NHS: Maternity Care
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Lord Hunt of Kings Heath (Lab)
My Lords, I, too, very much welcome the initiative of my noble friend Lord Harrison in allowing us to debate these very interesting issues. I agree with many of the points that he made about the risk of fragmentation of services and the need for more prenatal and postnatal care. The noble Baroness, Lady Manzoor, made a very good point about mental health, and indeed it was raised at Oral Questions this morning by my noble friend Lady Royall in relation to postnatal depression. The role of fathers was given a great deal of emphasis by my noble friend and the noble Lord, Lord Farmer. Also recognised was the excellence of many maternity services. I agree with my noble friend that one of the roles of maternity services in this country is to share good practice globally.
On the question of choice, it is very clear that we have a problem at the moment. The Public Accounts Committee made some very important recommendations about choice in its report of January 2014. In particular, the National Federation of Women’s Institutes suggested that although many women wish to take advantage of midwifery-led units, not enough are given the choice. It is not always my experience that these units are used sufficiently once they are set up, and certainly, looking at the numbers in a lot of them, it is clear that they are bordering on viability. Despite the view that has come across from opinion polling, confidence in using those units needs to be built up among parents and mothers. That is something that the NHS may need to think about in the future. Often, the units are set up because the service has been downgraded. Services are now centralised and I am sure that that is appropriate, but it can lead to a loss of confidence among many members of the public about what is left of those midwifery-led units.
I want to ask the noble Earl, Lord Howe, something else that was raised by the PAC. It says that the NHS has persistently failed to deal with inequalities in maternity care. It adds that the latest data on women’s experiences show that black and minority ethic mothers are less positive than white mothers about the care they receive during labour and birth. What is the NHS doing about that? I also refer the noble Earl to Oxford University’s National Perinatal Epidemiology Unit, which found that the most deprived women in England were 38% less likely to be seen by a professional prior to 12 weeks’ gestation and 40% less likely to report being able to see one as early as they would have desired. Presumably they are the people who most ought to take advantage of those services. What can we do about that?
Can the noble Earl respond to the point raised by the PAC concerning confusion around the department’s policy on maternity services, what it wants to achieve and who is accountable for its delivery? Of course, this is partly a product of the arrangements resulting from the 2012 Act, but clearly it is very unsatisfactory in terms of having a cohesive policy at local level and then ensuring that it delivers. I point out to the Minister that, prior to the PAC report, the NAO inquiry found that the department did not fully consider the implications of delivering the ambitions that it had set out in its strategy for maternity services. It went on to say that it was unclear how local commissioners were monitoring the performance of the providers of maternity services and holding them to account. The noble Baroness, Lady Cumberlege, pointed to the ability of mothers to take advantage of home births. How can we make sure that the enunciated policy is implemented unless there is proper monitoring? I very much agree with what she had to say about that.
My noble friends Lady Wall and Lord Harrison referred to training commissions and training in general. There is a concern that with a huge increase in the number of births in recent years, the number of training commissions is not keeping pace with need and demand. That is one reason why so many midwives have left the profession and why it is such a challenge to bring them back into the service. I should just like the noble Earl to say a little more about how convinced he is that we have got the number of training commissions correct.
Is the noble Earl prepared to say something about the relationship between midwives and consultant obstetricians? My noble friend referred to Morecambe Bay, where I think one of the issues was a very poor relationship. We know that there are tensions up and down the country. I wonder whether there is a leadership role within the department to try to bring the professions together at a national level and to resolve some of those tensions. They cannot be good for the safety and quality of care within midwifery units. Yet this issue is being raised in a number of areas.
Finally, on midwifery leadership, it is essential that we have visible, strong leaders locally and nationally. Is the noble Earl satisfied that at his department’s level and at NHS England there are sufficient midwifery-led professionals and a visible head of profession, perhaps a chief midwifery officer? Often, midwives are subsumed within the nursing profession. They are a separate profession but they often come under the management and leadership of a chief nurse. Sometimes midwifery does not get a fair shot when it comes to issues about arguing for resources and priorities. I wonder whether the noble Earl is able to comment on how we can enhance leadership nationally and locally.
NHS: Financial Tariff for 2015-16
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what is their response to the rejection by National Health Service Trusts of the financial tariff proposals drawn up by Monitor for 2015–16.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we recognise the frustration and uncertainty this delay will cause providers and commissioners. My department is working closely with Monitor and NHS England to consider which option to pursue that provides the fairest settlement for different NHS organisations while ensuring that patients continue to receive the best possible care.
