Medicines and Medical Devices Bill

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Committee stage & Committee: 3rd sitting (Hansard) & Committee: 3rd sitting (Hansard): House of Lords
Wednesday 28th October 2020 Grand Committee

[Lord Hunt of Kings Heath (Lab) [V]]

My Lords, that was a very interesting opening speech from the noble Lord, Lord Patel, and I am very glad to have put my name to his amendment—although, of course, he went wider and commented on the government amendments. I very much agree with his desire to minimise delay for the UK to get access to new medicines. That has been a constant theme of our debates.

There are a number of elements in this, including the attractiveness of the UK to pharma companies, for our life sciences, our approach to access to early phase trials, the regulatory system for licensing medicines and the NHS’s willingness to take up those medicines, including the role of NICE. We have debated all of those.

The Minister on the first day in Committee responded to a number of those issues and said that the Government wanted to

“build on our established strengths so that the UK has the opportunity to anchor international drug development in this country and grow that capability. I am committed to international standards, international partnerships and multi-country clinical trials … The UK works closely with many other regulators; those relationships are underpinned by many shared international standards. The EU bases its regulations on exactly those standards”.—[Official Report, 19/10/2020; cols. GC 357-8.]

The issue is, that being said, will we in the end be aligned with Europe so that companies do not have to go through separate processes in which, because the market that we offer in this country is so small compared to the EU market, we will not be a country of first choice for developing new medicines and seeking a licence?

I refer the Minister to a comment that I picked up in the last few days from Britain’s pharmaceutical industry: it has appealed to the Prime Minister to strike a swift side deal with Brussels to avoid delays and shortages of medicines if we leave at the end of the year with a no-deal Brexit. We have heard continuously from the Prime Minister that he was preparing for—indeed, he would embrace—no deal on 31 December. The Government’s departure from any rationality or seeming concern for Britain’s industry and their posturing have left industry without the agreement on mutual recognition of standards that is needed to avoid hugely costly duplication of red tape to maintain the flow of trade in vital drugs. The one phrase that the Minister has not articulated in our debate so far is “mutual recognition of standards”. The fact is, if we are seriously going into a new world where we do not believe that mutual recognition between ourselves and the EU is a sensible or serious proposition, I am afraid that all the talk about this country being an attractive place for pharma will fall on rather stony ground.

The noble Lord, Lord Patel, has done a great service in bringing this matter back with a slightly different approach. I hope we can look for a positive response from the Government.

[Lord O'Shaughnessy (Con) [V]]

My Lords, I speak in support of the intention of Amendment 27 in the names of the noble Lords, Lord Patel and Lord Hunt of Kings Heath. As noble Lords know, I made my views on the Brexit approach of working with other regulators clear on the first day in Committee and I do not intend to rehearse them—I am sure that noble Lords will be relieved—but I was struck by how this might work in practice. While listening to the noble Lord, Lord Patel, who gave an excellent exposition, I reflected on his story about CAR-T therapies and how that provides a good example of what we need to guard against as we move out of the EMA post Brexit.

In September 2017, I went on a visit to Pennsylvania and had the opportunity to go to Penn Medicine, which is where CAR-T was developed, in a lab sponsored by Novartis. I remember sitting down afterwards and being told about the amazing progress they had made, how this was rolling out to patients and indeed how they were thinking about the next iteration of this medicine, how useful it would be and how much demand there would be for it to be given to American dogs—that is right, dogs. I was sitting there at a time when UK patients did not have access to CAR-T therapies, but American dogs were about to get access. This in a way exemplifies a problem that we have today as part of the EMA but are likely to have tomorrow: our unwillingness to accept the decisions of other stringent regulators who make good decisions and whose processes we trust.

The idea of how we could work with other regulators as expressed in this amendment is incredibly important and could be carried out in two ways. The first is, as I said, in accepting decisions from other stringent regulators, including the FDA, the EMA, of course, and others. There has been resistance—there certainly was in my time as a Minister—about so-called rubber-stamping of other decisions and the implications for legal liability if things go wrong, but I am absolutely confident that these can be overcome. Our regulator should be prepared to accept the paperwork submitted to other regulators and the decisions of other stringent regulators where we have confidence in their processes. Ideally, as the noble Lord, Lord Hunt, said, this would be in the form of mutual recognition, but it is perfectly possible for us to do that unilaterally as well. That would go a long way to assuaging the concerns of industry.

The second way, and they are not mutually exclusive, is that the UK could lead the creation of a third global market to go alongside the FDA and EMA by working with independent regulators in Switzerland, Australia, Singapore, Canada and so on. As I say, these are approaches that we could follow in tandem as part of, I hope, a global move towards a single approach.

I am confident that we can follow these routes without causing any harm to patient safety while improving patient access. I am not convinced that they require legislation. I can understand why the noble Lord has tabled the amendment and I support its intention; I do not know that we need to change the law. What I would like to hear, and I hope other noble Lords would like the same, is a commitment from my noble friend the Minister that the Government intend to take this kind of approach. We look forward to speaking to the director of the MHRA on precisely this issue, as she has kindly agreed to meet us next week.

Tobacco Products and Nicotine Inhaling Products (Amendment etc.) (EU Exit) Regulations 2018

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 4th December 2018 Lords Chamber

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

My Lords, in introducing the regulations before the House today, I want to stress how critical they are in maintaining the UK’s commitment to be a world leader in tobacco control as we leave the European Union. The Government strongly believe that tobacco control legislation is crucial for stopping people smoking and reducing the harms associated with smoking. Whatever the outcome of the Brexit negotiations, that belief is unwavering.

As noble Lords know, the Government are focused on the successful passage through Parliament of the deal which has now been reached with the EU. Nevertheless, we continue to plan for all scenarios. The regulations before us have been laid for a no-deal scenario. If the UK reaches a deal with the EU, the department will revoke or amend this instrument to reflect that deal.

This instrument will ensure that the UK domestic legislation that implements the two main pieces of EU tobacco legislation—the tobacco products directive 2014/40/EU and the tobacco advertising directive 2003/33/EC—functions effectively after exit day. The instrument, made under the EU (Withdrawal) Act 2018, makes appropriate amendments and revocations to correct deficiencies in UK legislation and retained EU legislation.

Regardless of one’s views on Brexit, I see no reason why the amendments we are proposing through these regulations should not be supported. The proposed amendments are critical to ensuring that there is minimum disruption to tobacco control in the event that we exit the EU without a deal in March 2019. I would like to draw the attention of noble Lords to three main changes that this instrument would introduce.

First, in the event of a no deal, the UK will need to develop its own domestic notification systems for companies that wish to sell tobacco products and e-cigarettes to the UK market. The notification process is essential for ensuring that companies are complying with legislation on product standards. Both Public Health England and the Medicines and Healthcare products Regulatory Agency have commenced work to ensure that domestic notification systems are in place and functional by exit day.

Secondly, in the event of no deal, the UK will not hold copyright to the EU library of picture warnings for tobacco products. Requiring the industry to continue to use these pictures would breach copyright law. Picture warnings are a key part of tobacco control, and it is therefore extremely important that we continue to require the inclusion of graphic picture warnings on tobacco products. The UK has therefore recently signed an agreement with the Australian Government to obtain picture warnings free of cost, and I want to take this opportunity to express this Government’s gratitude to the Australian Government for their assistance in this matter. I would also note that this approach has received endorsement from Action on Smoking and Health, which has said about our proposals on notification systems and picture warnings that they are, “pragmatic and practical, minimising the amount of additional work involved if there were to be a no deal Brexit. We support the Government proposals for dealing with this short-term issue”.

Thirdly, this instrument proposes a transfer of powers from the Commission to the Secretary of State, permitting the Government to respond to emerging threats, changing safety and quality standards and technological advances.

In introducing this instrument, I must be clear that it will have some impact on the tobacco and e-cigarette industry. The department ran a short technical consultation in October to seek feedback on the practical issues that will affect the industry in a no-deal situation. We received 32 responses. Tobacco control stakeholders showed support for the continued use of picture warnings and amendments to the notification system as an effective way of stopping people smoking and as a means of harm reduction. The tobacco industry did raise concerns about the timing of implementation and cost, primarily in relation to the changes to picture warnings. However, I would stress that we did not receive detailed evidence or a breakdown of costs.

As noble Lords know, we have no control over timing issues—or at least this government department does not—as the implementation timetable is dictated by the timing of EU exit. The Department of Health and Social Care has therefore consulted with external experts, who have confirmed that the change in timescale is likely to be difficult but manageable. To mitigate these issues raised in the consultation by the industry, we intend to publish detailed guidance on picture warnings and the notification process in January 2019.

Before closing, I would also like to stress that the devolved Administrations have provided consent for the elements of this instrument which are considered devolved.

I hope that noble Lords can see that this instrument constitutes a necessary and important measure to ensure that our tobacco control regulations continue to work effectively after exit day in the event of no deal. I must emphasise that, due to the instrument being made under the withdrawal Act, the scope of the amendments in it is limited to achieving this objective. At an appropriate point in the future, the department will review whether the UK’s exit from the EU offers us opportunities to reappraise current regulation to ensure that we continue to protect the nation’s health and so that the UK remains a global leader in smoking cessation and tobacco control for many years to come. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Lord for this opportunity to discuss e-cigarettes. It is also a great opportunity to press the Minister on the Government’s Brexit situation. I do not think that we have heard him on this matter before. It is interesting to reflect on the confidence set out in the Explanatory Memorandum that,

“as a responsible government, we will continue to proportionately prepare for all scenarios”.

That is just as well because I do not share the Minister’s confidence that the future is at all clear or, indeed, that all scenarios have been planned.

I am sure the regulations are sensible but the Explanatory Memorandum takes us back to our debate when they originally came through your Lordships’ House, during which a number of us expressed concerns that the directive on which they were based takes too draconian a view on e-cigarettes. I happen to think that e-cigarettes are one of the most successful public health measures to help reduce smoking that we have ever seen. It is a great pity that some elements of the public health community that I know well and love have such a downer on e-cigarettes that they have encouraged a disproportionate approach to their regulation. In Grand Committee, the argument was put that e-cigarettes should be regulated in a completely different way from tobacco-based products. I remain convinced of that.

Of course, we must be very careful about the potential impact on young people. I know there are those who think that attractive advertisements and the way e-cigarettes are marketed can sometimes lead young people to take up smoking. The evidence for that is very dubious. We know that e-cigarettes are attractive to people over whose heads most public health campaigns completely fly. Although I fervently hope that we do not exit the EU next March, if we do and if the Government bring forward at some point new regulations on tobacco products in general, I hope they will take note of our debates and look at e-cigarettes in a completely different way.

Health: Cancer

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 29th November 2018 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what steps they are taking to improve (1) early diagnosis of, and (2) survival rates for, cancer.

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

My Lords, we know that early cancer diagnosis improves survival. Last month, the Prime Minister announced a package of measures to be rolled out nationally with the aim of seeing three-quarters of all cancers detected at an early stage by 2028. Since 2010, cancer survival rates have improved annually and are currently at a record high. Around 7,000 people who are alive today would not have been had mortality rates remained at the 2010 levels.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, the targets set by the Prime Minister and the progress made are obviously welcome, but the Minister will be aware that data from the national cancer registration service has shown that the early diagnosis rate for cancers has been static for the past two years, with 16 CCGs showing a decline in the rate. Patients are reluctant to go their GPs, GPs refer less than in other countries and hospitals are overwhelmed by referrals. How are we going to see a step change in the approach so that our success rates are more closely aligned to those of comparable countries, and does the Minister agree that we need to see the spread of rapid diagnostic centres?

[Lord O'Shaughnessy]

I do agree with that point, and indeed it was one of the policies announced by the Prime Minister in October. Of course we need to make more progress on early diagnosis. One-year survival rates have improved in the past 10 years but we still lag behind our continental neighbours, as we have done for decades. The noble Lord mentioned GP referrals, which have been in the news this week. The threshold for referrals from GPs to specialist cancer doctors has been reduced in line with the NICE guideline. The consequence has been that in the past seven years, the number of people referred to a specialist cancer doctor has increased by 1 million—that is, an increase of 115%. Therefore, we are seeing more referrals at an early stage. We are seeing many more appointments and of course those will feed through over time into our survival figures.

Mental Capacity (Amendment) Bill [HL]

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Report: 2nd sitting (Hansard): House of Lords
Tuesday 27th November 2018 Lords Chamber

[Lord O'Shaughnessy]

That would be correct at the point at which it came before the House, but it would be published for consultation before then. There will be an opportunity for everybody—noble Lords, Members of the other place and stakeholders—to consider a draft and to recommend changes. The final product would be laid before Parliament.

We discussed the Mental Health Act review a little bit last week. We await its conclusions. Many of us have had conversations with Sir Simon Wessely about what it is likely to conclude, and about the interaction between the Mental Health Act and the mental capacity Bill when enacted. Since we are expecting its recommendations in the middle of next month—I think the scheduled date is the 12th—we will have an opportunity to consider the review’s recommendations before we move to the new system. Indeed, given that those recommendations will be out at about the time the Bill moves to the Commons, they will clearly be the subject of debate there. The Government will need to respond to those findings as we go through the Commons stages.

Amendments 143A and 147A, tabled by the noble Baroness, Lady Thornton, would require the Government, before the new system could come into force, to conduct public consultation on the Act with vulnerable people and other stakeholders and publish a report on its findings, as well as to publish their response to the Mental Health Act review and an equality impact assessment. I hope that I have dealt with the issue of public consultation, as well as consultation on the code and, equally, on the Mental Health Act review. The noble Baroness is quite right to bring the equality impact assessment to the House’s attention. It was prepared prior to introduction and required amendment following input from the Welsh Government. It will now need to be amended further to reflect the changes made in the Bill. I can commit to publishing the equality impact assessment before the Bill makes it to the Commons so that there will be ample time for consideration before it is debated there.

If the House will allow me, I will finish by thanking all noble Lords for their perseverance and patience during a sometimes difficult and challenging debate. We know that we all want to achieve the same end to our journey; there has been disagreement at times on the right way to get there. I am deeply grateful to all noble Lords for their contributions. The Bill has been immeasurably improved already in its passage through this House. That is a very good thing in itself and will have a very positive impact—notwithstanding the slightly gloomy prospect given by the noble Lord, Lord Hunt—when it goes to the other place and on to implementation.

Once again, I extend my sincere gratitude to all noble Lords. I hope that I provided reassurances on the amendments in this group and that they will feel able not to press their amendments.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the Minister. After such an uplifting response from him I do not want to drag us down again into negative thinking as we move on to Third Reading. I will just say that the problem with selective consultation is that it disfranchises some key respondents, and the problems we had over the summer were a consequence of that; it is a lesson to be learned for the future. I am grateful for the information about the work that has been done on the backlog. It will be important that the sector is clear as to which application falls under which part of the law. It is also very good that we will see the draft code in good time. Will the Minister arrange a briefing for noble Lords, rather than just going through a formal process? That would be extremely helpful.

Finally, Sir Simon Wessely’s review is clearly very important. It is obviously important that there be consistency, and the only thing I would say is that there are lessons for all of us for a future Bill in the way this Bill has been dealt with. There is no doubt in my mind that the issues raised by Sir Simon’s review lend themselves to pre-legislative scrutiny. Pre-legislative scrutiny is not fashionable any more, but my experience with the Mental Health (Amendment) Bill 2007 suggests that it doesn’t half pay off in terms of coherent legislation.

With that, I am very grateful to the Minister for his very full response and I beg leave to withdraw the amendment.

Vaping

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 13th November 2018 Lords Chamber

[Lord O'Shaughnessy]

The FDA has certainly said that it is facing an epidemic of childhood use, but the numbers are quite stark in their difference. In America, many more young people use e-cigarettes compared to in this country, where only 2% of 11 to 18 year-olds are using once a week. Generally, those are young people who smoke already—around 7% of 15 year-olds smoke. America did not restrict tank sizes until recently, but we did; it did not restrict bottle sizes, but we did; it did not ban advertising, but we did; and it does not have restrictions on nicotine, but we do. We have a very sensible system. I am not complacent about the need to make sure that young people do not use, which we are not seeing yet, and there are severe restrictions and punishments for any retailer who sells such products to children.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is it not clear from the evidence that, while we have to be very careful about use by young people, this is the most successful tobacco prevention or stopping measure we have ever had? It is important that we keep a measure of balance in our approach to this.

[Lord O'Shaughnessy]

I completely agree with the noble Lord, and I think that we have the right balance: 57,000 people a year quit smoking through e-cigarette use and that is just about the most important thing you can do to improve your health.

Cannabis: Medicinal Uses

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 1st November 2018 Lords Chamber

[Lord O’Shaughnessy]

We are, thankfully, now taking an evidence-based approach. The Chief Medical Officer said in her statement that there is evidence of therapeutic benefit from cannabis-based products, and that is why they have been rescheduled. However, we need to move cautiously. We know that the active ingredient, THC, is linked to psychotic illness and other things, so we need to make sure that, as we move ahead, its use is properly controlled and that the benefits always outweigh the risks for any patient who takes it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I think that the noble Lord, Lord Farmer, referred to prescribed medicine addiction in his question. The Minister will be aware that this is a growing problem, with very little support locally for patients who have terrible outcomes. PHE is undertaking a review of the evidence at the moment. Can the Minister assure me that, when that review is published, the Government will publish an action plan to try to deal with what is a terrible issue for many people?

[Lord O’Shaughnessy]

I absolutely acknowledge the scale of the issue. I think that the point my noble friend was getting across was that we do not want to create the next opioid addiction crisis, and I completely concur with that position. Public Health England is conducting that review and I will write to the noble Lord with specific details of what we as a Government intend to say after it has concluded.

Mental Capacity (Amendment) Bill [HL]

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Committee: 3rd sitting - (Hansard): House of Lords
Monday 22nd October 2018 Lords Chamber

[Lord O'Shaughnessy]

I am grateful to all the noble Baronesses for their amendments and for speaking in the debate on this group. Let me begin with a statement of principle. I accept the challenge from the noble Baroness, Lady Thornton, that we need to move from principles to practicalities, or in our case to the appropriate legislation. There is genuinely no attempt in the Bill to restrict people’s access to independent advocacy. As has been clearly voiced, not only in this Chamber but elsewhere, there is a concern that that will be the effect of what is proposed, and that is something that we need to deal with. But let me say at the beginning that that is not the intention. It must be the case that anybody who needs support to navigate these difficult and complex situations must be able to find the right support for them. I will explain why the Bill is as it is in a moment, but let me at least give that statement of principle at the beginning.

I will deal now with the specific amendments in this group. Amendments 63 and 64 aim to ensure that the Bill is robust on the appointment of the IMCA. I completely agree that it is vital that the care home manager notifies the responsible body that an IMCA should be appointed. That is required by the Bill. However, I know that there is great concern about the impartiality of this person and a requirement for strengthening in this regard. It is also our position that a responsible body will be able to appoint an IMCA if there is a request by, for example, a family member or the person themselves, or if there is a disagreement with the notification given by a care home manager. I am considering how we can make the Bill clearer in that regard. As we home in on the issue of the incentives for the care home manager to follow best practice, as we would want, I am aware that we need to do more work on this to get it right.

[Lord Hunt of Kings Heath]

My Lords, that is a very helpful comment but will the Minister pick up the point that part of the problem is that the care manager is not only the co-ordinator but often the gatekeeper to the protections that noble Lords wish to see included? Take, for instance, the definition of “relevant person”. It seems to me, looking at this afresh, that far too much authority is being given to the care home manager in relation not just to co-ordination but to the protections.

[Lord O'Shaughnessy]

I thank the noble Lord for that intervention. The debate we had last week was very much around the proper role for the care “home” manager—I take on board the rejoinder from the noble Baroness, Lady Thornton, about the specificity of terms. I do not want to rehash that debate, save to say that the care home manager model is the right one going forward, while recognising, as I did last week—here I agree with the noble Lord’s point—that there are a lot of concerns about conflicts of interest, training, the degree of responsibility and other things.

