Health: Dementia

Lord Hunt of Kings Heath Excerpts

Wednesday 22nd January 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

First, I refer noble Lords to my health interests as chair of a foundation trust, president of GSI and consultant and trainer with Cumberlege Connections. I, too, would like very much to thank the noble Baroness, Lady Gardner of Parkes, for allowing us to debate this important issue tonight. I also echo the tribute paid by my noble friend Lord Jones to the Alzheimer’s Society, both for the work that it does and for the very helpful briefing that I have received tonight.

If we come back to the question put by the noble Baroness, Lady Gardner, she is surely right about the important focus on improving information to the public, and trying to get over some of the stigma problems to which she referred. She referred to cancer—and I remember when, in the 1950s, people would not actually use the word “cancer”. It was almost hidden away. Clearly, there are issues with dementia, which we must tackle with enthusiasm. My noble friend Lady Turner spoke eloquently of the terrible impact that dementia can have on loved ones.

On a more optimistic note, both the noble Baroness, Lady Greengross, and the noble Lord, Lord Jones, said that much can be done. However, the problem is that often people do not know that that is the case. A major problem is the lack of information in many cases when a diagnosis is made. That, of course, assumes that a diagnosis is made. My understanding is that diagnosis rates are currently only 48% in the UK, and vary widely across the country. This suggests that more than half of people with dementia do not receive a formal diagnosis and therefore do not get access to vital treatment and support. How does the noble Earl think that we might improve diagnosis rates? Will he also consider the Alzheimer’s Society’s priorities for improving post-diagnostic support, to which my noble friend Lord Jones referred? That society’s priorities are that health and care professionals should provide post-diagnosis information packs, that information must be accessible and useful to people with dementia and not just available digitally—a very important point—and that commissioners must also consider the needs of carers of people with dementia in their local plans.

When a diagnosis is made of any condition, not just dementia, why is the information provided by societies such as the Alzheimer’s Society not automatically given to patients? It has long been a puzzle to me why the health service in particular finds it so difficult to give out this information. Any help the noble Earl can give in that regard would be appreciated.

Will the noble Earl say a little more about research? A number of noble Lords have referred to this. Research into dementia has improved but there is a long way to go compared with research into other diseases. I hope that the noble Earl will be prepared to comment on his own department’s policies on this issue and on the influence of the Medical Research Council in this area.

My noble friend Lady Turner said that people with dementia are best looked after at home. That must surely be right. However, the noble Earl will know that at the moment many patients with dementia are in National Health Service acute hospitals. Some people use the wretched term “bed blocking”, which I think is very unfortunate. However, there is no doubt that one of the problems for accident and emergency departments is the difficulty of discharging patients with dementia once they get to hospital, and, of course, those patients often suffer from co-morbidities. Has the noble Earl looked at the report of the Royal College of Physicians which suggests that, rather than having specialised hospital consultants, we need general physicians who can treat patients with co-morbidities? This is very relevant to people with dementia. Will he write to me on that issue if he cannot comment on it today?

The noble Baroness, Lady Gardner of Parkes, referred to nursing. I very much agree with her that in retrospect the phasing out of state enrolled nurses was an absolute disaster. I am afraid that it was done at the behest of the nursing profession. It is not satisfactory that we now have only one tier of registered nurse. I will not go back to the issue of healthcare assistant regulation, although rumours reach one of a Bill that will allow us to debate that again at some point in the near future. However, the substantive point the noble Baroness made was that we need to look at nurse training and, I think, healthcare assistant training, in this area.

We can tackle this issue only in a wider context. My noble friend Lord Jones said that the Question posed by the noble Baroness is a strategic one. I very much agree with that. The noble Baroness, Lady Greengross, talked of the need, in the case of an individual with dementia, for a navigator and co-ordinator. My argument would be that we need the equivalent at the national level also. We have the national dementia strategy for England but my understanding is that it is due to end in April 2014. I ask the noble Earl whether he thinks that the Government would be prepared to run with another national strategy.