Lord Hunt of Kings Heath (Lab)
My Lords, I thank the noble Earl for that reply. Can he confirm that this is the first time that NHS trusts have rejected the tariff on the grounds that they can no longer provide safe and quality care and meet financial targets next year on the basis of the tariff laid down by Monitor? Can he also confirm that the finance director of the NHS Trust Development Authority told Monitor that he does not consider that the efficiency requirement for next year can be met without risking quality of care? When will the Government take responsibility for the financial disaster coming upon the NHS?
Earl Howe
My Lords, it should not cause us any surprise that, at a time of financial stringency in the NHS and increasing demand, it should have proved more difficult than usual to arrive at a settled position on the tariff. The process is undoubtedly complex and challenging but we will continue to work with and support Monitor and NHS England in managing this in a way that attempts to be as fair as possible to all parts of the system.
Smoking: E-Cigarettes
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Earl Howe
My Lords, e-cigarettes are undoubtedly helpful to some people in enabling them to cut down on, or quit, smoking. The evidence is encouraging and we would not want to stop smokers trying out e-cigarettes as an alternative, particularly if other remedies have failed. Equally, we need to be cautious as regards the long-term health effects of using e-cigarettes. That is why the Chief Medical Officer is currently not able to recommend their use.
Lord Hunt of Kings Heath (Lab)
My Lords, does the noble Earl agree that the noble Viscount is perhaps guilty of a little bit of journalistic licence on this issue? The Cochrane review undoubtedly produces encouraging results, but its research contains a big “but”, in that it cautions that only two studies, covering just over 600 smokers, were reflected in the review. The Cochrane review says that we should await the outcome of further studies. Does the noble Earl agree, and can he inform the House when we are likely to see the outcome of those further studies?
Earl Howe
My Lords, the noble Lord is correct. The Cochrane review concluded that the quality of the evidence overall is low because it is based on only a small number of studies. The National Institute for Health Research has recently commissioned a large randomised control trial to examine the efficacy of e-cigarettes compared with nicotine replacement therapy when used within the UK’s stop smoking services. That project is due to end in 2018 and will certainly improve our current understanding.
Smoke-free (Private Vehicles) Regulations 2015
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Viscount Simon (Lab)
My Lords, the Minister knows—I suppose I should declare it as an interest—that in January 1995 I developed severe brittle asthma. On a motorway with my car windows closed, I probably will have an asthma attack if someone is smoking a cigar in another car. Children are particularly vulnerable to second-hand smoke as they have smaller lungs and breathe faster, and their immune system is not as developed as that of adults. This leaves them more open to ear and lung conditions triggered by passive smoking.
It has not been mentioned this afternoon and it is not generally known or acknowledged, but the concentration of tobacco smoke in a car with the windows half down is much higher than the amount of smoke that there used to be in pubs in the old days, and it increases to 11 times more in a stationary car with the windows closed. If parents knew of this, I suspect that they would stop smoking in their cars, but they do not know. We therefore have these regulations before us today. The Minister has given us an excellent description of how the regulations will work, and I support them.
Lord Hunt of Kings Heath (Lab)
My Lords, I, too, welcome the regulations. They follow on from my amendment at Report to the Children and Families Bill, which was agreed by 222 votes to 197, to ban smoking in cars when children are present. I am very proud of that amendment and I express my thanks to organisations such as ASH, the British Lung Foundation, the BMA and others who lent their support to it. I echo the tributes to the noble Lord, Lord Ribeiro, and to other noble Lords who have been campaigning on this matter for some years, including the noble Baroness, Lady Finlay, my noble friend Lord Faulkner, and the noble Baroness, Lady Tyler. My noble friend Lord Simon persuasively and eloquently illustrated the issues that we are dealing with. I am confident that these regulations, if they come to be successfully implemented, will do a lot on those issues.
My noble friend Lord Foulkes was very brave, a long time ago, to pioneer the proposal. What he had to say about the tactics and activities of the tobacco companies was a point very well taken. I welcome the Government’s decision to go ahead with standardised packaging regulations but we know that many of those companies will do their best, through representative bodies, to sabotage them—as I think they have attempted to do in Australia. We must be ever watchful about that.
I agree with the noble Baroness, Lady Tyler, that it is interesting how much public support there is for this measure. She may well have seen the work by the British Lung Foundation which has shown, in survey after survey, that a huge majority of children wanted action to be taken. We have also had the ASH poll conducted last March by YouGov, which showed that 77% of all adults—including 64% of smokers—agreed that action should be taken. Does the noble Earl agree that that shows that there is public support for measures such as this, particularly when it comes to the protection of children? I wonder whether he shares our ambition on this side of the Committee to reduce smoking prevalence to 10% by 2025 and, over the longer term, our goal that all children born in 2015 and beyond will become the first smoke-free generation in hundreds of years.