In this case, we are talking about notification of the appointment of an IMCA, where there is real concern that there is an element of marking your own homework. That is not what we are trying to achieve: we are trying to achieve the consideration of deprivation of liberty at the earliest possible point in care planning by somebody who is responsible for organising—although in lots of cases not personally delivering—that care. We are trying to deliver a more proportionate system than the one that we know is currently failing. As I committed to in last week’s Committee debate, I want to get that right. If we cannot get it right, the risk is that we end up replicating the system that we have now, which would be in nobody’s interests. I hope that, by restating that, I have satisfied the noble Lord.

Amendments 68, 71 and 72 relate to the criteria for appointing IMCAs. The Bill currently states that an IMCA should be appointed if a person has capacity to consent to being represented and supported by an IMCA and makes a request to the relevant person, and there is no appropriate person available. It also states that a cared-for person should be supported by an IMCA if the person lacks capacity to consent and being represented by an IMCA is in their best interests and there is no appropriate person in place.

I recognise the concern expressed by the noble Baronesses, Lady Barker and Lady Thornton, about the term “best interests”. Let me state again the intention that, in the vast majority of circumstances, we expect it would be in a cared-for person’s interests to receive representation and support from an IMCA or appropriate person. However, there may be a small number of circumstances where that is not the case. For example, if a person is adamant that they do not want this sort of representation, and has refused advocacy support in the past, it would not be right to impose such an advocate on them. If we remove the best interests consideration, we risk a situation where responsible bodies can override the past and present wishes of the person.

Personal Social Care: Funding

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 16th October 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness makes an excellent point. I do not know about the distribution of such services, but she is absolutely right that what everybody wants—the cared-for person and those looking after them—is to stay in their homes and remain independent for as long as possible, which is why so much more care must be delivered in the home. I will write to her on the specifics of meals-on-wheels services.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord talked about taking a firm policy decision. I have yet to understand why the Government commissioned the Dilnot commission, accepted the principles of its recommendation, legislated to introduce it but then failed to implement it. Why?

[Lord O'Shaughnessy]

The noble Lord is right: the Dilnot commission proposed risk pooling, which we legislated for, and it was decided that it was not the right time to proceed with those proposals. However, I can tell the noble Lord that Sir Andrew Dilnot continues to be involved in the policy-making process, as does Dame Kate Barker, who chaired another review. We want to ensure that we can draw on their expertise as we put our ideas forward.

Mental Capacity (Amendment) Bill [HL]

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Committee: 2nd sitting (Hansard): House of Lords
Monday 15th October 2018 Lords Chamber

[Lord O’Shaughnessy]

We believe that case law does establish that suitably qualified people need to be appointed. Clearly that is something we need to continue to discuss to persuade the noble Baroness that that is the case, but that is our understanding. As she pointed out, “suitably qualified” can include medical and other qualifications.

On care home managers’ capacity, they are of course carrying out some assessments. The intention is they will carry out more assessments. I agree with the noble Baroness on that point. The point that the noble Baronesses, Lady Barker and Lady Thornton, raised was about the capability and capacity of this group of people to carry out these roles. On our previous day in Committee I committed to explain how we would ensure that that group of people had the requisite training and skills to carry out these kinds of assessments.

The noble Baroness made a point about weakened access. I want to update the House on our thinking about making sure that the person is consulted. We are trying to create a more proportionate system such that, where all those concerned with the care of a person are content that the arrangements have been properly put in place, it does not need to be escalated and reviewed by an AMCP or similar person. The problem we have at the moment is that the system takes every decision to the highest possible level. This is not about weakening access but about trying to have a proportionate system and also about making sure—we will debate this further tonight—that at every stage there are the right opportunities to seek advocacy support and to refer concerns so that an AMCP or responsible body can intervene and review a case if necessary.

Unless we find a way to deliver a more proportionate system we will simply be re-enacting the system we have now, which is not working. This is why I am so keen to work with noble Lords to make sure that we can determine the proper role and responsibilities of, and checks and balances on, care home managers so that we can get the system right and deliver a reform that saves money, enables more people to have their cases reviewed and enables us to make sure that people are protected, which is what we want to do.

[Lord Hunt of Kings Heath]

The Minister read out a list of safeguards that will still be in place despite the streamlined nature of the Bill. The issue I have with that is that the care home manager seems to act as the gatekeeper to many of them. I hear what he says about a streamlined approach, which I agree with, and I also hear what he says about the people who will do the assessment. But there is still a real issue about why the care home manager, of all people, is the person overseeing this whole process. If the Government are really willing to sit down and talk about how to achieve a streamlined programme but continue with some of the essential safeguards that are in the Bill at the moment, clearly the role of the care home manager has to be looked at seriously.

I am not really hearing from the Government whether they are seriously prepared to debate the fundamental construct that they have come forward with. It seems to me that they dreamed up an answer to the problem but did not consult fully—they had selective consultation where individuals were picked off—and the result is that they do not now have consensus support, and the Bill is in trouble because of that.

Mental Capacity (Amendment) Bill [HL]

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 15th October 2018 Lords Chamber

[Lord Hunt of Kings Heath]

No, it was not.

[Lord O'Shaughnessy]

In which case I will not go any further.

On that basis, I hope that I have dealt as thoroughly as I can with the substance of all the amendments in the group. Clearly, we want to make sure that the evidence is as good as possible when making these very important and serious decisions. As I said, in this instance the code of practice is a good vehicle for much of this work. On that basis, I hope noble Lords will not press their amendments.

NHS: Dangerous Waste and Body Parts Disposal

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 10th October 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for her question. I will certainly take up the issue of waste disposal in general with my colleagues in Defra who, as she knows, are responsible for it. On the specific question of incineration capacity, Defra calculated that in 2017 there was a total of more than 30,000 tonnes of spare capacity for clinical and hazardous waste incineration. That was across a year, but we know that the NHS has identified more than 2,000 tonnes of incineration capacity this month. So the capacity is there; the point is that it should be used to get rid of the stockpile. As I said, the contracts are now in place to ensure a continued flow of service to NHS trusts.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I do not understand the timescales in this. According to the Statement, the Environment Agency notified the Government on 31 July. Why did it take until October for NHS Improvement to write to the company expressing its concerns? As for reporting to Parliament, we met for two weeks in September. Why did Ministers not come to the House during that period? The Minister seems to be saying that commercial secrecy trumps public accountability.

[Lord O'Shaughnessy]

I am absolutely not saying that. To go through the timescale, the noble Lord is quite right that 31 July was the escalation from the Environment Agency to Defra, which then contacted the Department of Health and Social Care. Ministers were informed on 8 August, by which point a huge amount of effort had gone in not only to analyse the problem but to put in place contingency plans. A final enforcement notice for the Normanton site was issued by the Environment Agency with a need to comply by 25 September, which fell after the two-week Sitting that we had in September. In the meantime, plans were put in place—the Secretary of State chaired a cross-government meeting—and on 3 October the partial suspension was put in place. That is what triggered the termination of contracts by NHS trusts and their replacement by a new contract with Mitie.

Mental Capacity (Amendment) Bill [HL]

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Committee: 1st sitting (Hansard): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Lord O'Shaughnessy]

In answer to the noble Baroness’s question, the point that I was making is not that the role of the care home manager will not change but that they are not being asked to do something of which they have absolutely no experience or responsibility for at the moment. As the noble Baroness, Lady Finlay, pointed out, care home managers are already required to make applications and to consider capacity and restrictions, so they already have a role. The distinction is that, as the Bill sets out, the assessments can be made within the care home itself—of course, not by a person with direct responsibility for care. That is one of the issues, of avoiding conflict of interest. In all cases, those will be authorised by the local authority. If there is any reason, through that authorisation, for concern—for example, of conflicting views between the person cared for and their family—then the AMCP, the mental capacity professional, will have the opportunity to decide on the right course of action. That is what I meant by escalate—not that there is a choice of whether to escalate authorisation to the responsible body, as that will happen in all cases, but that there is a further opportunity for consideration by an AMCP if there is any sense of this happening. We will explore in more detail in future groups whether there is a reason for further investigation, including, of course, speaking to the cared-for person, their family and others.

[Lord Hunt of Kings Heath]

With regard to what is going to be a desktop exercise, the question then arises as to how the local authority will know that there are concerns. On conflicts of interest, it seems that the job of the care home manager is to make sure that their home is filled. There is a fundamentally wrong issue here. The initial assessment will be done by someone with a financial interest in its outcome. It is wrong.

[Lord O'Shaughnessy]

Perhaps I may say that to some extent we are getting ahead of ourselves, because we will explore these issues in further amendments. There is clearly already a system in place, which will continue and will be enhanced, to make sure—whether it is through family members and others with an interest, or, as we have discussed before, through those with a lasting power of attorney—that those who have an advocate working for them are able to register their concerns, objections or whatever it is through the process. So it is not simply the case that the care home manager would be able to wrap up the entire discussion and not let any other point of view be heard—quite the opposite. And, as I said, we will discuss that in further detail.

On training issues, addressing the second point talked about by the noble Baroness, Lady Thornton, she is quite right. That is precisely why I said that it is important for us, the Government, to explain, on the basis of consultation with the sector, what will be required to make sure that those who will have these extra responsibilities will be able to exercise them properly. We will discuss that outside this Chamber. I know that noble Lords want to make sure that, where there is a proposed change, even if they still require some reassurance about the benefits of such a change, it will be implemented properly. Clearly, that has big implications for training, capacity and so on. So we will take that away and make sure that we are able to provide more detail on it.

Mental Capacity (Amendment) Bill [HL]

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Committee: 1st sitting (Hansard - continued): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, this group of amendments tests the proportionate nature of the decisions being taken. Amendment 29 would put the views of the cared-for person at the centre of the assessment and ensure that adequate weight was given to their wishes and feelings. I have not been able to find in the Bill where that is expressed, and that is shocking and surprising. We have to see a clear statutory duty to consult the cared-for person, and the scope of that consultation must include their past wishes, feelings, values and beliefs. I invite the Minister to tell me whether he believes that the Bill as it stands achieves that, because I cannot see that it does. If this amendment is not agreed to, the Minister and the Bill team must think about how they can best make sure that the Bill reflects the need for consultation with the cared-for person.

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

I thank noble Lords for tabling their amendments and for contributing to a debate that has continued the discussion that we had before dinner. It again gets to the heart of why we are here, which is to make sure that when people need to be deprived of their liberty, it is in their best interests to do so and that the restrictions are proportionate and necessary and so on.

I agree with the spirit of the amendments. It is important that we intend to, and do, safeguard the well-being, wishes and feelings of the cared-for person. Dealing with the first set of amendments, I take this opportunity to reassure noble Lords that the changes being sought are already required by law in several ways.

First, the European Court of Human Rights has made it clear that a decision on whether arrangements are necessary and proportionate must include consideration of the cared-for person’s wishes and feelings about the arrangements. It should also be noted that, as the noble Lord, Lord Hunt, pointed out, wishes and feelings are already a part of the first-stage best interests decision-making under Section 4 of the Mental Capacity Act and I can confirm, as I have done already, that the Bill does not change this. Furthermore, wishes and feelings will also be considered as part of the “necessary and proportionate” test, and the code of practice will provide further detail about how that will work in practice.

Going even further, as has been referenced by several noble Lords, we have created in this Bill a specific requirement to ascertain a person’s wishes and feelings in relation to the proposed arrangements through the duty to consult with anyone with an interest in the cared-for person’s welfare—first and foremost the person themselves, as well as their family, carers, friends, advocates, interlocutors or anybody with a substantive interest in their care. I believe that there is substantial legal protection, force and direction to make sure that the person’s wishes and feelings are considered first and foremost in any of these kinds of arrangements. As this debate has demonstrated, there are clearly lingering concerns that that is not the case, because of the existing framework, notwithstanding the enhancements through the duty to consult that we are introducing. However, I am eager to make sure that it is well understood, and to work with noble Lords so we can make clear that those responsibilities already exist, both in statute and—

[Lord Hunt of Kings Heath]

I understand the Minister’s argument, were it not for the fact that the amendment, in paragraph 17(2)(a) to (d), just copies what is already in the best interests clause. I would argue that, if we are going to copy four of those, why do we not copy the issue about the cared-for person being listened to? The Minister is arguing different points from amendment to amendment on this.

[Lord O'Shaughnessy]

We try to be consistent, but it is not always possible. The noble Lord makes a good point; it is something that I would like to explore further.

Turning to the matter of considering less intrusive arrangements, again this is incredibly important. Case law establishes that the test of whether the arrangements are necessary and proportionate must also include consideration of whether less intrusive arrangements are available and have been fully explored. As we discussed in the last debate, it is already a principle under the Mental Capacity Act. The code of practice will provide further detail about how that will work in practice.

This has been a useful debate, continuing, in some ways, the previous debate on best interests. As we have all agreed, it is important that the person’s wishes and feelings are at the centre of arrangements being proposed. That is certainly our intention through the liberty protection safeguards scheme that we seek to introduce. I want to continue working with noble Lords over the coming weeks to make sure that there is clarity that that is the case. I hope that on that basis, the noble Baroness will be prepared to withdraw her amendment.

General Practitioners: Indemnity Scheme

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 16th July 2018 Lords Chamber

[Lord O’Shaughnessy]

My noble friend makes an excellent point and I will certainly do so. There is an attempt not just to recruit many more GPs into service but to recruit them into hard-to-reach areas, such as rural areas, through a targeted recruitment campaign. I am sure that that is one of the areas that we will want to look at.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is it intended that locums will be covered by the scheme?

[Lord O’Shaughnessy]

My understanding is that the scheme is for all providers of primary medical care services under GMS, PMS and APMS contracts.

Health and Social Care Act 2012

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 5th July 2018 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government, in the light of the Prime Minister’s criticism of the regulatory framework established under the Health and Social Care Act 2012, what plans they have, if any, to bring forward measures to amend or repeal that Act.

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

My Lords, the Government have announced a five-year funding settlement, and we have asked the NHS to develop a 10-year plan to transform health and care. As my right honourable friend the Prime Minister said, as it develops its plan we will listen to the NHS about whether there are any barriers created by legislation. We will consider, after that, what changes may be needed.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in her speech on 18 June the Prime Minister referred to chief executives of NHS organisations having to make so many reports to different regulators that they have no time to improve their own organisation, and to a typical clinical commissioning group having to agree 200 contracts with other parts of the NHS. Is not the answer to the first question from the noble Lord, Lord Hamilton, that the NHS, employing 1.3 million, is not hard to manage, but the fact is that the Government have bequeathed to it an organisational structure that is dysfunctional and costs billions of pounds? If he really wants to help the NHS, will the Minister not come forward with a Bill to repeal the Health and Care Act 2012?

[Lord O'Shaughnessy]

My Lords, since the 2012 Act was passed, there have been some significant improvements in NHS performance, not least in cancer outcomes, for example. There are also around 42,000 more staff since 2010. So improvements have clearly been able to happen within the legal framework set by Parliament in 2012. Nevertheless, we recognise that as the service is required to become more integrated and people across different care functions are required to work together, we need to look at the structure. There is already joint working, for example, between NHS England and NHS Improvement at the regional level. But if the NHS identifies any barriers, we will look at those.

Gosport Independent Panel: Publication of Report

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 20th June 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord makes two excellent suggestions. His suggestion about whether cover-ups should count as serious professional misconduct will be something the regulators will want to consider, as is better training on the use and prescription of opioids. We have made some progress in recent years. The freedom to speak up guardians are in place, and we talked about the learning from deaths programme. There is also the duty of candour. They are clearly steps forward but the panel has exposed that we are still not there yet. The suggestions the noble Lord makes are good and serious and we will want to consider them.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I had ministerial responsibility for this area in 2002 and the beginning of 2003, which is reported in the report. First, I associate myself with the Minister’s remarks, his commendation of Bishop James and his panel and the apology that has been given. Reading this report, the question I think about is whether, if those circumstances arose now, the response would be very much different. I am not at all sure it would. First, the report shows the reluctance at local level to have what it saw as interference from the centre in causing inquiries to take place. Secondly, while the police investigations were going on the other inquiries felt they could do nothing, as the noble Baroness, Lady Jolly, said. Thirdly, once the police investigation had been completed and the decision that no prosecutions would take place had been taken, there was an agonised debate within the coronial system about whether inquests would be appropriate. The real issue seemed to be resources. The local coroner’s office did not feel that it had the resources to conduct the inquests and if it did so it would undermine the rest of its important work. In the work now being undertaken, will a real effort be made to grip the issue of the deadening impact of police investigations in stopping us learning lessons immediately? Is the Minister confident that the changes in the coronial system will prevent the kind of unseemly debate that prevented inquests taking place for some time occurring in future?

[Lord O’Shaughnessy]

I thank the noble Lord for associating himself with that apology. He asked the right question. It was very well put. If the circumstances arose now, would the response be different? I think there is reason to believe it would be, for the reason I have set out—the improvements that successive Governments have made on patient safety—but we should not be complacent. We cannot assume that those things are enough. I hope they are an improvement. We believe they are an improvement, but we need to ask ourselves that very difficult question about whether they would be enough. That is what we will be doing through this process.

Resources are one of the issues. We need to make sure not only that there is clarity about the circumstances under which the different bodies can carry out inquiries without impinging upon inquiries by other bodies, but that they feel that they are capable of doing so. That is one of the things we are going to need to investigate.

Education (Student Support) (Amendment) (No. 2) Regulations 2018

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 21st May 2018 Lords Chamber

[Lord O'Shaughnessy]

That is quite right. That is fully funded clinical placements—just for the sake of clarity. I thank the noble Baroness.

There is understandable concern among noble Lords, which has been expressed previously in this House, about the new system of financial support, but I want to be clear that we are giving the group of postgraduate students that we are discussing access to undergraduate maintenance and tuition fee loans, just as we do with postgraduate teachers. This represents a more generous package of support than the postgraduate master’s loan. We are also making available additional funding for childcare, travel to clinical placements and exceptional hardship funding to ensure that the students are fully supported and are able to complete their studies.

Furthermore, as many noble Lords have mentioned and as the noble Lord, Lord Hunt, and the noble Baroness, Lady Watkins, welcomed, in the debate on the regulations in the other place on 9 May, my honourable friend the Minister of State for Health set out a range of additional support that we are investigating for postgraduate nursing students. This includes specific incentives such as “golden hellos” for postgraduates who go to work in mental health—where the noble Lord, Lord Willis, was quite right that we need to attract more nursing and where there has been a shortfall—the area of learning disability and community nursing. The Government have announced £10 million to support such incentives and we are considering how this should be best delivered.

Many noble Lords have expressed concern about the drop in number of undergraduate applications to nursing courses. We acknowledge that early indications from the latest UCAS data, published in April, show that the number of students applying to study nursing has decreased from this point in the cycle last year. However, that cycle is not yet over, so we need to apply some caution.

It is also worth noting, as noble Lords have pointed out, that there is a distinction between the decline in number of applications and that in the number of students starting their courses. That was exemplified last year, which showed a 23% drop in the number of applications compared to a 3% decline in the number of acceptances. That is regrettable, but it was still the second-highest number of acceptances on record. Several noble Lords have expressed their desire for further information on how this develops. I can confirm that my department has committed to publish an update in autumn 2018 following the close of the 2017-18 application cycle.

As the noble Baroness, Lady Watkins, pointed out, there is a global challenge to recruit more nurses. We are working hard to make nursing as attractive a profession as possible. As a result of constructive dialogue over recent months, NHS Employers and the relevant trade unions began a consultation exercise on a three-year pay deal for NHS staff employed under the Agenda for Change contract. Under the plan, the starting salary of a nurse will rise to £24,907 by 2021, not only rewarding current staff for the incredible work they do but sending a clear signal to the country about how much nurses are valued.