This is a terrible illness. It impacts on 850,000 people at the moment; I believe that that figure is estimated to increase to 1 million or so by 2021. The need for national leadership and a national strategy is overwhelming. The noble Earl might not be able to commit to that tonight but I hope that he will take the message from noble Lords here, which is that this is a terrible illness, much can be done to help people with dementia if we have co-ordinated action, much more research ought to be done, and we need greater co-ordination at local level.

I hope that the noble Earl will pick up the suggestion of the noble Baroness, Lady Greengross, that local co-ordinators and navigators of care would be extremely helpful. Perhaps he will also pick up the point raised by my noble friend Lord Jones about the role of business and industry in supporting local societies. He gave a brilliant example of how that can pull people together and provide real support for organisations such as the Alzheimer’s Society at local level.

Health: Flour Fortification

Lord Hunt of Kings Heath Excerpts

Tuesday 21st January 2014 Lords Chamber

[Earl Howe]

I am sure the noble Lord would agree that we have to take a decision based on the most up-to-date data. The data that we had prior to this were 10 years old and it is important to take a decision in the context of the nutritional state of health of the population. On his first question, all I can say is that the risk to which I referred was considered as part of SACN’s overall assessment and we will draw on that in reaching our decisions on the fortification of flour and give it the appropriate weight that it deserves.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the issue of up-to-date information, as the noble Lord, Lord Rooker, has said, we now have the Wolfson study, which actually leads that organisation to recommend that all countries should introduce folic acid fortification. The Government already have the recommendation of the Scientific Advisory Committee on Nutrition for mandatory fortification. Yes, it says it should be accompanied by actions to restrict voluntary fortification of food with folic acid for the reasons to which noble Lords have already referred. Why on earth are the Government delaying action on this?

[Earl Howe]

My Lords, I can only repeat what I said before, which was that taking this step would be a major step by any standards. We must base it on a proper assessment of the risks and benefits. We have some excellent advice from SACN and we need to evaluate that advice fully before taking a decision.

Public Health Responsibility Deal

Lord Hunt of Kings Heath Excerpts

Tuesday 14th January 2014 Lords Chamber

[Earl Howe]

My Lords, we should welcome any measure that encourages us all to improve our diet, to reduce physical inactivity and to be aware of what we need to do to keep our weight under control. I do welcome that letter.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I hope that the noble Earl will encourage his own noble colleagues to look at themselves in the mirror in the light of that unwarranted attack on my own Benches. Perhaps I can just refer the noble Earl to the report of the National Obesity Forum yesterday, which suggested that, on one of the worst-case scenarios, more than half of the population of this country will be obese by 2050. Does he not think that the volunteer approach may no longer be appropriate? Do the Government not have to take a greater lead on this?

[Earl Howe]

My Lords, there are certainly no grounds for complacency on obesity levels throughout the nation. However, the current data do not support the claim by the National Obesity Forum. In 2007, the Foresight team projected that, based on data from 1993-2004, more than half the population could be obese by 2050 if no action is taken. An analysis based on recent data suggests a flatter trend than the one projected by the Foresight team. I do not agree that we should belittle the responsibility deal. It has many worthwhile achievements to its credit and they are being added to month by month.

Health: Birth Defects

Lord Hunt of Kings Heath Excerpts

Wednesday 18th December 2013 Lords Chamber

[Earl Howe]

My Lords, I recognise the opinion that is shared among many members of the medical community on this. However, the advice we received from SACN, our expert adviser, clearly showed that there are risks and benefits associated with this proposal. It is not an open-and-shut case. Among the things that we have had to consider are the practical implications of implementing SACN’s advice, which is no small matter.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Earl not recognise that in fact the scientific committee he referred to has looked at the issue that he raised and has upheld its previous recommendation that the Government should go ahead? Some 50 countries have already done that; the scientific advice is clear; why on earth are the Government not getting on with it?