I noted that the regulations come into force on 1 October 2015. The noble Earl explained why 1 April is not appropriate but I wonder whether 1 July could not have been chosen instead. The noble Baroness, Lady Finlay, raised the experience in Wales. Is the noble Earl confident that the provisions for Wales will come in at the same time as those for England? Could he say a little more about the public marketing plan being developed by Public Health England? That very much relates to the questions asked by my noble friend Lord Foulkes about enforceability, which is so important. I am confident that a great majority of the members of the public will in fact respect the change in the law. The evidence is pretty strong on that. None the less, we need an effective public health campaign and the support of the police in being prepared to take action against those who transgress the law.
Earl Howe
My Lords, I am very grateful to all noble Lords who have spoken and I am grateful for their universal welcome for these regulations. I begin by referring to the remarks of my noble friends Lady Tyler and Lord Ribeiro and the noble Viscount, Lord Simon, all of whom reminded us why we are doing this—the noble Viscount from a very personal perspective. Three million children are exposed to second-hand smoke every year and we want to protect them. Existing smoke-free legislation is popular, as has been said, and has a very high rate of compliance. Personally, I credit the public with more willingness to follow the law and therefore protect their children from second-hand smoke, rather than thinking of elaborate ways to break the law.
The noble Lord, Lord Hunt, asked about public attitudes in relation to these regulations. We know from the responses to the consultation that there is widespread support for protecting children from the harms of second-hand smoke. I do not expect people to go to great lengths to carry on smoking in cars when they know that it is an offence to do so. As has been said, legislation can be instrumental in driving behavioural and cultural change. That has certainly been true in other areas of regulation in the past. Of course, we have to inform the public in a reasonable way before these regulations come into force.
More generally, we agree that education is essential in informing people of the harms of second-hand smoke, particularly to children, and we recognise the importance of social marketing campaigns. The department and Public Health England will continue to protect children from the harms of exposure to second-hand smoke by encouraging voluntary action through social marketing. Previous campaign results illustrate that such campaigns have been effective both in changing behaviour and in driving quit attempts. Of course, I agree with the noble Lord, Lord Hunt, that our ambition as a nation should be to drive down the prevalence of smoking to the maximum extent that we can. We are going to monitor progress in respect of these regulations by assessing the reduction in the number of children who are exposed to second-hand smoke in cars from the current level of 26%, and it is possible to do that.
As I said, I agree with my noble friend Lord Ribeiro about the importance of building public awareness of these health harms. Once again, I pay tribute to all his efforts in this sphere of activity. I also add my thanks to the noble Lord, Lord Foulkes, for his welcome for these regulations, and I acknowledge his far-sightedness in this context, even if he felt like a voice in the wilderness for a number of years. He expressed concern about the enforcement of the regulations—in particular, in view of his perception that the police do not go to great lengths to enforce the mobile phone laws. In fact, my advice is that the police assure us that they endeavour to enforce mobile phone legislation, as they would any law. In fact, in 2012 more than 90,000 fixed penalty notices were issued for mobile phone offences. We estimate that considerably fewer fixed penalty notices will be issued for smoking in private vehicles—possibly around or slightly above 2,000 each year.
The noble Lord, Lord Foulkes, also questioned whether the £50 figure was sufficient. The regulations were drafted following discussions with the police and others to provide for effective enforcement. As I said, the police have confirmed that they will enforce these regulations in the same way as they enforce other laws, such as those relating to seat belts and the use of mobile phones. It is for individual police forces to decide how enforcement will be carried out locally. They have advised that this can be taken forward by local police officers in conjunction with their wider functions on road safety. For example, when running an operation to check compliance with the laws on seat belts or child car seats, the police would also check for anyone smoking or discuss the offences with the driver if there was tobacco in the car. A fine of £50 is consistent with the existing smoke-free legislation, but that level of fine could certainly be subject to review when the regulations as a whole are reviewed.
Mental Health Services: Sign Language Users
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Lord Hunt of Kings Heath (Lab)
My Lords, I, too, thank my noble friend for instituting this debate and Sign Health for its valuable briefing. I welcome the input of the noble Lord, Lord Borwick, but my noble friend’s Question was quite specific. I fully accept that however widely you define deafness, the scale of mental health problems is serious and deserving of attention. I thought that the noble Lord, Lord Addington, put it well. The focus on British Sign Language users is valuable in itself, but it is also a signal of more general problems.