We are boosting the attractiveness of the profession in a number of other ways, too. Nearly 4,500 nurses have started the return to practice programme and 3,000 have completed it. Across the country, NHS trusts are developing arrangements for flexible working and there is a concerted effort to tackle workplace bullying through an NHS-wide call to action. Our homes for staff programme is supporting NHS trusts to dispose of surplus land to help up to 3,000 nurses and other staff access affordable housing. I hope that gives the noble Lord, Lord Clark, some concrete examples to back up the warm words we use about supporting the nursing profession.

Several noble Lords have touched on new routes into nursing, which the Government are prioritising. The most significant innovation in this area was the announcement of a new nursing associate role in November 2016. Health Education England has already trained 2,000 nursing associates in a pilot programme and is planning to train up to 5,000 in 2018, with up to 7,500 nursing associates trained through the apprenticeship route in 2019. As well as creating a much-needed new role in its own right—I emphasise “in its own right”, as it is an augmentation to the nursing and other professions—nursing associate training offers an alternative route to becoming a registered nurse. We expect this “earn and learn” approach to be more attractive to older students, a concern which many noble Lords have raised.

To support this career path, Health Education England is developing a shortened nurse degree apprenticeship to facilitate transition from nurse associate to registered nurse, which will also automatically recognise the prior learning and experience gained in the nursing associate role. For the first time, apprentices will be able to work their way up from entry-level health work through to advanced clinical practice in nursing.

Several noble Lords expressed their concern about the apprenticeship route and the figure of only 30 nurses. The official data has been delayed and we believe that the figure is more like 250. We will be able to confirm that. It is a better start but, clearly, not yet the target that we want to reach. However, we believe that this stepped approach through the nursing associate role, giving the opportunities for a pause after two years and then to go on for two years, ought to be more attractive to employers than the current four-year commitment. This development of the nursing associate route therefore provides for a better use of the apprenticeship route.

I want to address a couple of what are perhaps misconceptions. The figure of 40,000 vacancies is used often in this House. I might be pedantic and disagree with that number—the quantum is just about right—but it is important to say that these are not empty places. They are being filled by agency and bank staff. Part of the reason for that is that people want flexibility and more pay, two of the things that we are trying to address so that we can provide more permanent contracts for those people who currently work flexibly.

The noble Lord, Lord Clark, and the noble Baroness, Lady Garden, talked about EU staff. I hope your Lordships will agree that I miss no opportunity to say from this Dispatch Box how much we value those staff and that they have just as much right to apply for settled status as anyone else in this country, provided they fit the criteria. However, it is worth pointing out that there are more EEA staff in the NHS than there were in June 2016. The one category where the figure is lower is in nursing and midwifery but the reason for that was the introduction of a more stringent language test. We are dealing with that issue, which I hope will mean that we continue to see an increase in EEA staff working in our NHS.

The noble Lord, Lord Willis, asked specific questions about the apprenticeship levy. I will need to write to him on that issue having consulted my colleagues in the Department for Education.

Turning quickly to the second point of the Motion, several noble Lords, including the noble Lord, Lord Hunt, the noble Baronesses, Lady Walmsley, Lady Watkins and Lady Garden, and others said that we should postpone the introduction of the reforms until the post-18 education and funding review has been completed. As noble Lords know, the Prime Minister launched the review earlier this year to ensure that we have a better system of higher education support that works for everyone. Many aspects of the current system work well and, as was set out in the terms of reference for the review, there are important principles that the Government believe should remain in future. One of those is that sharing the cost between taxpayers and graduates is the right approach, as I rehearsed earlier in my speech.

I take the point made by the noble Baroness, Lady Walmsley, about looking at the Welsh example. I have looked at it myself and I am sure it is something that the review would want to consider. However, it is important that we do not prejudice the work of the expert panel established to support the review or prejudge its outcomes. The fact of the review should not delay these healthcare education reforms, not least because they predate the launch of the review by some distance and already apply to the vast majority of nursing students. We believe it would do more harm than good to further delay these reforms, although it is worth underlining that any relevant reforms stemming from the review will apply equally to this group of student nurses.

In conclusion, I recognise the well-motivated concerns expressed by noble Lords during this debate. However, I hope I have been able to demonstrate that the student finance reforms that this Government have introduced have allowed both the removal of the artificial cap on nurse training places and the largest expansion of student nursing places in a single year ever seen. These two facts are not coincidental; they are inextricably linked. The latter is possible only because of the former and they form part of a wider set of workforce reforms designed to expand, train and reward our nursing profession better so that we can continue to deliver the high standards of NHS care that patients demand. On that basis, I hope the noble Lord, Lord Hunt, will feel able to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to all noble Lords who have spoken in this debate, particularly the noble Baroness, Lady Watkins, who returned early from the WHO to take part in it.

I am left, though, with huge concerns and a real puzzlement as to the Government’s approach. As the noble Lord, Lord Willis, said, faced with this huge crisis in nursing in particular but also among the other professions covered by the regulation, the Government, without any evidence base, seem to be setting out a plan to discourage older women and people from black and minority ethnic groups from entering nursing, midwifery and other professions. In the breakdown of postgraduate healthcare students, the statistics show clearly that 64% are over the age of 25, women are largely attracted to this route and there is a higher percentage of minority ethnic students. We also know from the Department for Education’s own analysis that those groups are known to be more debt-averse. So the consequence is bound to be a negative impact on the very group of people we probably most need to come into the nursing profession.

NHS: Cybersecurity

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 2nd May 2018 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the response of the National Health Service to cyber attacks.

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

My Lords, as the lessons learned review into the WannaCry attack by the Chief Information Officer for Health and Care set out, the NHS responded well to what was an unprecedented incident. However, a number of areas for improvement were also identified. Consequently, several immediate actions were taken to improve the cyber resilience of the NHS. They included updating and testing incident plans and investing more than £60 million to improve security in local IT infrastructure.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome the measures that have been taken, but the noble Lord will know that recently the Public Accounts Committee has identified that his department and the NHS were wholly unprepared for what was a relatively unsophisticated attack, and that many trusts failed to act on warnings that they had been given to patch exposed systems. I understand that the committee said that, extraordinarily, at the time it took evidence some trusts had still not patched up their systems. My understanding is that that is because those systems were linked to the use of medical equipment, and in patching up the systems they could have damaged a lot of the service-giving infrastructure. That suggests that the NHS is in a very poor condition indeed to deal with this kind of threat in the future. Can he reassure me that the recent announcement by the Secretary of State will really do the job?

[Lord O'Shaughnessy]

The PAC review found that the use of Windows XP was at the heart of the problem, as an unsupported and unpatched system. Several things have happened as a consequence. First, XP usage has gone down from 18% in 2015 to 1.7% now. We also have a customer support agreement with Microsoft now and are transitioning to Windows 10, which is of course fully supported and much more secure. We also have a system now called cursor collect. The notifications that go out, called cursor notifications, are due to be acted on within 48 hours. That exposes the fact that we did not have a way of tracking that. We now have a way of tracking that and enforcing action at trust level. So there is a much higher degree of security than there was. Of course, no security is ever perfect and our vigilance carries on.

--- Later in debate ---

[Lord O'Shaughnessy]

The noble Lord makes an excellent point. One thing we are now doing is more intelligence-led penetration testing based on work that the Bank of England does, which is to probe in a safe way any weaknesses and to make sure that they are dealt with. The CQC has also added data security to its well-led criteria for inspections. We have now demanded that a board member of each trust takes responsibility for cybersecurity. Indeed, for a trust to be rated as well led, it has to demonstrate that competence.

[Lord Hunt of Kings Heath]

My Lords, one of the things that happened when this occurred made it clear that NHS trusts did not follow the instructions they were given to patch their systems. Is the Minister assured that, if this were to happen in future, trusts would follow, without exception, the instructions given?

[Lord O'Shaughnessy]

I am absolutely assured that they would perform much better than they did that time. I do not think I can give the assurance that every single one would do it, because there are still capacity issues in some trusts. The investment that we are carrying out is designed to deal with that. It is a much better performance, but we need to make sure that we are always vigilant for weakness in the system.

NHS: Winter 2017-18

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 18th April 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right. That is one of the reasons we have taken some big decisions over the winter, one of which is to reduce the amount of delayed discharges. I think it has been reduced by about 1,500 beds. It was also the reason behind what was undoubtedly an unpopular decision and one that we did not want to take: to suspend and postpone some elective surgeries during January. That freed up a number of beds, which helped us to cope with the emergency admissions. Happily, it has not had to be reinstated since the end of January.

[Lord Hunt of Kings Heath (Lab)]

My Lords, a huge debt is owed to the NHS for the way that it has responded to the pressures this winter. However, can I ask the Minister about elective treatments and the cancellations in January? He will know that the maximum 18-week wait target has not been met for, I think, at least two years. Given that the BMA has said that winter pressures will really never come to an end—they simply continue throughout the year—does he think that we will ever meet the 18-week target again under the current Government?

Prescription Drugs: Dependence

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 19th March 2018 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they have plans to provide a network of support, nationally and locally, for people affected by dependence on prescribed drugs.

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

The Government take seriously the issue of dependence on prescription drugs. The Public Health Minister has commissioned Public Health England to review the evidence on the scale and nature of the problems with some prescription medicines, and how those problems can be prevented and treated. The review is due to report in spring 2019.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I very much welcome the review, but there is a real problem: many, many patients are suffering huge damage as a result of overdependence, often because they have been prescribed a particular medicine for too long a period. There appears to be woeful ignorance among many people in the health service about this impact of dependence. There are no national programmes for supporting people. Instead, people rely on local charities, which are grossly underfunded. Does the Minister not think it is time for a national action plan, a national helpline and support for local charities, and to get the NHS to start taking this seriously?

[Lord O'Shaughnessy]

I agree with the noble Lord that it is a serious issue. A NatCen study found that there has been a doubling of the use of serious painkillers. Indeed, deaths due to opiates of all kinds have risen by about two-thirds in the past five years; of course, that is illegal as well as legally procured drugs. We agree that there is a problem. That is why the review is taking place. It is premature to say what the outcomes of that review will be, but undoubtedly we need a comprehensive approach to dealing with this problem, because it is getting worse.

Emergency Hospital Admissions

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 7th March 2018 Lords Chamber

[Lord O’Shaughnessy]

One of the issues the NAO reports is that we do not yet have good enough data on what is happening in the community. The creation of the community services dataset will enable us to track precisely what is available in the community in every area. Concerns have been raised in this House before about the number of district nurses, which unfortunately has fallen over recent years. It has now shown a small increase year on year and we hope we are starting to turn the corner on community nursing numbers, too.

[Lord Hunt of Kings Heath (Lab)]

My Lords, there are two stark facts from the NAO report. First, the real problem has been the reduction in social care funding. Surely the real answer to this problem, above all else, is to restore what has been cut. Secondly, I refer the Minister to the chart in that report which shows that, despite the increase in demand, bed capacity has been cut by 6,000 beds since 2010-11. I understand that in February the occupancy rate reached a dangerously high level of 95%. Does the Minister accept that, while we need to prevent avoidable admissions, it is very unwise to reduce acute care capacity at the moment?

[Lord O’Shaughnessy]

I agree with the noble Lord about funding. The Government have now made £9.4 billion of extra funding available to local authorities over three years, including in the most recent local government funding settlement. The noble Lord makes a good point about bed capacity: it had shown a downward trend for a long time before stabilising in recent years. I point to two successes this winter. The first is the improvement in delayed transfers of care—we have really started to get some traction on that. The second is about £60 million, I believe, of funding that went into providing extra bed capacity over winter. Occupancy levels are too high. The NHS is getting better at managing it more efficiently, but we certainly need to do better.

National Child Obesity Strategy

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 26th February 2018 Lords Chamber

[Lord O’Shaughnessy]

I reassure the noble Lord that the national curriculum, through PSHE, includes elements around nutrition and healthy eating. Indeed, many schools offer the kind of classes he is talking about.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer the noble Lord to your Lordships’ Select Committee on the Long-Term Sustainability of the NHS, which said that the Government,

“should not cite unwillingness to behave as a ‘nanny state’ as an excuse for inaction on the major public health issues, including obesity”.

If the study that is being undertaken at the moment shows that outcomes are poor, will the Government move from their current voluntary approach to take more decisive action?

[Lord O’Shaughnessy]

The point here is that we know that these are difficult decisions and, of course, children have decisions made on their behalf by their parents, people in schools and others, so there needs to be a combined approach of statutory action and voluntary action. We should applaud the voluntary action that many people have taken—supermarkets, food producers and others—but clearly there is a continued role for the Government and I do not think questions of nanny statism come into it.

Health: Pelvic Mesh Implants

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 6th February 2018 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they intend to review the safety of the use of pelvic mesh implants.

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

My Lords, NHS England’s mesh working group report outlined recommendations to optimise care when surgical mesh is used to treat stress urinary incontinence and pelvic organ prolapse. We continue to implement those recommendations. NICE has now published eight pieces of updated interventional procedure guidance related to vaginal mesh. Updated clinical guidance covering urinary incontinence and mesh will be published in February 2019. The MHRA continues to review available evidence to make sure that our regulatory position is up to date, liaising with EU and non-EU partners.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for his personal involvement in the decision to conduct a retrospective audit into vaginal mesh surgery, but will he go a little further? He will be aware that an increasing number of women have reported suffering from complications that include debilitating pain, infection, inflammation, the loss of sex life and mobility issues. A number of countries have now banned the use of mesh implants completely. On the precautionary principle, will he suspend the use of mesh until the audit that he has announced has been completed and new guidelines issued by NICE?

Dental Care

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 1st February 2018 Lords Chamber

[Lord O'Shaughnessy]

We have talked about fluoridation a lot in this House recently. My noble friend knows the position: it is up for local areas to come forward with proposals. On his particular issue about dentists, they are doing a fantastic job in the NHS. We have more of them than ever. I want to point out that the 1% cap that was applied—we know that was because of the fiscal retrenchment that has had to take place in this country—no longer applies; indeed, we are waiting for dental review bodies to report on it so that we can arrange future payments for dentists.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I remind the House of my presidency of the British Fluoridation Society. The noble Lord says that we have talked a lot. We have not quite talked enough, because the problem is this: fluoridation would deal with a lot of the areas with high numbers of oral health issues. The local authority is responsible for this and for paying the revenue costs, but the benefit falls to the health service. The cost annually for an average local authority is £300,000. Would the noble Lord be prepared to convene a discussion between himself, NHS England and Public Health England to see whether there could be a way to find some resources to help local authorities implement schemes?

[Lord O'Shaughnessy]

I recognise the benefits of fluoridation that the noble Lord has pointed out. There is no question about that. But we know that this is a very difficult and vexed issue locally—there are strong feelings either way. That is why the position was reached in the 2012 Act. The noble Lord’s idea of a discussion is a good one. I should point out that it is not a policy area on which I lead so I will have to speak to my colleague in the department, but if we can get that going and think about ways to encourage more action it would be a very clever thing to do.

NHS: Nurse Retention

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 17th January 2018 Lords Chamber

[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 and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, nursing numbers have increased since 2010, including 11,700 more nurses on hospital wards. To retain more of these hard-working staff and to build a workforce fit for the future, the Government are increasing the number of nurse training places by 25%, supporting new flexible working arrangements in the NHS and delivering a new homes for nurses programme.

[Lord Hunt of Kings Heath]

My Lords, even for the Minister, that is remarkably complacent. The overall number of nurses may be rising, but it has nowhere kept pace with the increasing number of patients. For years, the Government have failed to get new recruits coming through, while failed policy decisions such as the NHS pay cap and the ending of the NHS bursary have contributed to the growing crisis. Last year, 33,000 nurses left the NHS. More than half of those who walked away were under 40, and the number of leavers outnumbered joiners by 3,000. There are now more than 100,000 vacant posts in the NHS. Does the Minister accept the need to lift the pay cap, fund proper rises for nurses, restore bursaries and support this precious profession, which has been so unappreciated by this Government?

[Lord O’Shaughnessy]

The noble Lord is quite wrong to say that it is an unappreciated profession; nurses are deeply appreciated by everybody in this country, and that includes members of the Government.

Of course we want to reduce the number of nurses leaving the profession. It is important to point out that the number is down on two years ago, which was the peak in both number and proportion, and that the number of nurses has risen over that period. The noble Lord mentioned the pay cap. He will know, I hope, that in the Budget the Chancellor announced that he would be funding pay increases above the pay cap for nurses and other professionals on the Agenda for Change contracts, which is extremely welcome. We know that pay matters.

The noble Lord is right to focus on under-40s; that was an area that concerned me. The programme whereby we are promising to deliver 3,000 social homes for nurses is an important part of retaining staff, because we know how important housing costs are, particularly in the south of England.

Finally, we have been around the issue of bursaries a number of times, and there is no evidence that their introduction will make a long-term impact on our ability to recruit the nurses we need. Indeed, we are increasing the number of nurse training places from next year by a further 5,000.

Smoking: Vaping

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 19th December 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Viscount is right to highlight the benefits of vaping: it is considerably safer than smoking and is a very effective quitting aid. There is no particular evidence that it encourages people to take up smoking or to transition into smoking. Government policy has, obviously, been made under the EU regulatory framework—and we think that it is pragmatic and evidence based. Direct advertising is, as he will know, banned, but the department, Ofcom and the Advertising Standards Authority are looking at the current guidelines in this area. I should point out that Public Health England includes in its public health campaigns positive messages about the relative benefits of vaping, so that message is getting out. In the end we must beware of renormalising the act of smoking, even if with a different device, particularly for children, so there is a balance to be struck.

[Lord Hunt of Kings Heath (Lab)]

My Lords, lest Brexiteer noble Lords get too excited, will the Minister confirm that it was the British Government who pressed the EU for draconian regulations, and the EU modified what Britain wanted? We should beware repatriation of those regulations.

[Lord O'Shaughnessy]

I will only talk about what I know, and what I know to be coming up, which is that we want to take a pragmatic and evidence-based approach. Other countries are looking at the balance we strike in this country with allowing smoking and vaping to take place—and indeed, positively encouraging vaping. I think our approach is sensible.

Health: Atrial Fibrillation and Stroke

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 12th December 2017 Lords Chamber

[Lord O’Shaughnessy]

I thank my noble friend for making that point. He is quite right that atrial fibrillation is easily diagnosable and treatable. In the end, it has to be a clinical judgment on what kind of medicine is appropriate for any given patient, but the variation in the prescription of anti-coagulants demonstrates that there is not uniform understanding of the options. There are a number of things I could point my noble friend to, such as the NICE guideline which promotes not only self-monitoring systems, which are typically what we have had, but encourage patient choice for the new types of anti-coagulants which have a lower risk of bleeding and are much more popular with patients.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister say why the national stroke strategy has not been updated or renewed? We had outstanding success in London in concentrating hyperacute services in a small number of centres, which improved outcomes and mortality rates. Why on earth has the NHS been allowed to stop proposals in other parts of the country taking that forward so that outcomes there are higher?

[Lord O’Shaughnessy]

On the stroke strategy, a follow-on plan is being developed by NHS England and its partners, including the Stroke Association, which will take forward that approach. The noble Lord will also be pleased to know that it is an integrated-service approach including ambulances, community care and secondary care. On the point about reorganisation, he is quite right that London has seen excellent success through the specialisation and concentration of services, and we certainly encourage the rest of the country to do that too.

Children: Oral Health

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 4th December 2017 Lords Chamber

[Lord O'Shaughnessy]

I am sure that milk does have those benefits. I should also point out that one of the best things one can do for all bone health is to have vitamin D and calcium supplements, which are recommended for young children.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that we are all grateful to the Minister for his wisdom in advising us on such important matters. I declare an interest as president of the British Fluoridation Society. To return to the point that I have raised with many Ministers over the past few years, the Minister says that it is down to local decision-making. The problem is that the hurdles that have been put in place make it almost impossible for local authorities to get fluoride into their water supplies. Will he look again at the rules and the law and agree that this is a strategic decision that needs to be made by government?

[Lord O'Shaughnessy]

I am certainly happy to look again at that issue because we know the benefits of fluoridation. That is one reason why more children are having fluoride varnishes, for example.

National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 16th November 2017 Lords Chamber

[Lord O’Shaughnessy]

For clarity, they are not covered under the exemptions.