[Earl Howe]

My Lords, as I said, SACN’s recommendations highlighted both the risks and the benefits of this proposal—and I certainly acknowledge that there would be benefits. However, there are also implications. For example, SACN recommended that mandatory fortification should proceed only if accompanied by:

“Action to restrict voluntary fortification of foods with folic acid; measures for careful monitoring of emerging evidence on any adverse effects of long-term exposure to intakes of folic acid … and guidance on supplement use for particular population groups”.

We have to take those recommendations into account before taking any long-term decision.

Smoking: E-cigarettes

Lord Hunt of Kings Heath Excerpts

Tuesday 17th December 2013 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I apologise to the Committee for being a little late for the start of the debate. I welcome this debate and I congratulate the noble Viscount, Lord Astor, on allowing us to discuss a very interesting subject. I am sure that we are all looking forward to the noble Earl’s response to the many questions that have been put to him.

With more than 100,000 people dying from smoking-related diseases across Britain every year, it is clear that we need to do all we can to support people to give up smoking and discourage young people from taking it up in the first place. One thing I am convinced about is that e-cigarettes have the potential to provide a significant boost to public health. I understand that the National Institute for Health and Care Excellence supports the use of nicotine-containing products such as e-cigarettes to aid smokers in cutting down on tobacco. As we have heard, an estimated 400,000 people across the UK have already switched from smoking to e-cigarettes.

I noted the comments of the noble Viscount, Lord Ridley, on the risks of regulation, and I agree with him that it is important that regulation does not stifle innovation. On the other hand, as with any new and fast-emerging product, some additional safeguards may be needed to cover any gaps in our existing consumer regulations. I want to ask the noble Earl, Lord Howe, about this. Does he consider that the medicinal regulation of e-cigarettes would put a lot of the current e-cigarette companies out of business? The noble Earl is of course very well acquainted with the work of the MHRA, issues to do with the regulation of medicines and, indeed, herbal medicines, which may be relevant in this context. I wonder if any work has been done to estimate the cost of regulation for these products.

For instance, I imagine that a dossier has to be produced with scientific evidence to show the efficacy and safety of these products. I wonder whether the noble Lord has an estimate of the cost of this, and whether that would inhibit many of the small companies in this market from being able to carry on in business when this is introduced. I support regulation that is light-touch and permissive rather than restrictive.

As the noble Viscount has said, the regulation of e-cigarettes has been debated as part of the EU trilogue negotiations on the tobacco products directive. Can the noble Earl inform the Committee of the progress of those negotiations? I understand that they are scheduled to end in the coming weeks, and an update would be appreciated, as would some sense of the timeline between agreement within Europe and the implementation of this proposed directive.

As the noble Lord, Lord Borwick, has commented, e-cigarettes have clearly been very successful in encouraging smokers to quit and to use e-cigarettes instead. He posed the question of whether there are circumstances in which e-cigarettes could be a passport to tobacco smoking. I think he talked about teenagers in particular, implying that some of the marketing approaches of the e-cigarette manufacturers might provide a cool image to young people, who would take up e-cigarettes and then be tempted to go on to tobacco products. I do not know whether the noble Lord, Lord Borwick, saw the complaints made about an advert for e-cigarettes screened by ITV on 3 December during “I’m a Celebrity”, which appeared to show a woman talking about oral sex, while at the end of the advert it was revealed to be a reference to e-cigarettes. The question I put to the noble Earl is: how do we ensure that e-cigarette manufacturers are not able to advertise in such a way as to make e-cigarettes attractive to young people who would not ordinarily have come to smoking, so that they act as a passport to tobacco smoking?

If the noble Earl can reassure us that regulation can be light-touch, that the process of being regulated as a medicinal product will not be overbearing, and that there can be appropriate controls on advertising, then we should welcome the impact of e-cigarettes, because the evidence is clear that they have helped a lot of people come off tobacco smoking. Surely, in the end, that is to be welcomed.

