course undesirable, because nicotine vapour is very addictive, and I would not want to see children being attracted to spending their money on something so addictive and with no known benefits to their health. Indeed, more research needs to be done on the effect of nicotine inhalation combined with the various flavouring chemicals used in e-cigarettes. Some evidence is emerging that if inhaled, some of the flavourings may be harmful to the delicate cells lining the lungs. But although e-cigarettes have been around for years, there is no significant evidence that they are attracting non-smokers to take them up. On the other hand, we now have a large and growing cohort of people who use vaping devices, which is why I call on the Government to fund research on the benefits and—if there are any—the dangers of vaping.

Everything should be done to encourage smokers to switch to vaping, which is why my Motion also regrets that little attention has been paid to those vapers who claim that they need the higher-end concentration of nicotine products, which would be banned by some of these regulations, to help them give up smoking. Only time will tell whether that is the case. That is why the Government need to monitor and report on the implementation of these regulations and their impact on public health. While the further regulations on cigarette packaging are likely to be good, those on vaping devices could turn out to be bad.

Therefore, like the noble Lord, Lord Hunt, I do not support the Motion in the name of the noble Lord, Lord Callanan—that the Government should withdraw these regulations—because we need the ones that affect tobacco. However, although I sincerely regret the Government’s current intention to withdraw from the European Union in the fullness of time and hope very much that it never happens, the current situation does give us an opportunity. As things stand we are not able to keep the good tobacco regulations and ditch the undesirable ones, but the forthcoming negotiations do give us an opportunity to do a bit of cherry picking.

I therefore ask the Minister, what is the Government’s intention with regard to these and other EU regulations? Do they plan to adopt them all and then repeal the ones they do not like? If so, I call on the Government to consider carefully any deterrent to smokers switching that might result from these regulations, and to repeal the ones that deter them as soon as possible. Of course, that would require careful monitoring and publication of the results. On the other hand, in the unlikely event that the Government plan to repeal all EU regulations and then adopt new UK ones, I call on them to replace only the ones that affect tobacco packaging and marketing to further decrease the public health burden of tobacco and the terrible effects on the health of individuals and the NHS.

Given that all these regret Motions are non-fatal, I do not intend to vote on mine, although if the noble Lord, Lord Callanan, votes on his, my colleagues and I will vote against it. We are where we are. What matters now is what the Government do in future. Lives depend on it.

--- Later in debate ---

[Lord Prior of Brampton]

It is possible. There is always a possibility when there is a regulation that a black market will develop, and for the very high-strength products, which had to be regulated by the MHRA—the ones above 20 milligrams—there is a risk that there will be a black market. I think I recall that the noble Lord said earlier that a black market had already developed in this product. We are trying to bring some minimum quality standards, at least, into this market so that people who are thinking of moving from smoking to using e-cigarettes can have confidence that the product they use is regulated to a minimum standard.

I remind noble Lords that new and important tobacco control measures are also contained in these regulations. I have not talked about them specifically because they are slightly off the main point of this debate. The regulations will be reviewed within five years of entering into force. I also commit, here and now, to commissioning Public Health England to update its evidence report on e-cigarettes annually until the end of this Parliament and to include within its quit-smoking campaigns consistent messaging about the safety of e-cigarettes.

Clearly, there are strong arguments on both sides of the debate. As I said, I am not an instinctive regulator by any means but I feel that these regulations are proportionate. They do not go over the top, are entirely sensible and are backed by the RCP and all the major charities in this area. I hope that my noble friend Lord Callanan will not wish to push this to a vote, but of course that is entirely his decision.

[Lord Hunt of Kings Heath]

My Lords, I thank the Minister for his wind-up, which I think was very fair. I agree with him that this has been an excellent debate and various views have been put forward. I understand why some noble Lords have concerns about e-cigarettes, particularly in relation to young people. I understand that there are still some uncertainties. I accept that there is a need for some regulation in relation to e-cigarettes.

The Royal College of Physicians produced an excellent and dispassionate report but in the end it concluded that, while not absolutely safe,

“the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco”.

That is a pretty powerful statistic. The royal college supports the regulations—I understand that. We have been told by the noble Baroness, Lady O’Cathain, that 2.8 million people currently use e-cigarettes. We know that often it is the poorest people in society whom many of the traditional approaches to giving up smoking have not touched. Equally, we know that there is a problem with smokers who think that e-cigarettes may be much more harmful than they actually are.

The noble Lord, Lord Prior, rightly said that smokers are aware of e-cigarettes: I take that point. However, there is this worrying statistic that many smokers feel that e-cigarettes are very harmful—almost as harmful as smoking cigarettes. That worries me. I worry that the regulations may make that worse. This is where the absence of cohesive, strongly financed public health programmes comes in. That is why I believe that my amendment finds a delicate way through the morass that we have been debating today and why I wish to test the opinion of the House.

NHS: Unsafe Hospital Discharges

Lord Hunt of Kings Heath Excerpts

Wednesday 15th June 2016 Lords Chamber

[Lord Prior of Brampton]

The noble and learned Baroness is right, up to a point. I said one or two because the PSHO report focuses on nine individual cases. In so far as they are representative of behaviour across the country, they are important, but I want to put on record that the vast majority of hospitals the vast majority of the time are getting their discharge procedures right and are doing an outstanding job.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister has readily identified the problem of unsafe discharges. Why is there no explicit reference to this issue in the NHS mandate to NHS England for 2016-17?

[Lord Prior of Brampton]

I cannot give the noble Lord a reason off the cuff. It is very much a part of the better care fund. There is a CQUIN for 2016-17 that is focused on delayed discharges. One of the fundamental purposes underlying the STPs and the vanguards, which are a critical part of taking the Five Year Forward View into a serious plan, is to reduce delayed discharges and improve the relationship between acute care and social care.