The second change the amendments make is to the requirement that any care not deemed immediately necessary or urgent by a clinician is paid for up front. The published guidance, again, for nearly 30 years, has recommended this. This practice ensures that a chargeable patient can make an informed choice about their care and therefore does not unwittingly incur debts when they could instead, for example, choose to wait for treatment until they have travelled home. Given that our NHS is facing unprecedented levels of demand, I hope noble Lords will agree that mandating this position is a sensible approach and that it will help make sure that all users of the NHS make an equitable contribution to ensure its continued success and viability.

The noble Lord, Lord Hunt, has asked whether this practice will not create barriers between vulnerable patients and treatment and result in racial profiling as the front line seeks to determine eligibility for free care. I have already drawn noble Lords’ attention to the exemptions in place and the fact that all GP and A&E services remain free for all. I am also clear that immediately necessary or urgent treatment—such as all maternity services—will never be withheld, regardless of the patient’s ability or desire to identify themselves or pay. To reassure the noble Baroness, Lady Taylor, and other noble Lords, it is for clinicians, and no one else, to determine whether a treatment is immediately necessary or urgent.

On whether patients may face discrimination, this is always unacceptable and not compliant with anti-discrimination legislation. As my noble friend Lord Leigh pointed out, our guidance is clear that simple, short questions should be asked by trained staff of all patients whose records do not already indicate residency status to assist in identifying those not eligible for free care. That information can then be captured in the patient record for the future.

To support the implementation of these regulations, we have developed with front-line staff a “cost recovery toolbox” containing extensive guidance and template letters to patients and clinicians, as well as patient and staff-facing leaflets and posters and a web-based forum for peer support. As my noble friend Lady Redfern pointed out, working with NHS England and NHS Improvement, the department has published operational guidance to support the introduction of the regulations. This includes an average price list to provide consistency in up-front charging. The department has recruited a senior, experienced cost recovery team of NHS professionals who have led improvement visits to over 20 NHS trusts over the last six months. Action plans are in place for each trust and the team will support improvement and the sharing of best practice across the wider NHS.

I would like to end on an issue which has been raised by many noble Lords in this debate: the assessment carried out before we introduced these changes. As I have explained, up-front charging did not represent a change in policy, but instead has existed for many years before the consultation on other amendments. Over the course of the consultation and decision-making process, the Government carefully considered the impact the charges may have and published a full impact assessment alongside the regulations. This concluded that the package of changes would identify up to £40 million a year for the NHS. This is additional income and takes into account any administrative costs associated with the changes. I will also place in the Library copies of the equality assessments carried out by my department to inform the regulations, so that Members of the House will be able to review how the impact on vulnerable and protected groups was very carefully considered prior to the introduction of these changes.

All noble Lords have asked about the implementation of these changes and it is right, of course, that we proceed cautiously and sensibly and that we review how we are doing. So I am very aware of the need to keep the impact of these regulations under careful review in order to make sure they are implemented as planned and with no unintended consequences. My department will therefore undertake a full, formal review of how these amendment regulations are implemented, and monitor delivery closely, particularly where healthcare is provided to the most vulnerable. If further action is needed I will commit to update the House accordingly.

I hope I have been able to reassure all Members of this House about the long-standing principles that underpin our approach to cost recovery, the care that has been taken to protect vulnerable groups, and the reflective approach we will take during the implementation of these policy changes. I believe that they provide an equitable and reasonable step forward in making sure that all the NHS’s users, wherever they come from, make a fair contribution to the sustainability of the NHS, which is what British citizens expect. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to all noble Lords who have taken part in this debate. The fact we spent nearly an hour on it as last business on a Thursday is testimony to the importance of the matter, which is why I welcome so many noble Lords having stayed to take part. I will not push this to a vote, and I will withdraw the Motion, but I do think it is an opportunity to raise some very important points with the Government.

First, the noble Baroness, Lady Hamwee, made some very important points about the analysis of the impact assessment, the doubtful financial benefits set against the bureaucratic costs, and the impact this may well have on some of the most vulnerable people—the very people who, not just from their point of view but the public health point of view, need to access these services.

Secondly, from the evidence that I have received—and I have received many such examples—there is a real concern that people who are legitimately entitled to NHS services may get turned away. The noble Baroness, Lady Hollins, rightly asked what the safeguards were to prevent this.

I think it right that we talk about racial profiling because again there is some evidence that, in spite of what the Minister said and what is promised in guidance, this is taking place in some parts of the country. The NHS has many organisations—we have a lot of community organisations—but it turns out that staff who are given such responsibility may not be aware of the importance of this issue and its sensitivity. The obvious case here is British people with foreign-sounding names being challenged in a way which I think is inappropriate.

The Minister did not respond to the point from the noble Baroness, Lady Hamwee, about the Home Office requiring medical records. I do not know whether he will be prepared to respond to her in writing; I understand that the question goes much wider than his brief today, but I am concerned about the ethics of the Home Office requiring people to open their medical records.

The noble Baroness, Lady Hollins, was of course right to point out the barrier to people with mental health and other disabilities. This is not just about who is eligible: having to produce evidence to legitimise a right to treatment could prove difficult for vulnerable people who find everyday living hard and challenging.

Like my noble friend Lady Taylor, I say to the Minister—the noble Baroness, Lady Redfern, and the noble Lord, Lord Leigh, both spoke about this—that I have no problem with the principle of cost recovery. I accept that it is right that the NHS seek to recover costs from the people who are not eligible for NHS treatment. My problem, particularly with these regulations, is that I have a feeling they will be counterproductive and I doubt they will raise very much in the way of resources. My noble friend also teased out the point about the position of failed asylum seekers, who seem to be particularly vulnerable. I welcome what the Minister said about unintended consequences; that is a very important point.

Operational guidance, which the Minister referred to, is one thing. I would have preferred to see some of the points he has made and reassurances he has given in the regulations, rather than operational guidance. I also noted with great interest what he had to say about accident and emergency and GP services. From the confidence with which he said it, can I take it that the Government intend that they will remain free for all in future? Perhaps I can ask him quite what he meant by that, because in the briefings that I have had people have emphasised that it is the Government’s intention to extend the charges to accident and emergency services and GP services.

[Lord O’Shaughnessy]

We are talking about the regulations that we are implementing, and they do not introduce that. That is the point I was making.

[Lord Hunt of Kings Heath]

Noble Lords will interpret that response in the way they wish to. That is a bit disappointing.

The Minister has promised a review. I very much welcome that. He said it would be a full, formal review; let us hope it will also be an independent one. Asylum Matters has reminded me, in the most efficient way that that organisation works, that of course in 2016, a review was promised. I hope this time, we will actually get such a formal review.

Having said that, this has been an important debate. A lot of people are looking with great interest at what your Lordships have discussed tonight. We knew we were not going to be able to stop these regulations but I hope we have expressed those legitimate concerns. I am grateful to noble Lords for taking part and beg leave to withdraw the Motion.

Veterans: Mental Health

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 7th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I reiterate the point I made in my Answer: NICE guidance on the treatment of post-traumatic stress disorder is clear that clinicians should take into account a range of factors when seeking to make a diagnosis. That should include the patient’s detailed case history, including medicines taken and under what circumstances. Regardless of whether the person is treated while serving or afterwards, that should be on their patient record, be accessible for anyone giving them direct care, and influence any prescriptions of treatments given. I also point out to the noble Countess that veterans’ issues are now in the training curriculum for all GPs. That came out of the Armed Forces covenant.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the treatment of veterans is clearly important, but so is prevention. Will the noble Lord confirm that for the drug the noble Countess referred to, whatever geographical area you are in in the world, there is always an alternative? Will he also confirm that the Surgeon-General told the Defence Select Committee last year that he could not guarantee that every member of the Armed Forces had a face-to-face risk assessment before the drug was given to them? Have the Government now ensured that face-to-face risk assessments take place?

[Lord O'Shaughnessy]

For the drug in question, Lariam is the brand name and mefloquine is the generic name. There are indeed alternatives available, and only 1% of antimalarial drugs prescribed to the Armed Forces are of mefloquine. There are instances when alternatives are not available, which may be because of a particular response to individual drugs or because the prescribing details are different—mefloquine is given on a weekly basis, for example—but the proportion is only 1%. The Defence Committee set out several recommendations, one of which was that there should be face-to-face risk assessments before prescribing. That figure is now up to 89% of the total; for the remaining 11%, the problem may be about recording rather than their not happening. The rate is much higher than it has been historically.

Greater Manchester Combined Authority (Public Health Functions) Order 2017

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 7th November 2017 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

I beg to move that the draft Greater Manchester Combined Authority (Public Health Functions) Order 2017, which was laid before this House on 20 July 2017, be approved.

The draft order we are considering today, if approved and made, will confer local authority public health functions on the Greater Manchester Combined Authority as agreed in the devolution deals, and support Greater Manchester’s programme of public sector reform.

The Government have, of course, already made good progress in delivering their commitment to implement the historic devolution deal with Greater Manchester. Since agreeing the first deal with Greater Manchester in November 2014, we have passed the Cities and Local Government Devolution Act 2016, followed by a considerable amount of secondary legislation for Greater Manchester, including: establishing the position of an elected mayor; new powers on housing, planning, transport, education and skills; transferring fire and rescue functions and assets; and setting out the operation of the police and crime commissioner function, which transferred to the mayor on 8 May.

The draft order we are considering today provides a further significant step for Greater Manchester. Greater Manchester has identified public sector reform and population health improvement as priorities. This draft order provides for the conferral of certain local authority public health functions on the combined authority. Once the order is made, the combined authority will be able to exercise those public health functions concurrently with the 10 metropolitan district councils in its area.

The main new function is conferral of a local authority’s duty to take such steps as it considers appropriate for improving the health of the people in its area. The effect of the order will be to treat the combined authority as if it were a local authority, with the same duty to improve population health and the same consequential requirements to comply with guidance and the NHS constitution, and with the ability to enter into partnership arrangements with local authorities and NHS bodies.

Conferral of local authority public health functions will enable a Greater Manchester-wide strategic leadership approach to the delivery of agreed public health functions and commissioning responsibilities—for example, public health intelligence, health needs assessment and health protection. It will support a Greater Manchester-wide approach to tackling health inequalities, variation in quality and service improvement to promote fair and equitable access and to achieve an upgrade in health outcomes for the population of the wider city. It will also support strengthened collaborative decision-making for population health through the identification of city- wide commissioning priorities and intentions, underpinned by shared principles and common commissioning standards —for example, commissioning for whole-system sexual health and substance misuse services. Finally, it will enable population health to be embedded across the city’s health, social care and wider public services through the Greater Manchester strategy and the population health plan.

Noble Lords will want to know that the statutory origin of the draft order before us today is in the governance review and scheme prepared by the combined authority in accordance with the requirement in the Local Democracy, Economic Development and Construction Act 2009. Greater Manchester published this scheme in March 2016 and, as provided for by the 2009 Act, the combined authority consulted on the proposals in the scheme.

The consultation ran from March 2016 to May 2016, in conjunction with the 10 local authorities in its area. The consultation was primarily conducted digitally, including promotion through social media. In addition, of course, respondents were able to provide responses on paper, and posters and consultation leaflets were available in prime locations across Greater Manchester. As statute also requires, the combined authority provided to the Secretary of State in June a summary of the responses to the consultation, and the Secretary of State concluded that no further consultation was necessary.

Before laying this draft order before Parliament, the Secretary of State has also considered the other statutory requirements in the 2009 Act. He considers that conferring these functions on the Greater Manchester Combined Authority is likely to improve the exercise of statutory functions in the area, and he has had regard to the impact on local government and communities, as he is required to do. Also, as required by statute, the 10 constituent local authorities and the combined authority have consented to the making of this order.

In conclusion, the draft order we are considering today, if approved and made, will confer local authority public health functions on Greater Manchester Combined Authority, enabling it to play a key role in improving the health of the population in Greater Manchester. I commend the draft order to the House.

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I thank the noble Lord for his explanation of the order. As I am going to touch on oral health in Greater Manchester, I declare an interest as president of the British Fluoridation Society.

The order is unexceptional and we support it. It takes a sensible approach, enabling the combined authorities in Greater Manchester to undertake public health duties which at present fall just to individual local authorities. The Greater Manchester Health and Social Care Partnership has published a very interesting population health plan, which has a lot of very good things in it, and I commend the local authorities and the combined authority for what they are doing.

I mentioned my interest in oral health. It is well known that Greater Manchester has very poor oral health. It is also well known that, at a stroke, this could be dealt with by the introduction of fluoridation in the water supply in the north-west. All I would ask is that when the order has gone through, Greater Manchester be gently urged, through the Minister’s good offices, that an improvement in oral health be one priority that the combined authority—and indeed the mayor, who I know is a passionate believe in fluoridation—might take on. I hope the Government will encourage them in the right direction.

The order proposes that for some interventions, there can be reductions in visits to urgent care, a reduction in the number of people with chronic conditions, and that 700,000 people will be able to manage their chronic conditions more effectively. But of course, this takes place in the context of a very rocky position for the NHS and social care. The funding gap and the demographic pressures on the health service are severe. Inevitably, this is going to impact on the effectiveness of what Greater Manchester can do on health and social care as well as public health.

--- Later in debate ---

[Lord O’Shaughnessy]

I thank noble Lords for their contributions and for their broad support for the order before the House today. As I outlined, it represents another significant milestone in the Government’s devolution agenda and I am glad that that has been welcomed across the House. I will try to respond to the various points that noble Lords have made.

Like the noble Lord, Lord Hunt, we support the idea of the population plan, which will clearly differ from place to place where there is this kind of devolution. I stress that an important and distinctive part of this plan is that it confers on the combined authority the same powers and responsibilities as a local authority. It is therefore about them acting concurrently, rather than in an overbearing way, or seeking to override.

I have been in your Lordships’ House long enough to know that fluoridation is an area of particular interest. I wonder only why it has taken so long for me to have to answer a question on it. This is a devolution deal, and it is therefore about those powers being taken locally and acting in concert. I do not think it is consistent with the idea of devolution for me to urge any combined authority to point in one direction or another, and it sounds like my noble friend Lady Gardner has been doing plenty of urging already. Any such move would have to be made in concert by all 10 of the local authorities and the combined authorities and be done through the usual processes of consultation and so on, with regard to all the responsibilities that attend on those public health powers. I hope that provides some reassurance to my noble friend Lady McIntosh.

[Lord Hunt of Kings Heath]

After the Strathclyde case and the ruling from Lord Jauncey, the then Conservative Government took legislation through both Houses of Parliament to make sure that fluoridation was legal and above board. That was based on evidence that has not been undermined since.

[Lord O’Shaughnessy]

I am trying to make the point that there is an established regulatory framework around such proposals. As noble Lords can tell, I am trying to avoid coming down on one side of the argument or the other. In the end, this is an issue both for local areas and for clinical opinion and research. On the broader position of public health, difficult decisions had to be made about local authority budgets as a consequence of the financial crisis and the deficit which it brought about. It is still the case that local authorities are getting £16 billion to spend on public health over the five years from 2015 to 2020. Alongside that, power and decision-making have been devolved to local authorities on using that money and combining it with other functions that have an impact on public health. One of these would be housing, the quality and condition of which has a huge impact on the public health of local people. You cannot both welcome devolution and say that local authorities should not have the power to act in different ways, so long as they comply with their statutory obligations. From that point of view, local authorities should not act outwith those obligations, whether in the case of contraception clinics or any other public health responsibility.

The noble Lord, Lord Beecham, asked about integration: I stress the point about pooling of budgets. As he will know, a chief officer for health and social care has been appointed in Greater Manchester. That person is an NHS England employee, because the NHS is a national health service and NHS functions have not been devolved. We are clearly trying to achieve greater integration of services, through the sustainability and transformation programme. We hope that doing this at a level where there is a degree of integration by the relevant local authorities will be fertile ground, and that it will provide evidence for and leadership in the move towards accountable care systems, which NHS England is now leading through its five-year forward view.

On the final point about information being spread to epidemiological centres, I again stress that this measure confers the powers of a local authority on to a combined authority, so it will absolutely have the responsibility to share data. Indeed, it will not be able to assume responsibility for any functions if the 10 local authorities do not want it to do so. Obviously, we hope that they will. Indeed, by committing to support this order, they have signalled their intention to do so. I reassure the noble Lord that there is absolutely no risk that these kinds of responsibilities will be watered down as a consequence of this order.

In conclusion, I hope that I have answered noble Lords’ questions and inquiries about the impact of this order on fluoridation and many other issues. It is an important order and I hope that all—

[Lord Hunt of Kings Heath]

I am sorry to intervene again but I have just reflected on what the noble Lord said about fluoridation. He seemed to say that he was not prepared to come down on either side. That sounds to me like a new statement of government policy, as traditionally government has been in favour of fluoridation.

NHS: Winter Staffing Levels

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 26th October 2017 Lords Chamber

[Lord O’Shaughnessy]

We recently debated community pharmacies. Reforms have ensured that most people—more than 80%—are within a 20-minute walk of a community pharmacy. As a consequence of these reforms, there has been no decrease in the number of community pharmacies in England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the case raised by my noble friend relating to Essex goes to the heart of the problem of discharging patients from NHS hospitals because of the lack of support in the community from social care and the reduction in nursing home places during the last four years. Is the Minister as surprised as I am that, despite this, up and down the country the NHS, through its sustainability and transformation plans, is putting forward proposals to cut out community hospitals and community hospital beds? Will Ministers issue an instruction to the NHS so that this will not be allowed to happen?

[Lord O’Shaughnessy]

We have discussed the issue of nursing home beds. We also know that there has been an increase in the provision of domiciliary care packages which reflects people’s changing care needs. Figures published yesterday show that social care spending has risen by £500 million during 2016-17. I am sure this will be warmly welcomed across the House. On community beds, noble Lords should know that, in addition to the usual four tests for reconfigurations, last year Simon Stevens, the head of NHS England, said that there is now a fifth test—the bed test. There must be robust evidence that any proposed reduction in beds is because of a reduction in demand and not the other way round.

Medical Examiners and Death Certification

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 18th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is quite right to highlight this point. There have been calls for medical examiners since the Shipman inquiry; those were also endorsed following the inquiry into Mid-Staffordshire. Our intention is to ensure that, with planning time, the system can be introduced by April 2019, which is why the consultation and the regulations needed to underpin the planning for the system will be produced in short order.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I chaired a foundation trust where we trialled the medical examiner role. I commend to the House the value of having a senior consultant able to talk to relatives about concerns, drawing the attention of fellow clinicians to issues relating to practice but, above all, safeguarding the public against tragic and appalling actions such as those taken by Harold Shipman. Does the Minister expect every part of the NHS to be covered by medical examiners by April 2019, or is that the start of the rollout? I hope that it can be extended throughout the NHS by that date.

[Lord O'Shaughnessy]

The noble Lord is quite right to highlight the pilots; indeed, early adopters have followed in their wake and have provided a much better service. The intention from April 2019 is for the service to cover the entire country, but it is most likely to start in secondary care and then move out into primary and community care.

Care Homes: Hospital Discharges

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 16th October 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, on behalf of my noble friend Lord Dubs, and with his permission, I beg leave to ask the Question standing in his name on the Order Paper.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

My Lords, information is collected on the number of bed days occupied by patients waiting to be discharged from hospital. The latest available information estimates that on an average day in August this year, 1,574 beds were occupied by patients waiting to be discharged to nursing or residential care homes.

[Lord Hunt of Kings Heath]

My Lords, that is a big number. I understand that over the last financial year, about 2.3 million days were essentially lost because of transfer delays. We know the number of nursing home places has been reduced by 4,000 over the last two years; we know social services are under pressure; we know the health service is not using housing services sufficiently. Why does the health service seem determined, in its STP plans for each area, to rush into yet further plans to cut acute capacity when hospitals are under so much pressure at the moment?