Olympic Legacy (S&T Report)

Lord Hunt of Kings Heath Excerpts

Wednesday 11th December 2013 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, welcome this debate and the report of the committee chaired by the noble Lord, Lord Krebs. I think it is a truth universally acknowledged that the Olympic Games in London were outstanding and never to be forgotten and that the legacy is as important. The argument for investing in sports science in elite performance and in non-elite sports and exercise has been very persuasively put by all noble Lords who have spoken in the debate this afternoon.

The question first posed by the noble Lord, Lord Krebs, was: the performance of Team GB in the Olympics was outstanding, but could it have been even better if even more use had been made of science? The noble Lord, Lord Moynihan, answered in the affirmative and pointed the way forward in terms of there being a very strong case for future investment in science in relation to elite sport.

The noble Lord, Lord Krebs, referred to heated shorts. As a commuting cyclist, I am very attracted to the idea, particularly as Christmas is coming up and the winter will, no doubt, get colder. More seriously, it would be good to hear from the noble Earl, Lord Howe, about future investment in sports science in elite and non-elite sports. The noble Lord, Lord Moynihan, made a very important point when he said that there is a problem with the sharing of knowledge with the vested interests of investors in sports science as opposed to the non-vested interests. That does not necessarily have to be government, but government can, no doubt, play an important role.

The other question that arises from this is about the extent to which we are investing in science to increase our knowledge of the impact of exercise on good health. This is the second argument that has been put in your Lordships’ debate this afternoon. The noble Lord, Lord Krebs, and other noble Lords referred to the health benefits of exercise, and it is striking that although this is increasingly known about, it does not seem to have much impact on the general public’s desire to exercise. The post-legacy figures for the public taking up sport or more generally taking part in exercise have been very disappointing. The figure of 150 minutes of moderate exercise per week seems as far off for many of the population as it ever was. Noble Lords probably know that I live in Birmingham, and my understanding of the latest statistics there is that 22% of young people in Birmingham are classified as obese. That is a shocking figure. We know the impact that that will have in future years in terms of health inequalities and demands being made on the health service. As we know, we have an epidemic of diabetes in many parts of society and of the country. As regards the figure of 22% obesity among young people in Birmingham, you do not need much knowledge of science to know that that will lead to huge pressures being put on the health system in that city in the coming years.

I wish to ask the noble Earl, Lord Howe, about the role of general practitioners. A number of points have been made in that regard. It was argued persuasively that if GPs were to prescribe exercise that might have a positive impact in terms of people’s response. We know that as regards health issues, particularly smoking, nothing is more effective than a GP telling a patient that he or she needs to think about giving up smoking. It would be helpful to ensure that GPs are all facing in the right direction on this issue.

Does the noble Earl think that health and well-being boards ought to prioritise investment in sport and exercise vis-à-vis local authorities and the health service? After all, health and well-being boards recognise that local authorities have a big role to play in this area. Local authorities are also responsible for running extensive leisure services—or at least they were—and have a wider role in this area in liaising with schools. Surely sport and exercise ought to be a major priority in joint strategic needs assessments, which attempt to bring together wider health policies. Will the noble Earl assure the Committee that the Government will push health and well-being boards in that direction? I would argue that they could be the local equivalent of the committee set up by the BMA in the 1930s, and its successor organisations, to which the noble Lord, Lord Moynihan, referred.

Another very important point raised by the committee of the noble Lord, Lord Krebs, was the attitude of the Department for Culture, Media and Sport towards the health benefits of sport. The Government reject the committee’s assertion. My own experience in government suggests that there is a gap between the Department of Health’s policy of encouraging exercise and the DCMS’s focus on sport. Indeed, I have taken part in theological debates between the two departments on where one element ends and the other begins. This is a fruitless exercise as it is patently obvious to anyone with any common sense that sport and exercise go together. If those departments find it difficult to resolve that issue, something else needs to happen. That could involve assistance in the form of a Cabinet committee, to which the Government refer in their response to the report of the noble Lord, Lord Krebs, or, as the noble Lord, Lord Moynihan, suggested, we should simply make it clear that a good health outcome is the number one priority. I believe that something more needs to happen in this area.