Interesting work published recently in the British Medical Journal has shown, first, as is well known, that deaf adults in the UK occupy poorer socioeconomic positions, have poor literacy and have limited access to communicate through speech. Their health is generally poorer than that of the general population, with probable underdiagnosis and undertreatment of chronic conditions. As for mental health, other research shows that 40% of deaf people are likely to experience a mental health problem. Although the incidence rate of schizophrenia is probably similar to that of the hearing population, the rate of common mental health problems is much higher. Going back to the BMJ research published only a week ago, the rates of depression self-reported by deaf participants was 24% overall—32% for women and 14% for men.
In any response to the mental health issues facing many deaf people, it is abundantly clear, as the noble Baroness, Lady Tyler, said, that there is no national strategy to which one can turn to describe what services deaf people could expect from the NHS. That is related to confusion about what should be commissioned at national and local level. We see lots of indications that clinical commissioning groups find it very difficult to commission services for what inevitably will be a small population in their area.
Equally, I fully accept that not all of that can be commissioned at the national level. We need to find a way that will help clinical commissioning groups to commission services locally for these smaller population groups so that there is much more of a cohesive approach. I do not think that CCGs will do it if left to themselves. That is the real problem that we face, alongside the funding issues around commissioning at a national level for speciality services. This is not an easy issue, but we have to do better than at the moment.
A number of noble Lords referred to the position facing speciality services, and I want to add to the points that my noble friend made about this. I want in particular to raise the question of the Deafness Cognition and Language Research Centre at University College London, which I understand is putting together a costed business case for a national neurological service for British Sign Language deaf users. I understand that it has met Norman Lamb; it has also met my colleague Andrew Gwynne. This has clear cross-party support. The centre is putting a business case forward to secure the presence of a clinic beyond 2015; I do not know if the Minister will be able to update me on progress in that area.
My noble friend and other noble Lords have mentioned the Improving Access to Psychological Therapies service, which showed very promising results from the date of its introduction. Other noble Lords referred to the outcome measures. This has clearly fallen foul of the problem of being delegated to CCGs to commission; they are clearly not going to do so. I had the privilege of meeting SignHealth with Mr Norman Lamb. We had a very good hearing and I was left with considerable optimism that some way would be found to fund this. Again, if the Minister were able to give us some updates on the progress of that, I would be very grateful.
We come back to the point that, if this is left to local CCGs, there is no hope for services that need a contribution from each CCG to make it viable. One way or another, we have to find a way for there to be some kind of national leadership. Indeed, if I were to ask for one thing above all else, it is that the Minister would see if his department was prepared to produce some kind of cohesive strategy around deaf issues and mental health issues for deaf people. That would then give us some encouragement that we would be able to tackle these issues in a coherent way. I always thought that national service frameworks were a very good idea; I am not sure that the current Government think so but, if we are not to have them, we need something in their place.
I want to ask the Minister about the equality duty in relation to deaf people. Is he satisfied that the NHS understands its responsibilities under the equality duty? The noble Baroness, Lady Hollins, suggested that many staff in the health service are very much unaware of the issues for deaf people and the barriers that they face. The issue here is that we lack national standards against which local NHS bodies could judge their performance. The noble Baroness raised the question of reception and waiting room experience. The fact is that work has been done showing that 90% of deaf people have missed many GP appointments through not hearing their name called out in the surgery. That is just one example of the kind of communication problems that they face. At this point it would probably be better if I sat down and gave the Minister even more time to answer the questions.
Medical Innovation Bill [HL]
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Lord Hunt of Kings Heath (Lab)
My Lords, I, too, welcome the amendment and thank my noble friend for his efforts. I also thank the noble Lord, Lord Saatchi, for the way in which he has been prepared to listen and to support amendments which we see as improving the Bill. This amendment goes a long way to meeting some of the concerns expressed by medical bodies about what might be described as unintended consequences arising from the Bill.
I do not agree with the noble Baroness, Lady Gardner, that this amendment could be seen as delaying action. I think it is rather the reverse. Having this provision and the need to act within it would give confidence to doctors. I think the definition of,
“a representative body of respectable medical opinion”,
is a question of you know what it is when you see it. I would have thought that doctors would have no doubts about to which responsible body they should turn.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, my interpretation of the amendment moved by the noble Lord, Lord Winston, is that it aims to ensure that in obtaining the views of one or more appropriately qualified doctors, a doctor is carrying out a test equivalent to the Bolam test. I recognise that these words are carefully chosen, and I listened closely to what the noble Lord, Lord Winston, said. However, I do not believe that the language of the amendment accurately reflects the requirement of the Bolam test.