[Lord O'Shaughnessy]

I am glad the noble Lord mentioned the number within a year. He will be interested to know, as other noble Lords will, that the number of delayed transfers of care went down year on year between August 2016 and August 2017. That is good news. That reduction has been caused by greater funding in that period and a greater focus on accountability, particularly for local authorities and trusts together. In terms of acute capacity, the number of beds has been relatively stable recently and NHS England has introduced a new test for any reconfigurations that adds a fifth category, looking at the number of beds available in any given area.

Health and Social Care

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 12th October 2017 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty's Government what is their response to the conclusion of the Care Quality Commission in its annual state of care report that 1.2 million adults are not getting the care they need as the health and social care system is “straining at the seams”.

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

My Lords, the Government are committed to improving the quality and availability of adult social care in England. The Care Act 2014 introduced, for the first time, a national eligibility threshold for care, and the Government are increasing funding for social care by £2 billion over the next three years to meet growing demand.

[Lord Hunt of Kings Heath (Lab)]

My Lords, two days ago, in answering a Question on this report, the Minister spoke of a 20-year search for consensus on the funding of long-term care. We had consensus about the Dilnot proposals, which capped the amount a person would have to contribute to their own care. The Opposition co-operated with the Government in getting the 2014 Act through Parliament and the Government announced the cap at £72,000, but then they postponed its introduction and in the election they effectively abandoned it. No explanation has ever been given to Parliament about why the Dilnot proposals have been abandoned.

[Lord O'Shaughnessy]

There has been a 20-year search for a solution to this problem. It was not me who said that; it was the chief inspector of hospitals, who said:

“I think the one thing I regret is that 15 or 20 years ago when we could see the change in the population the NHS did not change its model of care”.


This is something we have all grappled with, but we have not yet come up with the solution that we need. That is why, through this consultation, we will be looking not just at finance but at quality of care, variation and sustainable staffing to rebuild the consensus that we need to move forward.

National Health Service

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 10th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord makes an excellent point. It is true to say that in this country we are very good at creativity and innovation but not always very good at spreading it round. In a way, that is one of the biggest challenges the NHS faces. I would merely highlight a couple of areas where the NHS is working well. The first is the test beds programme, which is working with industry, taking new innovations and spreading them round. Secondly, we have committed to publishing our response to the accelerated access review by the end of the month on how to make sure the most transformative drugs, devices and therapies are taken up throughout the system.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can I ask the Minister about the sustainability and transformation programmes? Has he seen the report issued by the King’s Fund last week that said we have fewer acute beds in this country than almost any comparable country? It also pointed out that the plan of many STPs is to reduce acute care numbers even further. I fully accept that we could use our beds and discharge patients more effectively, but the King’s Fund warns that STP plans to further cut acute beds are unsustainable. Will the Government consider that?

[Lord O'Shaughnessy]

Simon Stevens, the head of the NHS, made an important point several months ago about reconfigurations. Any reconfiguration has to meet four criteria: clinical need, popular support and so on. He added a fifth, which was about taking out beds. Those STPs are judged on their ability to meet the changing needs of their population. If there are proposals to take out beds which mean that those needs will not be met, such reconfigurations will not be accepted.

Health: Sepsis

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 14th September 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right. Trusts are now incentivised to report incidences of sepsis and their performance against these quality standards. That is happening. Unfortunately there is still variation within the system. That is why the documents that came out yesterday are so important. For the first time, we have an operational definition of adult sepsis. Clearly, that is critical to making sure that it is spotted in time.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the action plan is very welcome. It seems apparent that when patients come through, particularly from A&E, they are not recognised as having sepsis. Clearly, there is an issue about health service staff not recognising the symptoms or understanding the scale of the problem with sepsis. The Minister will be aware of a 2015 report by the national confidential inquiry which criticised the way coding is designed so that, in fact, sepsis does not appear as the prime responsibility for a death. The Government have been asked to look at coding. If it is not in the action plan, will the Minister look at this?

[Lord O'Shaughnessy]

That is absolutely right: there was an issue with coding. The noble Lord will be pleased to hear that from April this year NHS Digital published new guidance on coding for sepsis to deliver exactly the kind of improved reporting he wants.

Care: Older People

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 7th September 2017 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

I thank the noble Lord, Lord Lipsey, for bringing forward this debate. I know that he has been a tenacious proponent of deferred payments and of reform of the care system. I pay credit to him for that—it is very rare that we have a debate where I can thank everyone individually, so I also thank the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. Unfortunately, I did not have the opportunity to know Lord Joffe, but I know how much the House has mourned his passing and have noted the contribution he made. I want to acknowledge that as we talk about this issue.

We have had a bit of a trip down memory lane today, although others might call it Groundhog Day. We seem to be going over this issue repeatedly without properly resolving it. Of course it is not easy; the ageing population is probably the greatest social challenge, at least the greatest domestic social challenge, that we face. It is not one that we have grappled well with in the past, and that is true of Governments of all hues. That is for a number of reasons, including obviously the money and the changing nature of society, particularly working patterns. What has been highlighted by all noble Lords is the interplay between the taxpayer funded, free at the point of use National Health Service and a social care system that works on a different basis. It means that any attempt, whether it is a Labour-proposed national health and care service or through integration at STP level, is made very hard, particularly as things move. So I do not underplay the importance of this issue, and, of course, as we think about the narrower issue of DPAs, it has to be set in a context of what is happening elsewhere.

In the short run, more money is going into local authorities to try to provide the social care that is required. It is particularly focused on delayed transfers of care. That has some interplay with this issue precisely because of the concerns about moving from one part of the health system into another, something mentioned by the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. It is about the difference between continuing healthcare and social care and the quite radical consequences of the different funding situations for families that are necessarily trying to navigate through it at a time of stress. It is a challenge, but we are trying to address it through this additional funding.

In the long run, as noble Lords have pointed out, the intention is to bring forward proposals on social care reform for consultation. The objective in the consultation—I am glad the noble Lord mentioned the Care Act—is to achieve the widest possible consensus. It should not be a completely open-ended “what shall we do” process, but it should try to put forward some proposals that, inevitably in the process of consultation, will change but will try to achieve some kind of consensus. The noble Lord, Lord Hunt, specifically asked about Dilnot. There was a lot of agreement around Dilnot, but I still come across people who think that Dilnot was the worst thing that could ever have happened. There is a more nuanced picture. If anything, that just underlines the importance of taking care as we try to build a consensus.

Moving forward to the specific issue of the debate, which is deferred payment agreements, as has been outlined, they are a means by which individuals can access equity in their home to pay for care without having to sell it, meaning that they do not have to sell their home in their lifetimes. As the noble Lord, Lord Lipsey, pointed out, DPAs have been in existence for a number of years and the issue was addressed in the Care Act precisely to attempt to create a more thoroughgoing national system to replace what had obviously been quite a patchy one. Even though some elements of the Care Act have not been taken forward, in particular the social care reform agenda, as has been pointed out, the Government took the decision to move ahead with the implementation of DPAs in order to fulfil the pledge of the previous Prime Minister—to whom both he and my noble friend Lady Sugg owe their position in this House—that people should not have to sell their homes in order to go into care during their lifetime.

In terms of the actual performance of the scheme, we had a year of voluntary data collecting for 2015-16, although it is now compulsory. A helpful note tells me that the next iteration of the data is 2016-17, and NHS Digital should be publishing them towards the end of October. We will then have a really thorough look at what is happening. The previous year showed that about one-third of local authorities responded, so it was only a partial picture. Nevertheless, it was disappointing that fewer DPAs were agreed than had been anticipated. Indeed, the noble Lord, Lord Lipsey, pointed this out as likely to be the case in the debate on the regulations. I will come to what we can do about it, but these are of course a means to an end in themselves. This is why I am not convinced that having a target is appropriate because it is about enabling a choice and adding to the choices that are available for people by providing a means of deferring payment until after death. There are many reasons why people may not choose a DPA, and of course the private market is evolving all the time. But we need to understand why there were fewer DPAs than anticipated and to ensure that those who are eligible for them can access one. If there are local authorities where not one has been signed, that suggests that something is going wrong at the local level in terms of communication between the local authority, individuals and the social care sector. So we need to know why that happens.

[Lord Hunt of Kings Heath]

In the noble Lord’s very helpful response, he referred to the private market. He mentioned that not everyone thought Dilnot was the right answer, because one of Dilnot’s aims was, by capping costs, for the insurance market to come in when they have been reluctant to. I wondered whether part of the consultation would seek to answer the conundrum of what could make the insurance market come into this area more enthusiastically. Clearly, that would be one way that we could solve some of the problems.

[Lord O’Shaughnessy]

The noble Lord makes a good point. I do not know if that will be laid out explicitly. We have talked a little about the manifesto and how it was a movable feast over the course of a weekend. We ended up with a floor and a cap. At the point at which you have a cap, in theory, you have an insurable product. It depends whether it is insured by the private market or the state, but that was clearly at the core of the Dilnot design. There was lots of disagreement about how you could take forward that principle, but I think it useful so that, in keeping with the nature of the market, you have a mixed economy of funding.

We have been talking to local authorities to understand why people may not be accessing DPAs. There are a number of barriers, such as lack of awareness, interest charges and administrative fees. We are considering what actions can be taken locally and nationally to raise awareness and understanding of the scheme. One example of that is that is the wide variation in administrative fees charged by local authorities. Clearly, it is important that those fees are not set at a prohibitive rate, nor that local authorities are or seem to be profiting from the fees. They are meant to be covering costs. However, I think interest rates provide quite a positive picture, because the interest rate is around a third of that offered by the standard equity release scheme on the market. With wider awareness, that would prove more attractive than it has done.

Regarding the eligibility criteria, £100,000 is a magic fee in this social care debate—even more so after the election. That was the point that the noble Baroness, Lady Greengross, made about the reform proposal and widening eligibility. There are two points I would like to make on this. First, the Government’s aim in establishing the scheme was particularly to ensure that people did not have to sell their homes, rather than run down other capital. I know that that is more limited than noble Lords might like, but that was nevertheless the aim of the scheme.

The second point is that, in expanding the criteria, a local authority should in theory be able to recoup its costs, but there may be some costs in taking on a wider group of qualifying people. There is always a balance to be struck, particularly in cash flow terms, between helping a group who are by definition better-off people, and fairness to local taxpayers. That is one issue that needs to be considered.

The noble Baroness, Lady Greengross, asked in particular about the deep dive that happened. She will be disappointed to hear that departmental protocol is that these are for internal use only, so I am afraid I am not in a position to share that information with her. It sounds like she has the detail on what happened anyway, so I am not sure that that would necessarily reveal anything that she does not know.

To conclude, it remains a departmental priority to make the scheme accessible to all those who are eligible and would benefit from it. We will continue to monitor the scheme and, once the data are published, may look at some of the ideas suggested by noble Lords on how to give this scheme more momentum. Clearly, the intention of it is not to be de minimis, but to reach the original target and more people beyond that. We are open to ideas on how that can be achieved.

Finally, any DPA scheme must in the long run fit into the wider context of social care funding and provision. That point has been well made in this debate. As the proposals come out for consultation, considering the interplay of DPAs and the overall funding environment will be critical in whether reforms are successful. I conclude by thanking the noble Lord, Lord Lipsey, again for tabling this debate and other noble Lords for their contributions. I look forward to working with them on getting consensus on real reform in the sector.

National Health Service (Mandate Requirements) Regulations 2017

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 6th September 2017 Lords Chamber

[Lord O'Shaughnessy]

That is the truth.

Next year the NHS turns 70. As my noble friend Lady Redfern said, it has a unique place in our society. The mandate to NHS England for 2017-18 goes further than ever before to ensure that we not only continue to deliver the best care and support for today’s NHS patients but also deliver the reform and renewal needed to sustain the NHS for the future. We know there is more to do, which is why we have put our commitment to support NHS England and the NHS in delivering the five-year forward view at the heart of the mandate. We will continue to do so. I hope that I have persuaded all noble Lords, including the noble Lord opposite, that their fears are unfounded, and that the noble Lord now feels in a position to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, that is one of the most remarkable speeches I have heard in your Lordships’ House. I have to say that if the Government really think that the NHS is in the healthy position that the Minister says it is, I feel very sorry for them and sorry for NHS patients. Talk to anyone on the front line and they will tell you of the pressures, of the hopelessness of the changes the Government made and of the Brexit impact on staff. The NHS is facing a critical time and to have this litany, this list of so-called achievements, does no good at all to the health service or to the credibility of the Government.

I shall make only two points. The Minister said at the beginning that the Government are still committed to the 18-week target, but towards the end of his speech he quoted the same words as I quoted, which made it clear, as Simon Stevens has made clear and as is made clear in Next Steps on the Five Year Forward View, that actually the Government have given up on the 18-week target this year. They have said that,

“elective volumes are likely to expand at a slower rate than implied”

by the 92% target. That was an open admission that the target is no longer set in stone. Talk to any chair or chief exec in the NHS and ask them whether the 18-week target is a firm target in this financial year and they will say no. Of course the NHS faces pressures. In the days of my noble friend Lord Reid the demographic changes were taking place just as fiercely as they are now, but he made a dramatic impact in reducing waiting times.

My point is this: if the Government believe it is so difficult to manage the health service in such a challenging time, they should be open and honest and say that the target has been taken away; but they have not been honest, they have not been open and patients will suffer. My Lords, I beg to move.

End of Life Care

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 5th September 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the right reverend Prelate for making that point. In Scotland there are different funding environments. I am aware of the 50% funding commitment from the Scottish Government. We are trying to make sure that CCGs in England not only have the funding they need by increasing NHS funding in real terms but that they understand how to spend it well for end-of-life care, and topping that up where necessary with central funds. So there is a big spending commitment there and with the new accountability framework we have a way of holding those CCGs to account for their performance.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister has talked about a new accountability framework but the fact is that the work that has been done so far shows that CCGs are simply not implementing the guidelines. What is the point of NICE guidelines if we cannot be assured that they are going to be implemented? I refer him to the NHS England mandate for 2017-18, which talks about developing a set of measures on end-of-life care against which CCGs will be judged. Can he assure me that the NICE guidelines will be fully part of those measures?

[Lord O'Shaughnessy]

It is important to point out that the NICE guidelines are not mandatory in and of themselves. What matters is that there is high-quality end-of-life care provided at the local level and indeed that CCGs are judged on that care. They can of course do things differently and that is the point of the system: to trust that clinical judgment. The noble Lord is quite right that end-of-life care is in the mandate—that in itself is a relatively new development. I will come back to him on the specifics that he asked for about the extent to which those metrics will be included in the mandate.

Health: Obstetrics and Gynaecology

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 17th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I agree that parents should be involved in such reviews—as those who are ultimately most affected by these tragedies, they absolutely should be involved. It is fair to reflect that issues around maternity deaths, brain injuries and so on have been going on for a very long time, and in certain trusts there have been acute instances of tragedy. That is why, as I said, the Secretary of State is determined to halve the number of deaths and incidents. We have had a number of reports, not only the one we are discussing today but also that of my noble friend Lady Cumberlege, Better Births, in an attempt to improve the way that services are delivered.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I want to follow on from the question about reviews. The royal college that looked at the way in which the local reviews were undertaken found wide inconsistencies between different hospitals. Not only did a majority of reviews not involve parents at all, but my understanding is that, in its initial report, it found that only 9% of the reviews involved external experts. I know that the Government are very reluctant to intervene, but surely it would be possible to issue very straight guidance to the NHS to say how reviews should be undertaken and that in all circumstances both parents and external reviewers should be involved. Will the Minister give that some consideration?

[Lord O'Shaughnessy]

I shall certainly give that consideration. There may be specific reasons why, in particular instances, that might not be possible or even desirable, but I shall certainly look into it. Take one of the instances: the tragedies at Morecambe Bay. It was found that there was a lack of objectivity in investigations and that that—along with other problems such as a lack of good data—led to the kinds of tragedies we saw, not happening once but over and over again. I completely take the noble Lord’s point, and I will look into it.

NHS: Working Conditions

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 5th July 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I just do not understand the Government’s response to this very pressing question. Already, recruitment from other EU countries has ground to a halt because of the anti-EU rhetoric of the party opposite. In this country we now have a net loss in the number of nurses coming into the NHS. Is the Government’s policy to recruit nurses from overseas countries other than the EU, as we have for generations? If it is, and I hear that the NHS is recruiting hugely in those countries, does that not make a mockery of the Prime Minister’s ludicrous target to reduce immigration?

[Lord O'Shaughnessy]

As the noble Lord knows, we have talked about one of the reasons for the drop-off in nurses coming from the European Union; it is because of the stricter language testing. Stricter language testing was brought in for reasons of patient safety and was supported by the noble Lord when the regulations went through in 2015. Indeed, I think there was cross-party support for that. As for anti-EU rhetoric, I do not recognise that in anything that we have said. We absolutely value the contribution of anyone who is living and working here in the UK, and indeed have made a very generous offer to solve this problem as part of the talks for leaving the European Union. As for recruitment, of course we want to recruit as widely as possible. We want the brightest and the best to be here, and that is an absolutely core part of any immigration strategy.

Health: Medically Unexplained Symptoms

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 4th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I congratulate the noble Countess on the important work that she does through Forward-ME on behalf of the illness’s sufferers. On who takes responsibility for the care of those suffering from CFS/ME, it is of course clinicians. They work to evidence of best practice, which is guided by NICE. She alluded to the fact that the NICE guidelines are being reviewed to make sure that we have the best possible understanding of what is effective in the treatment of the illness, but I reiterate to her the point that the Government’s acceptance of the WHO classification of it as a neurological disease has not changed.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the approach taken by the NHS and child protection services to CFS/ME and other unexplained symptoms has had a sorry history. Some clinical commissioning groups state with great authority that graded exercise and CBT are the appropriate response. The point made by the noble Countess is that in many cases they are not, and can cause damage. Unfortunately, where children are involved, patients who resist such therapies often find themselves in problems with child protection agencies—there was an excellent programme about this on Radio 4 over the weekend. Prior to the NICE guidance coming out, will the Minister look with his officials at whether CCGs might be given some rather more authoritative advice, because it is clear that some CCGs have got this wrong?

[Lord O'Shaughnessy]

I am certainly happy to investigate CCG practice and commit to write to the joint panel to make sure it understands both the nature of the classification of the illness and the fact of the NICE guidelines. Of course, those are guidelines for clinicians; they are not mandatory in themselves.

Brexit: Nursing Staff

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 27th June 2017 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the impact on the NHS of figures released by the Nursing and Midwifery Council showing a 96 per cent reduction in the number of nurses registering to work in the United Kingdom in the year since the referendum on leaving the European Union.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

My Lords, the Government are aware of a reduction in the number of European Economic Area trained nurses applying to register with the Nursing and Midwifery Council. The department’s assessment suggests that this is largely a consequence of the NMC introducing language testing, rather than the vote to leave the European Union. The number of European nurses working in the NHS increased by more than 400 between June 2016 and March 2017.

[Lord Hunt of Kings Heath (Lab)]

My Lords, what the Minister did not say is that there has been a 96% fall in the number of nurses coming from EEA countries in the space of nine months. This comes on top of a shortage of thousands of nurses in the NHS. The RCN has today issued a statement which absolutely disproves the Minister’s argument that it is to do with English language testing. It is quite clear that it is to do with the Government’s obsession with migration control at the expense of our public services and the imposition of a pay cap on nurses and other NHS staff. He and his fellow Ministers have found £1 billion to bung the DUP; when are they going to find the money that is needed to get rid of the cap on nurses’ pay and pay them what they deserve?

[Lord O’Shaughnessy]

I am afraid the noble Lord is mistaking cause for correlation in this instance, and let me explain why we think that is the case. The General Pharmaceutical Council introduced language testing in November 2016; it had experienced no significant drop-off in applications from EEA member countries after Brexit but before that point and a big downturn in applications after that point. So it is language testing; it also happened with the GMC as well when it introduced language testing. I know this is something that the noble Lord supports—he said as much in a debate on this very issue in 2015—because it is an issue of safety. That is why language testing has been introduced. I would like to say, however, that of course we value the work of EU staff who come here, and, indeed, all nursing staff. As the Prime Minister set out yesterday, we want them to stay and have offered a generous package to allow them to do so, and there are more EU nurses here than there ever have been.