Noble Lords have not really mentioned the role of the Department for Education despite the fact that it has a crucial role to play in this area. We have seen very regrettable reductions in government support for school sport and I hope that the noble Earl’s department has actively pointed out to Mr Gove the error of his ways. Following the reaction to the original cuts in government support for school sport, the Department for Education partly retracted its proposals and established the School Games project—as we are told in the Government’s response—which attempts to provide more opportunity for pupils of all abilities to take part in competitive sport in schools. But I would like to see more—and I would like to see the Department of Health become the champion in Whitehall of the need to promote school sports, competitive sports and other exercises.

I would also like to hear more about how we can encourage sports clubs to work in schools. The noble Baroness, Lady Heyhoe Flint, has done so much to encourage girls to take part in competitive sports; she will know of the Chance to Shine project, which is about encouraging state schools to come back to playing cricket. Part of that approach is to encourage local cricket clubs to send their coaches into schools. I would like to hear more about how the Government might encourage that in future.

We then come to the issue of investment. The noble Lord, Lord Krebs, referred to the role of the National Centre for Sport and Exercise Medicine. Clearly, there is a concern here about its future viability. Can the Minister give the Committee some comfort that the Government recognise that continued funding support needs to be provided? Does he think that the Department of Health’s own research and development fund could come up with some support? It seems a persuasive argument that, given that the department is concerned with improving the health of people in this country, and given that sports and exercise clearly have a vital role to play in doing so, I would have thought that the argument for some support and funding from his own department’s R&D fund, which is not extensive but is very significant, ought to be considered.

The noble Lord, Lord Addington, suggested that the noble Earl, Lord Howe, and I were interlopers in this debate. However, I have no doubt that the encouragement of sports and exercise can play a critical role in improving the nation’s health and well-being. I am also in no doubt, having listened to the debate and read the report, that investment in science and science research could help us and use that knowledge to encourage more of the population to play a part. When one looks at some of the great health problems that we face—of frailty, dementia and obesity—one can see emerging research that suggests that exercise and sports can very much help us to meet some of those challenges. Given the department’s role, does the Minister not accept that it could play a much bigger role in this whole area in future? I hope that the department will accept that opportunity.

Health and Social Care Act 2012: Risk Register

Lord Hunt of Kings Heath Excerpts

Wednesday 4th December 2013 Lords Chamber

[Earl Howe]

My Lords, the risk register, as the noble Lord knows, is simply a tool that records the risk assessment process and the actions that need to be taken to mitigate those risks. However, to be effective, the process has to be robust and consider all likely implications—and indeed some that are not so likely—of a proposed course of action. The candid recording of risks enables them to be effectively managed. However, as the noble Lord knows, we have gone as far as we can in publishing the areas of risk that are contained within the risk register. I remind the noble Lord that in 2012 we published an extensive document that set out quite a lot of detail. That document is still available on the department’s website.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my health interests. To return to the Question asked by my noble friend, is it not a fact that officials warned Ministers that they would be introducing a shambolic reform of the health service? Those officials, much-maligned by the noble Lord’s ministerial colleagues, have been proved to be absolutely right. As we are all looking forward to the new musical by the noble Lord, Lord Lloyd-Webber, can the noble Earl tell me which will be published first: the full Profumo papers or the noble Earl’s risk register?

[Earl Howe]

My Lords, I do not accept the noble Lord’s description of the transition, which has gone extremely smoothly. By most measures the NHS is performing very well indeed. Waiting times are low and stable, the number of people waiting more than 12 months has plummeted since 2010, hospital-acquired infections are at an all-time recorded low, we have more doctors and healthcare professionals in the system, and mixed-sex accommodation has been reduced to minimal levels. That does not indicate to me that the reforms have had a damaging effect—quite the reverse.