To go a bit further, I am concerned that the amendment would create more confusion than clarity for both doctors and the courts. In particular, how would a court determine what is meant by the phrase “command the respect of”? It certainly does not mean agreement. If Noble Lords want an illustration of the difference, I deeply respect the noble Lord, Lord Winston, but, as in this case, I do not always agree with him.
Like my noble friend Lady Gardner, I question what might count as,
“a representative body of responsible medical opinion”.
Again, this wording is not in the Bolam test. The Bolam test sets out that a doctor is not negligent if their decision is accepted as proper by a responsible body of medical opinion. Bolam accepts that a doctor is not negligent merely because there is a body that would take a contrary view. Therefore, the courts recognise that there is not necessarily a representative body of medical opinion. The wording of the amendment would be open to interpretation by the courts.
I recognise that the noble Lord’s aim in tabling this amendment is thoroughly worthy and is to ensure the protection of patients. I assure him that the existing provisions in the Bill seek to achieve that same aim. Therefore, the Government do not consider the amendment moved by the noble Lord, Lord Winston, necessary. The Bill’s provisions boil down to one key test: a test of responsibility. Clause 1(2) states:
“It is not negligent for a doctor to depart from the existing range of accepted medical treatments for a condition if the decision to do so is taken responsibly”.
This objective test of responsibility ensures that the decision about whether a doctor has been negligent is based on the same premise as the existing Bolam test: has this doctor acted responsibly? Patient safety is an integral part of this test. Clause 1(3) makes clear that the risks of any innovative treatment must be considered, so if the treatment was likely to compromise patient safety unacceptably, it is highly unlikely that it would be considered a responsible decision when later judged in court. Furthermore, the Bill does not require doctors simply to obtain the views of experts in the field; it requires a doctor to take full account of those views in a responsible way. As such, a doctor could not simply listen to, or note, the views of colleagues and then proceed to disregard those with which he or she disagrees. A doctor can fully expect a court to scrutinise closely how they have taken account of those views and consider whether they had acted on the views in a responsible way.
It is that requirement which ensures that the Bill is the nearest equivalent to that of the Bolam test. I fear that the amendment of the noble Lord, Lord Winston, despite its best intentions, would not add to the operative provisions of the Bill but would only risk creating confusion as to the language of the existing Bolam test. It is not just that the Government consider this amendment unnecessary—which we do—but that we also have serious concerns about whether the language of the amendment will create confusion for doctors and, indeed, the courts.
“comply with any professional requirements as to registration of the treatment under the provisions of this Act with a scheme for capturing the results of innovative treatment (including positive and negative results and information about small-scale treatments and patients’ experiences),”
Lord Hunt of Kings Heath
My Lords, throughout the passage of the Bill the noble Lord, Lord Saatchi, has been enormously helpful to the House in responding to concerns and in his willingness to accept constructive changes to the Bill. I am most grateful to him for adding his name to my amendment.
We had a useful discussion in Committee and on Report about the establishment of a register that could record uses of the Act. This would be immensely helpful to clinicians, regulators and doctors—and, indeed, patients. It would reassure those who have concerns about the implications of the Act. It would enable use of the Act to be tracked. I argue that it would also help spread good practice. It would inform legislators about further changes to the law that might be required in the light of practical uses of the Act.
On Report, I received considerable support around the House. The noble Lord, Lord Kakkar, is here today. He probably will not mind me quoting from what he said—that,
“the register needs to be obligatory, in which all innovation and the outcome of that innovation is properly reported. It would do much to ensure the development of an enhanced culture of innovation, but also, fundamentally, to provide very important protections”.
On Report, the noble Baroness, Lady Jolly, opposed the amendment on four grounds. First, she argued:
“Requiring doctors to record the results of innovative treatments in order to demonstrate that they have not been negligent … would impose requirements … additional to those in the existing law”,
and,
“may risk deterring doctors from innovating”.
Secondly, she argued that my amendment,
“would widen the scope of the Bill to cover all innovation. This Private Member’s Bill is not the right vehicle to make provision that would relate to all innovation”.
Thirdly—and quite remarkably—she said that,
“the act of putting something into legislation does not guarantee that doctors will adhere to it”.
Fourthly, she said that she would support a voluntary register,
“but it should be such that doctors would not dream of not recording on the register”.—[Official Report, 12/12/14; cols. 2062-63.]
My response is simply: let us put it beyond doubt by making registration mandatory.
On the question of the amendment going wider than the Bill, I have changed my amendment to make it clear that it relates only to this Bill—or Act, as it will become. On whether having to comply with this provision would dissuade doctors from innovating, I simply do not accept that. I would worry about doctors who were dissuaded because of the need to record an innovation in the register. I would have thought it created the conditions in which doctors would feel more confident in taking innovative action. On the suggestion that doctors will not adhere to the legislation, I simply do not accept that and ask what possible evidence there can be of it.