NHS: Shared Business Services

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 27th June 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister for repeating that. Clearly, this is a serious matter. More than 700,000 letters with patient information were waylaid, with more than 1,700 cases of potential harm to patients. The correspondence lost included blood test results, cancer screening appointments, medication changes and child protection notes. I will put just three quick points to the Minister.

I noticed that the Secretary of State, in this Statement, referred a lot to advice that he received from civil servants. I find it rather odd that a Secretary of State should announce to Parliament the advice given by civil servants, which usually is not disclosed. Why can he not stand on his own two feet in relation to the decision made to delay an announcement to Parliament by four months? Secondly, I am still not clear from the Statement why such a perfunctory Written Statement was made the day before Summer Recess last year. Why was a full Statement not made?

Thirdly, I understand that Shared Business Services makes £80 million a year from this NHS contract, and that so far the exercise of trying to discover where the letters have gone and to put this right has cost £6 million. Can the Minister confirm that the entire cost will be paid by Shared Business Services? Can he also say what other penalties the company will pay? Finally, the NAO points out that the Secretary of State has a conflict of interest, as he is a major shareholder in this outsourced company. Is this why he was so reluctant to come to Parliament to give information?

[Lord O'Shaughnessy]

I will answer the noble Lord’s four questions. The first was on taking advice from officials. I think the noble Lord would probably be alarmed if the Secretary of State was not taking advice from officials. That should be welcomed. It is clearly the case that he was thinking on his own, because he took the decision to follow that advice in the first instance in March, but was of the view by July that enough was known and that it was important to update Parliament before recess.

The second question was about the timing of the Statement. The noble Lord will remember that summer 2016 was a reasonably busy period after the EU referendum. The main point here is that the Statement was made before recess and was not held back until the autumn. As regards NHS Shared Business Services and the consequences for it, those consequences have been severe: it no longer has this contract and will, as my right honourable friend confirmed in another place just now, pay its share of the costs.

Finally, as my right honourable friend said, it could appear that there was a potential for conflict of interest, but in his view there was not one, because at all times—as confirmed in the NAO report—patient safety was the driving force behind the actions of the department and NHS England. It will always be the case, whatever arrangements the department has with an ALB—whether a standard agency, a joint company or whatever it is—that patient safety must come first. That was confirmed in the NAO report today.

Health: Electronic Patient Records

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 27th April 2017 Lords Chamber

[Lord O'Shaughnessy]

My noble friend makes an important point about the use of data. There is a balance to be struck. The first point to be made about the use of data is that patients need to be part of any decision about sharing them. In 2012, the NHS Future Forum published an independent report on this issue and used the phrase,

“No decision about me without me”,


to describe the role of patients. There is of course a need to share data among clinicians, particularly when they treat a patient themselves. There can also be wider concerns: for example, in a public health pandemic or some such incident data would need to be shared more widely. But that can be done only with patients being informed and offering their consent.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is there not a problem here? If all the focus is at national level, that usually takes a long time and it inhibits local progress. Does the Minister agree that one of the great challenges is being able to share information between the health service and social care if integrated care, particularly for older people who are discharged from hospital, is to be delivered? Is any progress being made in getting full integration at local level, which is clearly a challenging area?

[Lord O'Shaughnessy]

The truth is that there is patchy use of data within the health service. Practically all GPs now offer electronic patient records and something like 9 million people have registered to make appointments online. But it is not at the same level in acute trusts, mental health trusts and so on; there is still paper usage. The intention has been to have a paperless NHS by 2020. This means that with patient consent based around clinical need we would have the ability to share data around the patient pathway, whatever part of the health service they were in.

Health Service Medical Supplies (Costs) Bill

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Ping Pong (Hansard): House of Lords
Wednesday 26th April 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I look forward to the Minister’s answer to that last question. From the opposition Benches, I very much welcome the agreed amendment that has come forward from the Government today. It is good to see how wash-up can concentrate minds no end, and we have reached a very satisfactory outcome. I am very grateful to the Minister and his officials for their co-operation on this.

The Opposition have been in no doubt whatever that it is absolutely right to take action against those companies that have clearly been abusing the system. We should also pay tribute to the Times newspaper for its campaign, which has opened up some transparency in a pretty murky area.

There are two key issues that need to be taken forward. First, the key message of debates in your Lordships’ House is that, in seeking to deal with this particular problem, we must not underestimate the contribution of the pharmaceutical industry to this country, to the economy and to the life sciences sector. We have a problem in that we are incredibly innovative in the number of new drugs that are developed in this country, but the NHS is finding it increasingly difficult to invest in them and patients are not getting the benefit.

The second is the whole question of balance between the statutory and voluntary schemes—the noble Lord, Lord Lansley, referred to this. I have reached the conclusion that the current arrangements are simply not up to scratch in relation to how government should negotiate with the industry in the future. The patent lack of transparency about the real price paid by the NHS for individual drugs means, in my view, that the arrangements are no longer fit for purpose. I hope that the Government—whichever Government are in power post election—will look afresh at the need for new arrangements in negotiation which get a fair price and also lead to the adoption of innovative new drugs for NHS patients.

Can the Minister say when he thinks the Government will be in a position to implement the key provisions in this Bill in relation to prices?

[Lord O'Shaughnessy]

My Lords, I thank all noble Lords for their warm words and I reciprocate those feelings: it has been a very interesting, challenging and enjoyable experience working with noble Lords on this Bill on what is—as the noble Lord, Lord Hunt, has pointed out—a critical matter. It is critical not just that we get the best possible prices for drugs and that we crack down on those who are trying to rip off the system, but that we make sure we are also supporting the life sciences industry and are improving access for patients.

I am particularly grateful for the work done by the noble Lord, Lord Warner, and I appreciate his support for this amendment. My noble friend Lord Lansley and the noble Lord, Lord Hunt, made the point about the equivalence between the voluntary schemes and statutory schemes. There is equivalence in law and equivalence in spirit. It is in the nature of voluntary schemes that they take into account issues around access and life sciences, because that is, in a way, why they come about. You would not have one if you could not have some agreement on that. By making this amendment today we have provided something that was taken into account by the voluntary schemes by moving it into the statutory schemes and providing that equivalence.

My noble friend is quite right about the need to work in a constructive manner. It is possible to create a system in which the interests of patients, industry and the NHS align. There is no necessary reason for them to be in conflict and, indeed, we all want a system where we have improved access and keen prices that raise the standard of care available on the NHS.

I join the noble Lord, Lord Hunt, in congratulating the Times on its investigations, which continue. Indeed, I think that there was a story at the beginning of the week or the end of last week about that. It has put a turbo boost under this, but clearly there is more to do. This Bill will allow us to get up stream and not have to wait until things get to the Competition and Markets Authority many years down the track; it will allow us to improve things up front.

As to whether the current arrangements are up to scratch and what might happen in the future, noble Lords will understand if I resist making a comment on what might happen in the future, or what a future Government might do. My own observation—this is my way of answering the question from the noble Baroness, Lady Masham, which I will avoid slightly—is that any new system ought to be trying to rebalance spending towards innovative drugs, which can of course be done in any fiscal envelope; it is not necessarily a point about spending per se but about the balance of spending. Any system would probably benefit from being both simpler and quicker. I am sure that is something that Ministers in the Department of Health, whoever they may be after the next election, will want to grapple with.

I thank my officials who have done a fantastic job and have worked very hard with noble Lords across the House on the Bill and on amendments. I am very grateful to them. I think that 24 government amendments have now improved the Bill.

On a personal note, I have very much enjoyed taking my first piece of legislation through your Lordships’ House. Pending the election result, it may be my last, but I hope it will not be. Others may disagree.

[Lord Hunt of Kings Heath]

My Lords, I will not comment on that last remark. The key clause is Clause 5. Can I take it that once the Bill receives Royal Assent the Government can implement that straightaway?

[Lord O'Shaughnessy]

I believe that would be the case. Of course, there is a difference between what officials can do and what Ministers can give instructions to do in a period of purdah. However, as soon as the measure is in law, it is enforceable.

NHS and Adult Social Care

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 5th April 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Lord for that. I did not want to get ahead of myself but I thank him and all members of the committee for their work in putting together this document. I appreciate that it is an incredibly thorough and important piece of work, and I am also grateful to have received an embargoed copy of it yesterday. I will of course look carefully at all the recommendations and respond properly in due course. I am sure that we will also have an opportunity for a longer debate.

The noble Lord specifically asked about social care, and I completely agree with the priority attached to it in the report. He will know that the Government have committed more money in the short term to support social care, with £2 billion more having been announced at the Budget. But I know that his emphasis and the emphasis of his committee was on long-term reform. He is quite right to point out that the Green Paper is a very important opportunity to take a broad perspective and to put the system on a sustainable long-term footing.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I too commend the noble Lord and his committee for a thorough report, which I endorse and on which I hope we can have a full debate in due course. On the future of long-term care, the noble Lord will know that before the 2010 election Andy Burnham, as Secretary of State for Health, made some very striking proposals for its funding. I wonder whether the Minister regrets that David Cameron and other Conservative leaders at the time condemned this as a “death tax” and put back the search for consensus on the funding of social care for many, many years.

[Lord O'Shaughnessy]

The so-called “death tax”, to use the noble Lord’s words—

Hospitals: Patient Transport

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 4th April 2017 Lords Chamber

[Lord O'Shaughnessy]

There are challenges in patient transport, particularly in rural areas. That was one of the reasons for the Department for Transport creating the Total Transport pilots in an attempt to deal with the problem. In Devon, the local authority and CCG are now working together to provide better transport. As I said, it is in the clinical commissioning standard contract to provide that kind of transport and NHS England is responsible for making sure that it is provided.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister said that there are no national targets in relation to patient transport services, but there are targets in relation to ambulance services. Can he tell the House when those targets were last met by the ambulance services in England? Can he also tell me why, in the mandate for 2017-18 to NHS England, no guarantee is given that the NHS will come back to meeting those ambulance targets? Can I take it that, just as the Government have now decided to drop the 18-week target for surgery, they are also dropping the idea of a target for ambulance services to be met?

[Lord O'Shaughnessy]

I am afraid the noble Lord is wrong on the 18-week target—it has not been dropped. It is within the mandate. The 18-week target is being fulfilled in the vast majority of cases. Performance is much better than it was 10 years ago in terms of both median waits and the number of people who are waiting. I do not have the precise figure for ambulance services. However, they are in the mandate and local trusts are expected to deliver against the targets in the mandate.

[Lord O'Shaughnessy]

I am sorry to hear about the case of this young man and offer my sympathies to both him and his family. I appreciate the urgency and I understand that this person may not have long to live. I shall certainly speak to colleagues as soon as humanly possible and come back to the noble Lord with information on the situation.

[Lord Hunt of Kings Heath]

My Lords, the noble Lord said the Government have not dropped the 18-week target. What on earth, then, did the chief executive of the NHS mean when he said on Friday that the NHS would not achieve that target and that it would take less priority than other targets?

[Lord O'Shaughnessy]

The chief executive of the NHS was talking about the relative priority and importance of achieving A&E waiting times in particular to the targets that it is not hitting at the moment. The five-year forward view delivery plan refers to the fact that elective operations will continue to increase and that the median wait may move marginally. However, it is worth pointing out that 10 years ago the median wait for an in-patient for an elective procedure was 15.6 weeks—under a Labour Government, of course—and in January this year it was 10.6 weeks. The median may increase but it is still within the 18-week target.

Alcohol: Children’s Health

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Monday 3rd April 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

Now that we can see the end of the light-touch European regulations on alcohol labelling, can I take it that the Minister’s department is looking to 2019 to produce a much tougher labelling regime, for which we have called for many years?

[Lord O’Shaughnessy]

We are obviously looking at all aspects of alcohol control, and this has nothing to do with Brexit per se. It is worth pointing out that successive Governments’ alcohol policies have had a very positive impact on the activities of young people. Fewer young people than ever are drinking—it is fair to say that they set an example to older cohorts. However, there is more to do. Around 400 11 to 15 year-olds drink weekly. That is clearly not acceptable and we need to do more.

Nursing and Midwifery (Amendment) Order 2017

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 28th February 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank noble Lords for an extremely high-quality and very well-informed debate on both this order and the amendment. I will do my best to deal with the many questions and important issues that were raised by noble Lords.

First, I welcome the welcome that this order has broadly received. As the noble Lord, Lord Willis, pointed out, the separation of the professional interest and regulatory functions is best practice; that is how we expect regulation to take place these days. Unfortunately, in Morecambe Bay that lack of separation was one of the contributing factors, and that obviously has been a spur to change. I also welcome the words of support for the fitness-to-practise changes, which I think will bring in a quicker, more flexible and more proportionate system.

I turn to some of the points made by the noble Lord, Lord Hunt. There is undoubtedly an issue about the workforce, as he pointed out. There has been an increase in the number of births, and more is being done both to recruit existing staff and to retain them. But at the heart of this are three issues. The first is the point about silos versus integrated care. Of course we all want integrated care; that is the direction of travel. At the same time, necessary changes are taking place to the regulatory structure to deliver the kind of separation and clarity that we also want to happen. The concern being raised is whether, in doing so, we will in some way change the status of the profession, if you like—not intentionally, but by virtue of the removal of various statutory arrangements and so on. I can understand why some might draw that conclusion, but it is clearly not the intention of what is happening here, and I hope to set out a few reasons why that is the case.

The proposed changes do not alter the status of midwifery as a distinct profession with its own standards. There will be no change to the protected title of midwife, and delivering a baby remains a protected function for a midwife or medical practitioner; it is incredibly important to set that out at the beginning. As the noble Lord, Lord Hunt, pointed out, there are various tiers of representation, if you like, below Chief Nursing Officer: head of maternity, NHS England regional heads, deputy heads and so on. I do not know the specific reason why that is called maternity, not midwifery. I imagine that it might be because of integrated care and because, although it might have midwifery as the major focus of it, it might also involve other aspects of the birthing arrangements. I shall certainly endeavour to find out and write to the noble Lord about it.

The other issues were around whether the profession is getting the attention and respect that it deserves and indeed is properly represented at the right levels and in the right bodies. There is a midwife on the NMC. That is not a statutory requirement but the council ensures that it happens. It is also fair to say that we have a Secretary of State who is taking the issue of maternity safety incredibly seriously. I mentioned the national ambition, but we also had the publication of Safer Maternity Care in October and I will come on to some of the issues raised by my noble friend Lady Cumberlege as well. A lot is going on to support the profession.

One important part of that is making sure that this new supervisory function takes place properly and replaces statutory supervision. I quite understand why noble Lords will be concerned that that should take place. While on the one hand we have all agreed that the separation of regulation and supervision needs to happen and that the order creates greater clarity, there must be something to replace the supervisory arrangements that we agree need to change.

I reassure noble Lords that the four countries in the UK have been working together since 2015 to take account of the new employer-led models of supervision. In England, the NHS has evaluated the model in seven pilot sites to inform the model and its implementation, and there has been an education programme. Those pilots began last November and will complete in March, so they are informing the arrangements that go on in England. In the other countries, systemic reviews of the new system are taking place, on slightly different timeframes in different countries. But I reassure noble Lords that that will be happening. Not only is there preparation for the new system, there will be reviews into its effectiveness. Given all the points noble Lords have made about our experiences in Morecambe Bay and elsewhere, it is clearly essential that that happens.

A reasonable question was asked by the noble Baroness, Lady Walmsley, and my noble friend Lady Cumberlege about whether midwifery issues would be properly dealt with by the NMC and whether it has the capacity to do so, given its past problems. It received a much more positive performance review from the Professional Standards Authority, which found improvements down the line. Clearly, there is still one outstanding issue resulting from Morecambe Bay, but it is now an improved regulator and we can have confidence that it will do the kind of job that we now ask it to do.

My noble friend Lady Cumberlege raised the issue of the right level of insurance for independent midwives. I know that is incredibly important for maternal choice. Insurance is clearly a hot topic at the moment, but I will certainly write to her and find out exactly what the regulator is doing to give proper guidance, because that must happen. She is quite right to raise the example of Sweden. We know that there is a lot more to be done to improve maternity services in this country. Change is going on. My noble friend also mentioned the consultation going on with regard to regulatory redress. There needs to be a change of culture so that it is less adversarial and less litigious, and designed to increase learning and bring that to bear much more quickly on the process. We are undertaking that set of reforms and I pay huge tribute to her for her work in making that happen. My noble friend asked a set of other questions and I will certainly write to her so that I can answer her properly if I have not done so in the answers I have given already.

I end by paying tribute to the profession itself. The noble Lord, Lord Willis, made an excellent point, which goes beyond the scope of the order but is important. There is more that midwives can—indeed, must—do if we are to have a properly integrated system. We all want a healthcare system that, in the end, involves a personalised pathway. Whatever your experience, whether you are an older person, a young person, a mother or whatever, you can have someone by your side, leading you through that experience. Clearly, many pregnant women will want that to be a midwife, so I absolutely take the point about integrating with health visitors and many others besides. I hope changes are going on. That is perhaps not a subject for debate tonight but for another time. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his amendment.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to the Minister. I totally agree with the noble Baroness, Lady Walmsley, about the importance of the midwife being an integral part of the team. The noble Lord, Lord Willis, is right, as is the Minister, that one of the lessons of Morecambe Bay is the problem of different professions being completely unable to relate and talk to each other. Frankly, this is an issue that the health service suffers from and the Minister is right that, in a sense, it could be argued that the NMC is putting forward a more integrated approach to regulation. The risk is that, because of the disparity between the number of nurses and midwives—and we have often seen this before—integration could mean the marginalisation of certain people. This is the risk that we need to guard against—the unintended consequence.

The Minister has given a very good assurance that this matter will be kept under clear review; he emphasised that this would be a proper review and I very much welcome that. However, I still believe that, in the end, the answer to the question that he posed—“Are midwives around the right table?”—is that the experience of the health service is that they are never around the table at all. This is the problem. Whether the meetings are at board level of an English NHS trust, at the top level of the senior management team of a regional office of NHS Executive, at the NHS Executive itself, or at the department, they are never there. The big problem of how we get midwifery input at those top levels is one that we are still struggling with.

It is ironic that, having debated only two weeks ago the need for an approach to health regulation that covers all professions, we are now debating one profession. The noble Baroness, Lady Cumberlege, is absolutely right about this. I am indebted to the barrister Kenneth Hamer from Henderson Chambers who wrote to me after our last debate to point out that the Supreme Court is now using the Law Commission’s work on regulation to inform its own judgments. If there is any argument for the Government to produce a Bill in relation to unified health regulation very quickly, that is it.

On the loss of the midwifery supervisor, everyone agrees that the regulatory function needs to be separated off, and it is absolutely right that that is what the NMC should be concerned with. But there is concern about the loss of the supervisor at the local level. For me, the issue is safety. We know that NHS trusts are coming under huge pressure in relation to staffing levels from NHS Improvement because of pressure to reduce the deficit. The question, which I pose rhetorically, is who, given this pressure and given that midwifery does not have a voice at the board table, is going to defend the safety of the profession in terms of numbers when it comes to kind of hard decisions that are going to be made? That is my concern and frankly it has not been answered.

On the NMC’s performance, I remain of the view that the current chief executive has done a very good job trying to deal with the huge problems that she inherited. I hope that, whatever review is undertaken, it will not destabilise the NMC and that she will be given the time she needs to continue to make improvements.

The Minister said that he would exchange letters on the issue of independent midwives. I hope he will agree to go a little bit further and discuss this matter with his noble friend and the NMC. This issue has now been around for years, but it could clearly be sorted. A number of people are involved—the department, NHS England, the NMC and, I suspect, the NHS Litigation Authority—but if Ministers banged their heads together this would be sorted; that needs to happen. Frankly, even post the calamity of the 2012 Act, which has created such a discordant structure, Ministers can, in the end, determine something to happen here. That is what we need.