Tobacco: Packaging

Lord Hunt of Kings Heath Excerpts

Thursday 28th November 2013 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my health interests in the register. I am very grateful to the noble Earl for coming to the House and I am pleased that the Government have changed their position. We have seen plenty of U-turns in the past three years and this is a major one, undoubtedly caused by the Government’s fear of defeat in your Lordships’ House.

However, why another review? Why must we wait until 2015 before implementation? I have enormous respect for Sir Cyril, but the Government have already had a review. The evidence in that review was clear for all to see. Does the noble Earl agree that it found that standardised packaging would make cigarettes less attractive to young people? Did it not find that such packaging made health warnings more effective? And did it not refute the utter falsehood that some brands are safer than others?

Does the noble Earl accept that all royal colleges and health experts are united behind the case for standardised packaging? Is it not the case that if the Transparency of Lobbying, Non-Party Campaigning and Trade Union Administration Bill goes through in its current form, it would prevent charities such as Cancer Research UK ever raising issues like this in an election year?

Finally, the noble Earl will be aware of an amendment laid by my noble friends Lady Smith, Lord Rosser and Lord Beecham to ban proxy purchasing of tobacco products on behalf of children which will be debated in your Lordships’ House on Monday. Will the Government accept that amendment?

NHS: Clinical Commissioning Groups

Lord Hunt of Kings Heath Excerpts

Wednesday 27th November 2013 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what discussions they have had with NHS England regarding proposals to change the funding allocation formula to Clinical Commissioning Groups.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer noble Lords to my health interests in the register.

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

My Lords, the Government have been discussing health funding, including progress on the fundamental review of allocations, at regular accountability meetings with NHS England. This NHS England-led review began in December 2012. The independent Advisory Committee on Resource Allocation, ACRA, is providing advice on changes to the formula. NHS England will consider ACRA’s recommendations. Initial views should be available to inform 2014-15 allocations.

[Lord Hunt of Kings Heath]

My Lords, my understanding of the formula is that it would move resources from areas where people have worse health outcomes to areas where they have better health outcomes. The noble Earl has said that he and his ministerial colleagues are in discussion with NHS England. Can he confirm that this is a decision for NHS England? If that is so, what is the nature of the discussion that has taken place between Ministers and NHS England? Is it being left to NHS England to decide?

[Earl Howe]

My Lords, very definitely yes. It is precisely to avoid any perception of political interference that we made NHS England responsible for the allocation of resources to clinical commissioning groups. However, we were very specific in the mandate, as the noble Lord will recall, that the principle on which NHS England has to operate is equal access for equal need, with particular attention being paid to health inequalities while not destabilising the NHS. Those are the things we discuss in our regular meetings with NHS England but the actual nature of the formula that it will decide in its board meeting next month is entirely up to it.

--- Later in debate ---

[Earl Howe]

My Lords, ACRA has recommended that CCG mental health services allocations should be set using the same overall approach as that for other hospital and community health services. That means that a large part of the allocation is linked to the diagnoses reported for people registered with each GP. That makes the formula very sensitive to need. It has the potential to improve the way we allocate resources for mental health services, in particular.

[Lord Hunt of Kings Heath]

My Lords, will the noble Earl arrange for NHS England to meet interested parliamentarians before it takes its decision at the meeting next month?

[Earl Howe]

My Lords, I will certainly feed that request back to NHS England.

NHS: Accident and Emergency Units

Lord Hunt of Kings Heath Excerpts

Tuesday 26th November 2013 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I first declare an interest as chair of a foundation trust, president of GS1 and consultant and trainer with Cumberlege Connections.