I do not think it is unreasonable to say that every use of the Act should be captured and available, to check on patient safety from the point of view of regulation but also for the purposes of research. I beg to move.
Lord Saatchi
My Lords, I am so grateful to all noble Lords who have spoken on this amendment. I will not in any way detain your Lordships by reciting again what has been brilliantly and articulately expressed by other noble Lords. I will say only one thing about this amendment, which is to pay tribute to Oxford University, whose original concept it was—I refer to Professors Alastair Buchan and Stephen Kennedy at Oxford—that a database should be created to record the results, positive and negative, of innovation under the Bill. The reasons were, as expressed by noble Lords today, to advance scientific knowledge, as the noble Lords, Lord Giddens and Lord Winston, said, and to protect patients with full disclosure and full transparency.
A number of individuals and organisations have told me that any doubts that they had about the utility of the Bill would be removed by the emergence from it of this new and exciting initiative in data collection and sharing. This database will, I hope, be a significant—perhaps enormously significant—development in the field of medical practice. I am confident that my noble friend and the officials in the Department of Health will be able to devise a suitable system, in collaboration with the medical profession and the regulatory bodies, which will achieve what is wanted here.
I will end by saying that I do not remember ever seeing your Lordships’ House in full agreement, on all sides of the House, on one amendment. We have not just had that once, on Report, but have had an exhibition of exactly the same unanimity and strength of feeling again. I very much hope that my noble friend the Minister will not consider voting against the amendment should it be put, but will, as he said, take forward the Government’s commitment to ensure that the register happens and is put in place, and that he will be able to encourage the noble Lord, Lord Hunt, and all the rest of us here that that will happen.
Lord Hunt of Kings Heath
My Lords, it has been a very good debate; I am sorry that it has happened so late in the day. I, too, echo the words of the noble and learned Lord, Lord Woolf, in paying tribute to the noble Earl, who has been extremely helpful during the passage of the Bill. Of course, I am well aware that Sir Bruce Keogh, medical director of the NHS, has himself been extremely helpful in assisting with the drafting of some of the clauses in the Bill.
I will make three or four points. First, the noble Lord, Lord Ribeiro, was very helpful in giving us a practical example of why a register was necessary. The register that he referred to was a voluntary one and was used by most surgeons, but of course not by all. My contention is that, in the specific circumstances of the use of the Bill, we need greater reassurance by having a mandatory register. The noble Lord was concerned in essence that a mandatory register would be a disproportionate requirement, and that in so being it would discourage doctors from using the provisions in the Bill. I disagree with that. All of us have received, at every stage of the Bill, extensive letters from just about all the medical bodies you could think of, all of which have expressed some concerns about the provisions of the Bill. They recognise that the noble Lord has moved a very long way and in a very helpful way, but they remain concerned. My view is that the kind of amendments being proposed today would go a very long way to reassuring those bodies. In the end, the more that those bodies are reassured, the more likely it is that they would provide the advice that would allow their members to consider use of the provisions in this Bill.
We have had a very interesting debate, with contributions from the noble and learned Lords, Lord Woolf and Lord Brown, and the noble Lord, Lord Pannick, on the provisions of the Bill and their relationship to the Bolam test. I make it clear that my amendment refers only to the provisions of this Bill. At Report, my amendment was criticised by the Government because they thought that in its wording it might go wider than the Bill, which is why I have rewritten the amendment to make it clear that it provides only for the Bill. It may well be that, as the noble and learned Lord, Lord Brown, suggested, we should discuss the use of a register in relation to all innovation. However, that is not today’s argument. I believe that we are justified in seeking a specific requirement in relation to the use of this Bill because of its special provisions and, in particular, because of concerns raised by many responsible medical bodies.
On the question of the GMC, I agree with the noble Lord, Lord Saatchi, that it is not beyond the bounds of possibility that the Department of Health and the GMC can come to a sensible outcome within the confines of my amendment. In the end, it may well be that, in the circumstances to which my noble friend Lord Winston has referred, whereby rogue doctors use this legislation inappropriately, it should fall to a fitness to practise committee.
In the end, as the Minister said, we need to engage with the medical community. Many of us have been engaged with it for a long time and we have come under great criticism for seeking to help the Bill. Most of the letters that we received from very responsible medical bodies have asked your Lordships’ House to make sure that the Bill does not proceed. We have tried to be as fair to them as to the noble Lord, Lord Saatchi, and it is through these kinds of amendments that the Bill can go to the other place considerably enhanced. For that reason, I move the amendment.