There is no question about it: I am not interested in silo professional behaviour or in whether a statutory committee is the right way to go forward. But I am convinced that the voice of midwifery needs to be heard at the highest level. I hope that this excellent debate—I am grateful to the Minister, too, for his response—has been helpful in just making that point. I shall not press my amendment to the Motion.

Tobacco Control Plan

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 23rd February 2017 Lords Chamber

[Lord O’Shaughnessy]

My noble friend makes an excellent point. Indeed, the Royal College of Surgeons of Edinburgh has just started a campaign to encourage clinicians to help their patients to stop smoking, and making sure that that happens is clearly going to have benefits for the kind of major surgery that some of the people who are suffering severe effects of smoking will need to have.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I noted that the Minister said the tobacco control plan will be published shortly and that it was in an advanced state of preparation. That was the same answer that his honourable friend the Public Health Minister gave in another place on 15 November 2016. The last tobacco control plan actually ran out at the end of 2015, so the new one is 14 months late. When exactly will it be published, and what has been the delay? Could the reason have been the decimation of the public health budget for local authorities, which has had a devastating effect, with reductions in preventive programmes at a local level?

[Lord O'Shaughnessy]

I understand the frustration at the delay in publishing the plan. That does not mean that action has not been taking place: all the action set in train under the previous plan has been taking place throughout that period. As I said, the new plan will be published shortly. I look to my noble friend Lord Ahmad, who has given several master classes in the use of words to describe “shortly” in different ways. I will save a few of those for any future Questions and stick with “shortly” for now.

Health Service Medical Supplies (Costs) Bill

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

3rd reading (Minutes of Proceedings): House of Lords
Thursday 23rd February 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I too welcome the amendments. Clearly, the Opposition will support them. I must remind the House of my presidency of the Health Care Supply Association and GS1 UK.

First, I thank the Minister and his officials for their warm co-operation. The ability to have a number of meetings has been much appreciated. This has been a very good example of cross-House co-operation. Various noble Lords, including the noble Lord, Lord Warner, and the noble Baroness, Lady Walmsley, worked very hard together on the core issue of ensuring that NHS patients get access to effective new medicines. I say to the Minister that I hope Clause 3 will remain in the Bill when it comes back to your Lordships’ House, if indeed it needs to come back—I take the point of the noble Baroness, Lady Walmsley, that this House has done the job it is here to do: it has revised and scrutinised the legislation. I would have thought that the other place should simply accept the Bill as it is, and I hope the Minister will be able to confirm that when he responds. I also thank my noble friend Lady Wheeler for her tremendous support, and Dan Stevens, our health researcher.

It seems to me that the Minister has shown himself adept at handling health legislation in your Lordships’ House, and so we look forward to the next health Bill. If he is looking for suggestions, we are going to have the great repeal Bill and perhaps we can look forward also to the repeal of the Health and Social Care Act 2012. That would bring great joy to many.

[Lord O'Shaughnessy]

I am very grateful to noble Lords for their support for these amendments. I am also grateful to my noble friend Lord Lansley, one of the architects of this new approach to information notices; that was extremely useful and we have ended up in a good place. I am grateful to the noble Baroness, Lady Walmsley, who I have enjoyed getting to know through the process of this Bill. She is quite right to emphasise the vital role that this House plays through its proper constitutional role in revising legislation—I will not say anything more than that. I thank the noble Lords, Lord Warner and Lord Hunt, both of whom have been in my shoes in the past. Good will will certainly operate, and I hope that both noble Lords, and indeed the noble Baroness, Lady Wheeler, have found me to be open, open-minded and willing to work with them. Throughout the passage of the Bill I have been keen to ensure that it is a proportionate response to tackle this challenge, and I think we are all agreed on that.

To conclude, I am delighted that we have come this far on the scrutiny of the Bill and are now debating the final amendments to bring it to a close. As we end Third Reading I would like to take this opportunity to place on record my thanks to all noble Lords who have taken part in the debates, beyond those I mentioned just now, throughout all stages in this House. It is fair to say that the collected efforts of this House in bringing together different views have paid dividends in the improvements that we have seen. It has been a good example of the rigour and attention to detail that this House is known for.

I particularly thank the many officials involved in the Bill, who have worked not only to support me but to ensure that noble Lords are briefed and that any concerns are addressed, within what at times have been very tight timescales. They have done a tremendous job and I am sure the House will join me in paying tribute to them.

Although this may not be the final word on the Bill, I am convinced that the House is sending it back to the other place having been significantly improved in key respects.

National Health Service: Nurses

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 22nd February 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for that question. We should be looking at attrition rates in training and in the profession itself, and I would certainly be happy to work with him on that. I know he is particularly anxious about the turnover of nurses within certain training settings.

[Lord Hunt of Kings Heath (Lab)]

My Lords, what is the current deficit that NHS providers are running in the health service? Can the Minister assure me that the NHS will actually have the money to spend on more nurses next year?

[Lord O'Shaughnessy]

I do not have to hand the figures the noble Lord asks for. He will know that the Government are putting in £10 billion over the five-year forward view period in order to support the world-class NHS that we all want to see.

National Health Service Commissioning Board (Additional Functions) Regulations 2017

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Tuesday 21st February 2017 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for his comprehensive introduction to the regulations before us this afternoon. I was interested when in his opening remarks he referred to the NHS Commissioning Board, more commonly known as NHS England. What struck me is that, when challenged on NHS funding, the Minister and his predecessor have been fond of saying that the NHS got the extra money that it had asked for. But what he really meant to say is that the NHS Commissioning Board put forward a five-year forward plan which talked about a £30 billion gap between the resource needed and the resource that was likely to be got, on the projections then published. We know that it was then told by the Treasury how much it could actually ask for. When we come to debate the NHS and its funding, it would give a much better reflection of the actual position if the Minister were to say that the figure which the Government have produced is what the NHS Commissioning Board was told to put into the five-year forward view.

I was puzzled by the way in which NHS England changed the name of its organisation to be that. Much of the two years we spent debating the 2012 Act was around the work of the NHS Commissioning Board. I was a little surprised that a quango took it upon itself simply to change its name and give itself the kind of title to which, statutorily, it clearly had no right—nor is it in its remit. It is interesting that when it comes to regulations such as these, which we have frequently, they have to relate to the NHS Commissioning Board. I suspect that very few people know what it is. At the end of the day, either the Government should regularise this by legislating to call NHS England by that name or it should revert to being the NHS Commissioning Board. As a matter of principle and practice, it is not a good idea to use a name that has not been given in legislation.

These are interesting regulations because, in a way, they take us back to our debates in relation to the Health Service Medical Supplies (Costs) Bill. Much of those debates have been on the cost of medicines, and the operation of the PPRS scheme and the statutory scheme alongside it. I guess that the question I would put to the Minister is: since negotiations with the pharmaceutical industry currently lie principally with the Department of Health, what implications does the transfer of this unit to NHS England have for the department’s own capacity to negotiate agreements in future? Does it essentially mean that NHS England will take over those negotiations?

I have obviously seen the Explanatory Memorandum and the reference back to the Carter report. I understand the reasons why my noble friend Lord Carter, thought that the CMU would be best placed within NHS England. But does this transfer equate at all to the recommendation in the Accelerated Access Review, which called for the creation of a strategic commercial unit to be established within NHS England? Would I be right in thinking that the transfer of the CMU is, in essence, the strategic commercial unit that the accelerated access review called for? What it actually said is that it wanted an SCU to,

“have the capacity and capability to consider a range of flexible pricing models as part of a commercial dialogue with innovators”,

and envisaged:

“Win-win scenarios, where innovators benefit from earlier, and, in some cases, guaranteed market access and the NHS and patients benefit from better value through a reduced price”.


In a sense, that takes us back to our debates during the passage of the Bill about whether we can develop more of a win-win relationship with innovators so that patients get access to innovation at a much earlier stage—but also, because the NHS is moving from a culture that is very often opposed to the introduction of innovation to one that embraces innovation, it therefore gets the advantage of better value for money in the end. If that is not to be the case, does the Minister think that the CMU has the capacity, capability and expertise to agree new and innovative commercial arrangements with companies? Will those processes support improved patient access to medicines and will NHS England consult on any new methodology or guides that will support the commercial unit role? How will the reconstituted CMU within the NHS interact with NICE and the adoption of NICE-approved medicines? If it has an active role, will that affect a patient’s right to NICE-approved medicines as covered by the NHS constitution?

Clearly, the experience of companies dealing with NHS England at the moment is that it is inflexible and is interested not in quality and outcome but simply in price. I have had many representations to that effect. My understanding is that NHS England simply has not got the capacity to negotiate these rather more innovative approaches to innovation, adoption and value for money. At heart, the question is this: will the transfer of the CMU to NHS England enhance the capacity of that organisation to move from a crude bottom-line approach to purchasing to one which looks at best value, innovation and adoption?

Apart from that, I will be interested in the Minister’s responses. As this is about procurement, I should remind the Committee of my presidency of the Health Care Supply Association and of GS1, the bar-coding association.

[Lord O'Shaughnessy]

I am grateful to the noble Lord for his questioning which was, as usual, precise. I will attempt to respond to his questions as best I can. I shall start where he started. I do not think I can take any blame for any confusion that may be caused around rebranding the NHS Commissioning Board Authority as NHS England. It clearly has a commissioning role, and in that commissioning role there is clearly a good fit with procurement. That is what the noble Lord, Lord Carter, concluded. Bringing together specialised commissioning, general procurement capacity and the role of the CMU was a good fit and it might deliver better value for money for the NHS, which I know the noble Lord wants as much as I do, so we can clear that out of the way.

The noble Lord’s big question was about enhancing the capacity of NHS England to become more sophisticated. In one sense, he is getting slightly ahead of things because the regulations do not transfer the entirety of the functionality. Some of the functionality will continue to be in the department as it pertains to public health responsibilities—vaccination, for example, or the procurement of emergency treatments. However, those that are to do with the ordinary activities of the health service are moving over. From that point of view, therefore, there is no change: the framework agreements transfer and people transfer. It is simply transferring a unit from one place to another, but clearly with the idea that there will be an enhancement in everyday activities as a result.

The noble Lord is quite right to refer to the issue of access—we talked about that a lot during the Bill’s passage—and it may well be that in future, when we are thinking about what comes after the PPRS, the kind of things that he is talking about would be within the remit. It would be wrong for me to comment on that now, not least because the PPRS commits us to certain activities and behaviours on simplicity of pricing discounts and so on, and clearly the kinds of things he is talking about—the more sophisticated value-based pricing models—do not currently fall within that scope. I am clear, however, that the Government and the department will continue to take a lead in any future discussions about replacements that leverage capacity across the system.

In answer to a couple of the noble Lord’s other questions, there is no particular impact on NICE from these regulations. We know that within the PPRS there is a commitment to fund after three months: that is part of the agreement. I hope, therefore, that he is reassured about that. To repeat, this is, in essence, quite a simple measure that takes a set of responsibilities from one place to another with the aim of providing greater efficiency—by procuring framework agreements, and so on. That is separate, in a way, to what we have been discussing in the Bill, but it may be that in future the transfer and enhancement of that capacity could set the tone for the kind of negotiations that he would like. However, I hope that he will understand that it would not be right for me to make any commitment on that at the moment, bearing in mind the relationships that we have. If he is satisfied with those responses, I commend the order.

Health Service Medical Supplies (Costs) Bill

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Report stage (Hansard): House of Lords
Tuesday 7th February 2017 Lords Chamber

[Lord O’Shaughnessy]

The treatments become available throughout the NHS from three months after the appraisal.

[Lord Hunt of Kings Heath]

My Lords, given that I took the order through Parliament many years ago, I can confirm that the whole intention was that the NHS had 90 days to prepare for funding a medicine that had been designated by NICE as both clinically and cost effective. The problem is that, subsequently, in particular over the past few years, clinical commissioning groups have done everything they can to avoid this responsibility. Alongside that, the purity of the 90-day rule is being eaten into, and that is at the heart of the concern of this amendment.

--- Later in debate ---

[Lord O'Shaughnessy]

My Lords, I am grateful to my noble friend Lord Lansley for bringing this amendment and for the opportunity to talk about the intentions of the Bill. He is quite right to highlight that the reason for bringing the Bill forward is to stop the behaviour of switching between schemes in order to reduce liabilities. That has characterised behaviour in the past few years and has had an impact on the successful operation of the PPRS. I will discuss the PPRS towards the end of my speech.

Amendment 4 is about the relationship between the voluntary and statutory schemes. I thank noble Lords for their views in this area. This amendment would require us to secure that, for any given product, the voluntary and statutory schemes would have an equivalent impact. It presents a slightly different approach to securing equivalence between the voluntary and statutory schemes, but I understand that, fundamentally, equivalence is what the amendment is seeking to achieve. I gave my views on this matter in Committee and I am happy to respond in similar terms on this occasion.

The Government’s intention is for the two schemes to deliver a broadly equivalent level of savings as a proportion of the total sales covered by each scheme. However, to require the terms of each scheme to be the same, in so far as possible, is inappropriate and would restrict the scope of the two schemes to operate in a complementary manner. Requiring equivalence to operate at product level, as the amendment suggests, would be even more restrictive.

The voluntary scheme is a matter for negotiation with industry. As such, there is scope to have a range of measures included that reflect the priorities of both sides at any point. It may be helpful to the House if I reiterate some of the examples I set out in Committee. The current voluntary scheme, the PPRS, includes a range of provisions, developed through negotiation with industry, that sit alongside the payment mechanism. This includes price modulation, which enables companies to put prices up and down as long as the overall effect across their portfolio is neutral. This has commercial value to companies, which may be willing to accept a higher payment percentage as a result.

In another example, while new medicines in the PPRS are excluded from PPRS payments, the PPRS payment percentage level itself is set at a level to achieve the agreed level of savings across both new and older medicines. This means that each company’s share of the income due to government will vary depending on the balance of new and old products in their portfolio, with companies that have mainly new products paying less than companies with mainly old products. However, it would be very challenging to replicate this model in the statutory scheme, as many fewer companies are affected by the statutory scheme regulations than are members of the PPRS. As a result, there is a much smaller pool of companies with older products. To achieve the same level of savings overall from the statutory scheme as from the PPRS while exempting newer products would require an extremely high payment percentage. This provides an example of where minor differences in terms may be required in order to deliver an equivalent level of savings across the two schemes overall. As noble Lords know, as we discussed in Committee and as I now repeat, the detail of how any future statutory scheme will work will be subject to further consultation.

As was discussed here and in the Commons, the freedom to negotiate the voluntary scheme has been valued greatly by both industry and government. As the noble Lord, Lord Hunt, reminded us, I said as much in Committee. Our intention for the future of the PPRS is to work collaboratively and constructively with industry on future medicines pricing arrangements when the current PPRS comes to an end.

[Lord Hunt of Kings Heath]

This time, will NHS England be a full partner in the discussions and negotiations? Clearly, unless it owns the solution as well, you have the problem that an agreement can be reached but it does not quite translate itself into action on the ground. I realise that this is traditionally a negotiation between the Department of Health and the industry but it would be useful if NHS England were fully part of that.

[Lord O'Shaughnessy]

The noble Lord makes an excellent point. Clearly, as the budget holder, NHS England ultimately must be a key part of negotiations for any future schemes. We intend that any future voluntary scheme should be established through negotiation in this way, but linking the payment mechanisms would inevitably place a restriction on that freedom.

I am grateful to my noble friend for raising this issue and I hope I have reassured him on equivalence, while also explaining why I believe the amendment goes too far by focusing specifically on products. On that basis, I ask my noble friend to withdraw his amendment.

Sustainability and Transformation Plans

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 26th January 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord asked about funding and I want to provide him with an answer. The plans are backed by a £1.8 billion sustainability and transformation fund and £19 billion of capital spending over four years to help make these changes.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister has talked about the public being involved. Why then have the public, local authorities and clinicians been excluded from the STP process so far, as shown by the King’s Fund? These plans depend on investment in primary care, community care and social care. Where on earth is the money going to come from to invest in those services, when the acute sector is under such pressure?

[Lord O'Shaughnessy]

Clinicians and local authorities are involved in these plans. The whole point of the plans is that they bring everybody together within an area to create changes that are driven from the bottom up, so as to provide a much more efficient service. The noble Lord knows full well that more money is going into both primary care and the service overall.

Health Service Medical Supplies (Costs) Bill

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Committee: 2nd sitting (Hansard): House of Lords
Wednesday 25th January 2017 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I want to express some sympathy with the remarks of the noble Lord, Lord Lansley. I am not sure whether he has got the terms of his amendment right; my noble friend Lord Warner has an amendment in the next group which, in a sense, covers the same ground.

The noble Lord, Lord Lansley, knows that I am sceptical about whether these powers should be extended to non-medicines but the issue here is that they are very broad, as he says. As far as I can see, there are absolutely no safeguards regarding how these powers will be used. The safeguards are not in the Bill or the 2006 Act, and certainly not in the draft regulations as far as I can see. We are looking for the Minister to table amendments on Report to build in thresholds or safeguards to stop the department simply undertaking fishing expeditions. That would give us some sense of proportionality. I am not sure whether the noble Lords, Lord Lansley and Lord Warner, have got their amendments quite right but I am certain there will be a consensus for building in some safeguards over the use of these powers.

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

My Lords, it is nice to be back with you again today to finish the Bill’s Committee stage. I am grateful to my noble friend Lord Lansley for tabling his amendments, and for his support for the Bill’s ultimate purpose: more rigorous gathering of data to support voluntary and statutory schemes and pharmacy reimbursements. That support is very welcome. I have huge sympathy with his argument. It is because we agree with the need properly to set out the information powers that we have published two sets of illustrative regulations to help Parliament scrutinise the information powers in the Bill. Reflecting on those, I believe that I can reassure my noble friend about the concerns behind his amendment.

I start by addressing the general proposition that a UK producer should be provided with an information notice every time the Secretary of State seeks to require information from that producer. Many noble Lords have expressed concerns about the regulatory burden the Bill might impose, and the amendment could exacerbate those worries. Regarding routine information collection, the Government already collect information on prices and volumes every quarter to support the operation of the PPRS and statutory schemes, and to inform reimbursement prices for community pharmacies. The Bill would expand routine collections to inform reimbursement prices to enable us—as my noble friend pointed out—to use data from more companies, to make the reimbursement of community pharmacies fairer and more robust, and to set reimbursement prices for more products.

For the purposes of requiring information on a routine basis, the illustrative regulations clearly set out what information would need to be provided, the form in which it would need to be supplied, the period of time it would need to cover and the date by which it would need to be supplied. Where information is required on a non-routine basis, the illustrative regulations demonstrate that the Secretary of State would notify a UK producer of that request. The regulations set out the notice that the Secretary of State would give a UK producer, the form in which the notice would be given and the type of information that would be required. The regulations would also require the Secretary of State to inform UK producers of the time period the information would need to cover and the time within which the information would be required.

Turning to the purposes for which information can be required and the persons to whom confidential and commercially sensitive information can be disclosed, I reassure the Committee that the Government take these matters very seriously. We have sought clearly to set out in the Bill the limited purposes for which information can be required and the persons to whom confidential or commercially sensitive information can be disclosed in relation to those purposes. The Bill makes it clear that information can be required for only three purposes: first, to reimburse community pharmacies and GPs; secondly, to support the PPRS and the cost-control provision in the NHS Act 2006; and thirdly, to ensure that healthcare products provide value for money.

The information that we would collect under the first two purposes would generally involve routine collections, to operate the reimbursement system and our voluntary and statutory schemes. However, assuring ourselves that products or the supply chain provide value for money would be done through ad-hoc collections. This is where we get to the critical issue of thresholds. Those collections would be triggered by evidence from existing data that there may be an issue with pricing—for example, when the reimbursement price we set in primary care is increasing without obvious reasons—or patients, clinicians, commissioners or the industry raising concerns, for example about price rises without obvious reasons or access problems. I hope that that makes it clear that this is not intended for fishing expeditions, to use the expression of the noble Lord, Lord Hunt.