I too am grateful to my noble friend for raising such an important issue. The case she put for her local hospital, St Helier, was put with great force. The issues she raises are symptomatic of a whole range of issues around emergency care. They are well known, and they are symptomatic of a near collapse of the system in many parts of the country. My noble friends have already referred to the inexplicable closure of walk-in centres, and I ask the Minister why NHS England has pressurised clinical commissioning groups to close those centres. That has exacerbated poor access in primary care, and people are often left with no choice but to turn to A&E, with hospitals becoming very full as a result.

As my noble friend Lord Dubs said, the discharge of patients is becoming ever harder because the severe cutbacks in social services have impacted on councils’ ability to provide community support. The result of this cumulative failure is that more and more old people are left without the care and support needed to let them stay at home.

I want to reinforce a question asked by the noble Lord, Lord Kakkar. What are clinical commissioning groups doing about this? They are, as it were, the treasure of the Government—the people who are supposed to be able to sort the situation out. I see no sign whatever of their getting to grips with the issues. I echo the noble Baroness, Lady Manzoor, in asking; why on earth were they given the money to spend in relation to A&E? Why not give it to the hospitals to spend where it would have an impact on the system?

At a time when the NHS should be focusing all its energies on getting the system to work properly, as my noble friend Lord Kennedy says, the Government have forced it to spend the past three years implementing a costly and completely unnecessary structural change. Remarkably, during that time, rather than increasing staff we have seen a loss of more than 6,600 nurses.

There is a pressing need to integrate health and social care, provide whole person care and prevent avoidable admissions to hospital. That would also embrace the comments of my noble friend Lord McKenzie about accident prevention. Urgent emergency care has a similar need of change. Of course, the recent review by Sir Bruce Keogh argues for a “fundamental shift” in the provision of urgent care and for introducing two types of hospital emergency department with current working titles of emergency centres and major emergency centres. I am not opposed to reform of emergency care, but it is essential, before there is a stampede of closures of current A&E departments, that decisions are based on robust clinical evidence. Any signs of closure for financial reasons must be resisted. I agree with my noble friends Lord Dubs and Lady McDonagh about the domino effect of A&E closures on the services in those hospitals.

I finish by reminding the Minister that what happened in the case of Lewisham hospital was quite disgraceful. A good hospital suddenly found itself having its A&E proposed for closure to shore up problems in neighbouring hospitals. It is shameful that the Government forced through an amendment in the Care Bill to make this kind of thing much easier to force through in future. The Government’s disastrous reforms and failure to manage the system are putting the NHS under ever more pressure. It is time that they got a grip.

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

My Lords, I join other noble Lords in thanking the noble Baroness, Lady McDonagh, for raising this important issue, in which I know that she has a significant interest. I thank other noble Lords who have contributed to this very interesting debate.

I would like to respond initially by explaining the Government’s policy with regard to service change in general, before moving on to the provision of care in A&E specifically. I find it difficult to say much about the noble Baroness’s speech beyond observing that there is such a gulf separating us in our respective understanding of the facts and what is actually happening in the NHS that I shall have to write to her—and I shall do so.

The Government are absolutely clear that the design of front-line health services, including accident and emergency units, is a matter for the local NHS. It is the policy of this Government that services should be tailored to meet the needs of the local population. Reconfiguration is about modernising the delivery of care and facilities to improve patient outcomes, develop services closer to home and, most importantly, to save lives. Therefore, all service changes should be led by clinicians, and be in the best interests of patients, not driven from the top down. That is why we are putting patients, carers and local communities at the heart of the NHS, shifting decision-making as close as possible to individual patients, by devolving power to professionals and providers, and liberating them from top-down control.

[Lord Hunt of Kings Heath]

My Lords, if that is so, why has NHS England put so much pressure on clinical commissioning groups to close walk-in centres? It is simply not happening that clinicians are deciding. The fact is that NHS England is carrying on a micro- management of what is happening; it is simply not playing out in the way that the noble Earl describes.

[Earl Howe]

I would be grateful if the noble Lord could supply me with the relevant facts to back up his statement about pressure from NHS England to close walk-in centres.