Alcohol: Impact on Accident and Emergency Services
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Earl Howe
My Lords, we have taken a strong policy on taxation in recent years, particularly to reduce the availability of cheap, strong alcohol. Since the 2010 general election, duties on spirits have risen by more than 18%, which is well above RPI, and on wine by more than 21%, again well above RPI. We have also introduced a ban on the sale of below-cost alcohol, which should stop the worst cases of cheap and discounted alcohol sales.
Lord Hunt of Kings Heath (Lab)
My Lords, can I ask the noble Earl about the attitude of the drinks industry? He said that it is responsible but can he confirm that the long delay in the publication of new guidelines from the Chief Medical Officer on safe drinking levels is because she wants to reduce those levels but the drinks industry objects, and the Government have given in to it?
Earl Howe
Not at all, my Lords. As I explained the last time the noble Lord asked that question, the reasons were purely technical and nothing to do with a disagreement. The CMO is overseeing a review of the alcohol guidelines so that we can ensure that people make better-informed choices. That is now under way and in its second phase. During the review we will look at any significant new evidence that relates to pregnancy, in particular, to consider whether our advice needs to be updated. We expect to consult on new guidelines by the middle of this year.
NHS: Clinical Negligence
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Earl Howe
My Lords, moneys paid in settlement of clinical negligence claims cannot be reclaimed or recycled in the way that my noble friend appears to suggest because, in the nature of NHS care, it is free from the patient’s perspective. We are, however, concentrating on various ways to reduce the number of clinical negligence incidents and, indeed, to improve patient safety, which is of course part of the way in which we can reduce the number of claims in the first place.
Lord Hunt of Kings Heath (Lab)
My Lords, what view have the Government taken of the Medical Defence Union recommendation for repeal of the Law Reform (Personal Injuries) Act 1948? In essence, that would mean defendants could buy NHS healthcare packages as opposed to the more expensive private care packages, and, presumably, would reduce some of the cost of the claims that are currently going through.
NHS: Accident and Emergency Services
Lord Hunt of Kings Heath Excerpts(11 years, 1 month ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, this has been an excellent debate. I congratulate the right reverend Prelate on his very penetrating analysis of the challenges facing the NHS at the moment.
Like other noble Lords, I pay tribute to staff in the emergency services, indeed in the whole of the health and social care system, for the way that they are responding to the enormous pressure. The noble Lord, Lord Greaves, really put his finger on it when he talked about some of the pressures. We know that junior hospital doctors are at the moment not being attracted into emergency departments. Can the noble Earl tell me whether the Government have a strategy for finding ways in which we can both encourage new doctors into emergency departments and also relieve some of the pressure on them so that they do not burn out and find it overwhelming when they face situations as they do today? Will he also respond to my noble friend Lord Simon on the contribution of St John Ambulance and other services like it?
On the actual pressures, my noble friend Lady Gale spoke very eloquently about the pressures in relation to people with Parkinson’s. The right reverend Prelate the Bishop of Ely talked about the doubling of admissions over 20 years. Can the noble Earl say what the Government expect in relation to flows of patients through hospitals through A&E? He will know that the five year plans of NHS trusts and foundation trusts are all predicated on reducing capacity on the basis that something will happen elsewhere so that patients no longer need to go to hospital. There is very little sign that that is going to happen, and I would like to hear what the noble Earl has to say about that.
I understand the point about politics. I gently point out to the House that this yearly increase is nothing new. In the previous Government we managed to cope with it and keep within our targets. There is no doubt that something has happened. I have no doubt that the restructuring has had an impact. The one thing that is missing above all else at the moment is someone being in charge locally. There is no one single person in a health and care system you can go to and say, “You are in charge. You are responsible”. We desperately need to get that local leadership back.
On the 111 issue, which the noble Lord, Lord Jones, raised, are the Government going to undertake a review of it? Has the noble Earl seen the evidence given yesterday by Cliff Mann, the president of the College of Emergency Medicine, when he said that the “absurd” 111 helpline is to blame for overloading A&E with patients?
I also pull up the point made by the noble Lord, Lord Greaves, about the ambulance service. Is the Minister as alarmed as I am by reports today of ambulance staff from the East of England Ambulance Service leaving the dead body of a man on the floor so they could finish their shift on time and indeed the report yesterday of staff there on their own volition apparently not following procedures in relation to the maximum call-out times? What is going on in the East of England Ambulance Service? We need an external review of it. On ambulance services I also ask the Minister about the policy of some services very insensitively called “drop and run” where patients are left at the door of A&E without a proper handing over to A&E staff after a certain time limit of 30 to 45 minutes.