[Lord Hunt of Kings Heath]

Have I missed this? Are those qualifications for the use of the provisions set out in the Bill?

[Lord O'Shaughnessy]

They are not. I am using this opportunity to set out on the record the reasons why information would be sought.

The Bill is also clear about with whom confidential and commercially sensitive information can be shared. This is restricted to other Government departments, the devolved Administrations and specific NHS bodies and persons providing services to any of these bodies. The information can be disclosed to these bodies only for the purposes set out in the Bill—which I just reprised. The Bill also enables the Secretary of State to share information with trade bodies, and Regulation 11 of the illustrative regulations sets out the trade bodies with whom the Secretary of State might want to share information, and the type of information that he would want to share with them.

The illustrative regulations currently limit the information that we can share with trade bodies to aggregated data that cannot be led back to a specific company. Furthermore, the Bill enables the Government to prescribe in regulations any other person to whom the Secretary of State can disclose information. The flexibility provided by this regulation-making power allows the Secretary of State to disclose information to other persons who may become involved in payment or reimbursement for health service medicines, medical supplies or other related products, including, for example, in circumstances of regional devolution. Again, it would be possible to disclose confidential or commercially sensitive information to these persons only for the purposes set out in the Bill. We will have further opportunities to discuss these powers of disclosure when we discuss the amendments relating to the report of the DPRRC. In summary, we would not be able to disclose information to bodies not listed in the Bill or prescribed in regulations, so the legislation will restrict to whom we can disclose information.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, my noble friend is right because he goes to the heart of the argument about this Bill. I think we have all said that we support the core aim, which is to deal with branded products becoming generics and the issues that were identified. The question is whether the Bill is a proportionate response to that and what impact it will have on future investment in this country.

I have been wracking my brains to puzzle out why this was first legislated for in 1977. My noble friend will remember that that was the time of the prices and incomes policy. Lady Williams of Crosby and my esteemed noble friend Lord Hattersley were Secretaries of State for Prices and Consumer Protection. I would not be at all surprised if it had something to do with that. I have to say that it was not altogether successful as a policy, and I am not sure that it is a great precedent for the Minister to rely on now. Certainly, in 1979 the electorate did not think that it was a very successful policy, that is for sure.

The only point I want to put to the Minister is this: I think there is a consensus in the Committee that there needs to be some trigger mechanism. We have had elements of that. The noble Lord, Lord Lansley, proposed an amendment that included appeals. He suggested what would trigger action, which was very helpful. In his amendment, my noble friend suggested another approach. The Delegated Powers Committee is concerned about the general terms of this clause. It said:

“We consider the general power to be inappropriate unless the Minister is able to explain why it is not feasible to specify the further bodies to whom information may be disclosed on the face of the Bill, and why it is not feasible to limit the kinds of bodies to whom disclosure may be made”.


That picks up the point raised by the noble Lord, Lord Lansley, and I agree with him about NHS bodies,

The question is this. The only satisfactory safeguards will be in the Bill. This House has no influence on regulations. The Minister will know that only six or seven statutory instruments have ever been defeated, so regulations in themselves provide very little safeguard. This is our only opportunity to provide safeguards in the Bill. Essentially, the choice for us is to press on with amendments at Report or to come to some agreement with the Government about what is appropriate. That we need something in the Bill is not in doubt.

[Lord O'Shaughnessy]

I thank noble Lords for that very good debate, which has again got to the heart of why we are all here. While we are reflecting on the 1970s, we have an industrial strategy again, so who knows? The wheel turns.

I am grateful to the noble Lord, Lord Warner, for his amendment and understand that he seeks to minimise the burden on businesses; we agree with him on that aim. However, the amendment would have serious unintended consequences. I will set out why I believe that to be the case and in doing so, I hope to respond to other noble Lords’ questions.

The amendment would restrict the circumstances under which the Government could ask for information on revenues or profits accrued in connection with the manufacturing, distribution or supply of UK health service products. We have been clear throughout that the information that we seek for routine data collection does not go beyond that which would be required for tax purposes. That is the reassurance that we provide on the overall burden and how it would affect businesses. I appreciate that there is a separate question about non-routine data collection, which I will come to, but the overall intention is not to create any additional burden.

The amendment would restrict the information-gathering powers to where a specific health service product has significantly increased in price and where there are reasonable grounds to believe that the NHS is not receiving value for money. However, it would prevent us operating our cost and price control schemes. The reason for that is that the Government collect information on revenues from companies as part of the various cost and price control schemes to be able to determine the sales of those companies to the health service. This enables us to identify the savings achieved through price cuts and which, in our reformed statutory scheme, would be a prerequisite for calculating the payments due from individual companies.

The Government require this information at product level to satisfy ourselves that the terms of the scheme are being applied correctly. As noble Lords know, this model has been in operation through the PPRS for many years, and we have not heard concerns from industry about the burden that it places upon it. Indeed, it is precisely this mechanism which demonstrated to both the Government and the ABPI that the current PPRS was not operating as expected during 2016—something to which the noble Lord, Lord Hunt, referred during our previous sitting.

We had constructive discussions with the ABPI during 2016 about why the spend measured by the PPRS and used to calculate payments under the scheme had fallen, compared to the real growth in NHS spending on branded medicines, which continues to rise. Joint analysis of company data by the ABPI and the Department of Health shows that the NHS is spending more than ever on branded medicines, with spend growth in 2016 likely to be around 5.3% of the budget.

It became clear that the cap mechanism was not capturing significant areas of branded medicines spend—in particular, parallel imports. Also, some companies left to join the statutory scheme, or divested individual products from the voluntary to the statutory scheme, but this growth was not captured by the PPRS methodology. Without action, this would have led to a significant drop in income from the scheme while branded medicines spend continued to rise, which is obviously against the spirit of the agreement. After a short period of very constructive negotiation just before Christmas, we agreed a new deal with the ABPI to cover the last two years of the scheme, details of which I set out in a Written Ministerial Statement published last week, I think—it has been only three and a half weeks, but it feels longer. This shows how well industry and the Government can work together to develop and maintain voluntary arrangements, but we can do so only with the right information available.

We have provided illustrative versions of both the information regulations and the statutory scheme regulations. I emphasise that these regulations show that the Government have no intention of routinely collecting information on profits. They do, however, set out the circumstances in which the Government might want to collect information about profits.

First, the illustrative regulations set out that we would be able to ask for information related to products where a company asks for a price increase under the statutory scheme regulations. To agree such an increase, the Government require assurance that the product is no longer profitable at its current price. Information on profitability is therefore crucial to determine this.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I have a little list, which is a bit bigger than the Minister’s list.

[Lord O'Shaughnessy]

Have you seen it?

[Lord Hunt of Kings Heath]

Indeed so. In following the remarks of the noble Baroness, Lady Walmsley, this is really a probing question. Lists are generally avoided in primary legislation for the obvious reason that you need flexibility. I can see why a list of bodies has been put into paragraph (11) of the draft regulations. At this stage, I am just puzzled to know why those organisations which are in the list have been chosen and why others have not.

First, I see that the BMA is in the list. I assume that is because it represents dispensing pharmacists, but I would be grateful to have clarification. I think that may have been clarified. For instance, why is the British Healthcare Trades Association not in the list? Clearly, its membership, although sometimes the same, is rather different from the ABHI. There are other organisations that I have put down to probe how the department has come to that list. When we know that, we can then come back to the general principles that the noble Baroness has so rightly raised.

Health Service Medical Supplies (Costs) Bill

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Committee: 1st sitting (Hansard): House of Lords
Monday 23rd January 2017 Grand Committee

[Lord O'Shaughnessy]

My Lords, I am grateful to noble Lords for raising the issue of reporting requirements. We will address at the end the issue of access and my sympathy to reporting requirements, but I first want to deal with the amendments as they stand.

Under the current PPRS, the Government regularly publish information relating to the operation of the voluntary scheme. Of course, for a future statutory scheme I draw attention to the regulations that we have already discussed, in which there are annual reviews of the regulations and a requirement to publish a report on each review. The illustrative regulations require an annual review that will: set out the objectives of the scheme; assess the extent that our objectives have been achieved; and assess whether those objectives remain appropriate. These requirements will be tested through the consultation on the regulations and we will, of course, take account of those views. I totally accept that reporting is a critical principle, but believe that setting out the requirements in primary legislation is too restrictive because of the potential to change from year to year what the priorities are within a sector and within the NHS.

Turning to the specifics of Amendment 9, I reassure noble Lords that the content of annual reviews would not be restricted to reviewing objectives. They must also be able to address key issues arising during the year that might affect the operation of the scheme, so there is flexibility there. We also intend for the annual review to be published and put before Parliament, so there is the opportunity for that to be seen and discussed. On the details of what it is proposed to report—in particular, how the payments are used—to achieve the specific aims of the amendment, the department would need to ring-fence the funds and monitor where the payments are used. I do not want to rehash our discussion about ring-fencing. I take seriously the point that noble Lords make about driving access to innovative drugs but we do not think this is the right way of doing it.

Nor do I believe that, through these means, it is right to address matters relating to the NHS duty to promote innovation. This Bill is ultimately about controlling the cost of medicines and medical supplies. The NHS Act 2006 puts duties on the Secretary of State to take into account both the need for medicinal products to be available for the health service on reasonable terms and the costs of research and development, which is a big factor in innovation. By taking into account these factors, the Secretary of State is looking at the needs of the industry to support the R&D base as is necessary to support the development of innovative medicines and technologies.

The NHS duty to promote innovation is different. It is about promoting innovation in the provision of health services and there is an extremely broad agenda that goes well beyond medicines. We have already said that we all want to make the UK the best place in the world to design, develop and deploy life sciences products. We do not believe that the Bill will have a negative impact on our doing so. We have also talked about the accelerated access review, so I will not go over that.

Turning to the specifics of Amendment 10A, the supply of medicines is highly complex, and pricing is one part of it. Other issues of course include rigorous safety and quality standards. Difficulties faced in the take-up or availability of medicines can be influenced by a number of reasons which are nothing to do with pricing. There can be manufacturing problems, such as batch failures; changes in guidelines, such as antibiotic switches; and raw material problems, as well as regulatory changes.

For example, in 2015, there was worldwide withdrawal of a branded antipsychotic injection, Piportil, due to a global shortage of the active pharmaceutical ingredient. Sanofi was unable to find an alternative source of this ingredient and had to discontinue the product. I set that out to illustrate the point that it is not always easy to link changes in pricing to issues of availability or access: there are other things to take into account. That is why we do not believe that we should set out, either in primary legislation or beyond the commitments made in the illustrative regulations, specifically to assess the impact on availability, access and so on.

Leaving all that aside and returning to the recurring theme of the debate, I understand the desire for greater transparency, which is undoubtedly the right approach to access. We must think about how we can improve access to innovative medicines for NHS patients and, in doing so, improve the operating conditions, if you like, for the life sciences industry—the win-win situation to which we keep returning. I would be happy to meet noble Lords either individually or collectively to think about what more we could do, whether through the Bill or looking ahead to the life sciences strategy, to ensure that we deliver on this promise. I take very seriously the warnings that many noble Lords have issued; the Government absolutely want to address this. On that basis, I ask noble Lords not to press their amendments.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the Minister. On the two arguments he put forward against the amendments, he said, first, that primary legislation would be too restrictive and what one might need to report on one year, one would not in another. The three amendments cover payment, supply, R&D and innovation. I do not think that there would be any year in which it would not be appropriate to report on them. He also said that duties in existing legislation cover some of these areas, and that where they do, such as the duty on innovation—presumably in the 2012 Act—they go wider than the intent in the amendments. I fully accept that. None the less, there is a strong argument for progress being monitored and for Parliament to be involved in that. However, I am grateful to the Minister for agreeing to have further discussion about the core issue of access, and I hope that we may take this forward. In the meantime, I beg leave to withdraw the amendment.

--- Later in debate ---

[Lord O'Shaughnessy]

I thank noble Lords for the debate on Clause 5. I am also grateful for the tour d’horizon or history lesson on how this has all come about. It feels as though it has slipped through many nets, for which there are multiple responsibilities around the room.

I will first address the point about consultation. Noble Lords will appreciate it when I say that, personally, I have not had the chance of undertaking that consultation but it is something that I am committed to doing. Whatever has gone before, I can at least give the reassurance that I will meet the relevant bodies in the next few weeks and discuss their concerns ahead of Report. At least in a forward-looking way, I can provide that reassurance.

As everyone has stated, the critical point here is that the 2006 Act gives the Secretary of State the power to control the price of medical supplies and to collect information about medical supplies. What Clause 5 does is to ensure that the same enforcement and territorial extent to provisions apply to controlling the cost of medical supplies and health service medicines. It does not give the Secretary of State any new powers to control the price of medical supplies. There are currently inconsistencies in the enforcement and territorial extent provisions. For example, a contravention or a failure to comply with the current provisions in the 2006 Act for medical supplies can result in a criminal offence. By contrast, the equivalent penalty for medicines is a civil financial penalty. Clause 5, therefore, aligns the enforcement provisions for medical supplies with those for medicines and, in so doing, makes them more proportionate, as the noble Baroness, Lady Walmsley, has pointed out.

With respect to the territorial extent, the power to control the prices of medical supplies in the NHS Act 2006 currently extends only to England and Wales. Clause 5 would extend the power to control the prices of medical supplies to Scotland and Northern Ireland. That would be consistent with the territorial extent of the powers to control the costs of health service medicines. That is an important point.

A number of noble Lords asked why the Government need the powers to control the prices of medical supplies when they do not currently use them nor have ever used them. That is a perfectly reasonable question to raise and one that occurred to me, too. We do not have any immediate concerns about the pricing of medical supplies. It is true that the market for medical supplies is very different from the market for medicines. It is innovative and competitive, and new medical supplies are generally faced with competition much more quickly than is the case for new medicines. However, I remind noble Lords that until recently we did not think that we needed the powers to set the price of unbranded generic medicines. We thought that competition in the market was working well and keeping prices down. When we realised that the market was not functioning as well as we thought with respect to certain products, and we were faced with companies charging unreasonably high thresholds where they had no competitors, we realised that we did not have sufficient powers to intervene when needed. That is of course one of the reasons for the Bill.

A question was asked about thresholds and when such a provision could be triggered, which is a reasonable question. The two examples I can give are when we had evidence from existing data that there may be an issue with pricing—for example, the reimbursement price that we set in primary care is increasing without an obvious reason—or when there is effectively a bottom-up complaint where patients, clinicians, commissioners or industry raise concerns because it is not obvious what is driving a price rise. I want to minimise the need for future primary legislation on medical supplies pricing controls. The Government should have the ability to intervene, but only when the market is not working well. Whether it is for medicines or medical supplies, it is right that those powers exist but are used only when necessary and proportionately. On that basis, I ask the Committee to agree that Clause 5 stand part of the Bill.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the Minister for his response. I also thank him for his consultation and willingness to meet bodies before Report, which I am sure will be very welcome. I understand the first argument, which is that there is a need to ensure consistency in relation to this Bill and the 2006 Act. I fully understand that. I also understand the change from criminal to civil penalties. But we then come to the issue of whether this provision should be in statute at all. The Minister himself has acknowledged that this is a different market, with competitive tendering. It is very competitive. We can see no evidence that this measure has been used for 40 years, and as far as I can see there is no evidence to suggest that it will be used any time soon.

The Minister said that it was not thought that the switch from branding to generics would arise in relation to medicines, and therefore that we should look into a completely different sector and say that because something might happen in the future we need to have this overarching provision in the Bill. But that is not the right approach. It has become clear that there are two courses of action. One is to take this out of the 2006 Act altogether, which at the moment I rather favour. We should not regulate for something that might happen in the mystical future.

I, too, was a better regulation Minister and it was drummed into me that if you do not need it, get rid of it—and if you do not need it, do not legislate in the first place. In his heart of hearts, surely the Minister realises that this is unnecessary. The alternative approach is to take the threshold he suggested and put it in the form of an amendment so that we have some reassurance on the face the Bill that it will not be used inappropriately. Those are two particular options.

In my tour d’horizon, as the noble Lord said, I came across the comments made by the noble Earl, Lord Howe, in 1999 when my noble friend Lady Hayman was taking one of the many health service Bills through your Lordships’ House. The discussion was not about devices but about the PPR scheme, because the then Government had taken powers in relation to prices. The noble Earl, Lord Howe, said that the Government had,

“arrogated to themselves sweeping powers to bring the current voluntary scheme to an end and to control the price of any drug at will. Lower medicine prices are appealing but too much of that will kill the golden goose”.—[Official Report, 9/2/99; col. 118.]

If the noble Earl, Lord Howe, were here arguing for this Bill, I think that he would have reflected that the case had not been made for non-health service medicines to be involved. We need to find a way forward between this stage and Report, otherwise the persuasive argument will be to remove the offending sections from the 2006 Act.

Mental Health: Children’s Services

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Thursday 19th January 2017 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what is their assessment of YoungMinds’ analysis published on 21 December 2016 that 64 per cent of Clinical Commissioning Groups are diverting new funding for children’s mental health services to other areas.

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

My Lords, the Government are working with partners in the NHS and elsewhere to deliver an ambitious programme that improves access to high-quality mental health care for children and young people. This is backed by significant additional investment. NHS England’s new five-year forward view for mental health dashboard shows each CCG’s spend and activity on children’s mental health, as part of the robust assurance processes we have put in place.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for that. No one can doubt that Ministers have made all the right noises on developing mental health services for young people. The problem is in the execution. He mentioned extra money, but he will know that the promised £1 billion is simply not getting through to the front line. A recent survey by YoungMinds showed that about 50% of CCGs were simply not using the money that they had been given in their baseline budgets for mental health services for young people. With one in four young people not getting access to services and it being not until 2021 before we stop the appalling practice of young people having residential care hundreds of miles from their homes, there is grave doubt as to whether this will happen in practice. Will the Minister agree to consider ring-fencing this money to ensure that it is actually spent on young people?

Health Workers: Training

Debate between Lord Hunt of Kings Heath and Lord O'Shaughnessy

Wednesday 18th January 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Lord for his welcome. The WHO has identified a global shortage of medical staff of more than 2 million, so clearly there is a big need and, as he says, it is being driven by the development of countries, particularly those with large populations, and the need to grow their own staff. At the moment, about 25% of NHS staff in the UK come from abroad and, like all NHS staff, they do a fantastic job for us. Clearly, given the problem that the noble Lord identified, we will need to become less reliant on overseas staff, which is one reason driving our desire to increase the number of training places for doctors, nurses, midwives and others.

In answer to the second part of his question, I think something like 10 of the world’s top universities are based in the UK. We are a world leader in education; that is a great strength of ours and something that we want to continue. Healthcare UK is the government body responsible for working with universities to unlock partnerships with other countries, and there have been a number of successful examples of where that has happened.

[Lord Hunt of Kings Heath (Lab)]

My Lords, if we are such a world leader in education, it is disappointing that the Government are doing everything they can to stop overseas students coming to our universities to study. On the NHS, the Minister will know that it is under the most extreme pressure. Cancer operations are being cancelled, people are dying on trolleys waiting for beds, and all the Government can do is attack general practitioners. Has the noble Lord seen the NAO report this month which shows that, since 2010, almost as many GPs have left the service as joined and that falling retention and increasing retirement rates put the target of 5,000 extra GPs at risk? The Minister says that the Government hold NHS staff in high esteem, so why do they not talk to and work with GPs to put this right rather than slagging them off?

[Lord O’Shaughnessy]

I do not recognise the description of “slagging off”. We know that GPs do a fantastic job and we are recruiting more of them—5,000, as the noble Lord said. More money is going into general practice as part of the five-year forward view. The Prime Minister in her statement paid tribute to the work that GPs do and said that there were obligations around extended hours and the provision of out-of-hours healthcare—and it is quite right, with the pressures we face, that every part of the healthcare system steps up to fulfil its responsibilities just as others are doing, in order to meet the pressure we are under.