On the weekly A&E data, one trust last week hit only 53.7% against the 95% target. What impact does the noble Earl think that will have on mortality rates? Is monitoring going on to see what impact that is having on safety and quality?
Finally, does the noble Earl agree that there are all sorts of issues such as 111, primary care and people’s predilection to come through the door more often because A&E is a place where they are going to get high-quality care from a lot of staff which is not available out of hours elsewhere? However, when it comes down to it one single issue is clearly responsible for most of our problems—the swingeing cuts made by the Government to local authorities and the impact on social care. The real issue is that patients cannot be discharged into the community because the community facilities have gone. What is the noble Earl going to do about that?
London Health Commission: Smoking
Lord Hunt of Kings Heath Excerpts(11 years, 1 month ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, I start by reminding the Committee of my presidency of the Royal Society of Public Health. Of course I very much welcome my noble friend’s debate and, indeed, the excellent report. I like the aspirations and ambitions contained in it. Coming from Birmingham, I rather wish that we could have a similar report, and I will try to persuade my noble friend to come and write one. It strikes me that the traditional joint strategic needs assessments produced by directors of public health are often dry documents that do not really capture, in their very succinct message, the challenges and what needs to be done about them. I would love to see other parts of the country follow this model.
In Birmingham, 22% of young people are obese, and we know that that is going to store up huge problems for the future. Yet, looking at my noble friend’s paper, the figures are even worse for London. He mentions that:
“London has the highest rate of childhood obesity of any peer global city, and the highest proportion of obese children in all the regions of England. In London almost 1 in 4 children in Reception and more than1 in 3 children in Year 6 are overweight or obese”.
If you think about the scale of that problem, it is imperative that we start to do something about it. On smoking, my noble friend points out that:
“London boroughs with high smoking prevalence are also some of the poorest boroughs. Although there is a downward trend across most of London, there is a difference of 10% between the best and worst performing boroughs, and stark health inequalities are caused by smoking rates being much higher amongst people who work in manual or routine occupations”.
That is matched by the inequality experienced by children born today in different parts of London, who can have very wide differences indeed in their life expectancy.
The aspirations and ambitions seem to me to be excellent. I like many of the proposals. The idea of boosting the number of active Londoners to 80% is quite a goal. Gaining 1.5 million working days a year by improving employees’ health and well-being offers a very apt illustration of the link between health, well-being and the general economy. It is something that we need to really work on. I like the ambition to have the lowest death rates in the world for the top three killers. I agree that GP practices in London should be open from 8 am to 8 pm and that services should be delivered in modern, purpose-built and designed facilities. My noble friend told us how to do that quite a few years ago and it is to my eternal regret that we did not make enough progress on it. Anyone looking at the problems we are now facing in primary care and wanting to see the solution need not look much further than my noble friend’s report.
It is coincidental, though I would like to think that we planned it together, that the Labour Party today announced the public health programme that we wish to take forward post-election. It is very much dual-pronged in the sense that we see a really positive role in, rather than finger-wagging at adults, actually helping them to be empowered with information to make healthier choices and supported to get active, along with all the other things needed to improve their health. However, in the case of children, we wish to see statutory action and we particularly emphasise maximum limits to be set on levels of fat, salt and sugar in food marketed substantially to children. That would have a very big impact on obesity issues, alongside many more programmes around lifestyle in schools, particularly in physical activity.
On smoking, we wish to reduce smoking prevalence to 10% by 2025. We will have a goal that children born in 2015 will become the first smoke-free generation in hundreds of years. I was very proud to move the amendment to ban smoking in cars with children and I received support from almost every noble Lord present in the debate today. It was very good to see. I was struck by the overwhelming public support for that measure: it shows that the public will support these kinds of measures. We are also keen to introduce a levy on tobacco companies to be used to ensure that they make a greater contribution to the cost of tackling tobacco-related harm.
There is nothing further I could say about standardised packaging that has not been said already. I simply remind noble Lords that this was done on the basis of the report undertaken by Sir Cyril Chantler, who concluded that the body of evidence shows that standardised packaging is very likely to lead to a modest but important reduction over time. I stand behind Sir Cyril Chantler’s report.
I hope that the noble Earl is going to give us good news today. He will understand that there is a mite of scepticism about the Government’s approach to these matters. There is a suspicion that the Government are rather too close to some of the tobacco companies and rather too much under their influence. He could, at a stroke, put that right by telling noble Lords that these regulations are going to be laid within the next few days. I hope that he will do so.