Cancer Drugs: Licensing and Approval

Lord Kamall Excerpts

Monday 8th November 2021 Lords Chamber

[Baroness Morgan of Drefelin (CB)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare an interest as chief executive of the charity Breast Cancer Now.

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

NICE is committed to publishing draft guidance on cancer drugs around the time of licensing, with final guidance published within three months of licensing wherever possible. The MHRA and NICE work closely together to ensure that licensing procedures and health technology assessments are as streamlined as possible. For cancer drugs, the NHS in England provides funding from the point of draft positive NICE guidance, delivering faster access to promising new cancer treatments.

[Baroness Morgan of Drefelin (CB)]

My Lords, the delay between licensing and NICE technology appraisal has been dealt with in the case of two out of the three drugs approved under Project Orbis, through agreements between NHS England and the drug company concerned. Unfortunately for women with secondary incurable breast cancer, for which there are very few treatment options, no agreement has been made with the drug company Gilead, and this creates a new treatment lottery. Are interim access agreements meant to be the permanent solution, and if not, what can be done to address this lottery and close the gap between Orbis licensing and NICE appraisal?

[Lord Kamall (Con)]

I thank the noble Baroness for her Question. Clearly, there is distress and concern at the delay between MHRA approval and NICE licensing. The drug Trodelvy was licensed by the MHRA for both unresectable locally advanced and metastatic triple-negative breast cancer through Project Orbis. On NICE’s appraisal of Trodelvy to determine its clinical and cost-effectiveness for use in the NHS, NICE hopes to have guidance next year but, in the meantime, NHS England, NHS Improvement and NICE continue to work with the manufacturer to explore options for interim access to Trodelvy.

[Lord Hunt of Kings Heath (Lab)]

My Lords, despite what the Minister says, the fact is that innovative new drugs such as the cancer drugs the noble Baroness mentioned are reaching patients in this country far too slowly. We lag behind many other countries. How can we expect to be a centre of science and research if the NHS is so slow to develop the medicines that are produced?

[Lord Kamall (Con)]

I think noble Lords will agree with that frustration at the speed of approval and licensing, but in most cases it does happen speedily. One of the central issues is making sure that there is confidence in the ability to purchase. We are looking at a number of different ways to accelerate the process, including through ILAP—the accelerated partnership—while also making sure that MHRA and NICE can speak where they are allowed to, given some of the legal restrictions on their discussions. For example, I went a couple of weeks ago to a board-to-board meeting between MHRA and NICE at which they discussed issues of common concern.

[Baroness Brinton (LD) [V]]

My Lords, picking up on the point of the noble Lord, Lord Hunt, there is a particular problem in the United Kingdom with NICE and MHRA appearing not to talk together as much as they should to help streamline the process, where that is appropriate. An academic paper in March demonstrated that the CDC in America has a much stronger, streamlined system that works, with far fewer drugs being delayed. How can NICE and MHRA learn from what is happening abroad?

[Lord Kamall (Con)]

It is important that we learn the best lessons from abroad on incredibly important issues such as this. Where NICE and MHRA are allowed to talk to each other and co-operate—there are some restrictions, as I am sure many noble Lords are aware—both clearly recognise that there are great concerns and distress on the part of the many patients who want access to these drugs, and they are trying to work out how they can speed up the process as much as possible.

[Baroness Masham of Ilton (CB) [V]]

My Lords, how can we speed up the process once new, innovative medicines have been approved by NICE so that patients get their benefit? Is the Minister aware that other countries, especially Germany and France, are leading the way with cancer drugs while England is near the bottom of the list? That is not good enough, is it?

[Lord Kamall (Con)]

I thank the noble Baroness. It is important that NICE, MHRA and others hear some of the concerns, and the fact that we are being held to account today shows how important this is. Unfortunately, some existing legislation restricts MHRA’s ability to share information with partners, including NICE, which would help them to plan their processes more efficiently. NICE, MHRA, NHS England and NHS Improvement are talking about the concerns raised by noble Lords and generally about delays in the process. They are talking about how they can improve access, including through initiatives such as the Innovative Licensing and Access Pathway launched in January 2021, and sharing as much information as they can upfront. Both MHRA and NICE are aware of the concerns and made that clear when I met them recently after their board-to-board meeting.

[Baroness Thornton (Lab)]

My Lords, I will follow up on questions that noble Lords have already asked. The ongoing NICE methods and processes review missed the opportunity to propose a new process to mirror accelerated regulatory processes. There are concerns that capacity constraints will limit NICE’s ability to publish decisions as close to marketing authorisation as possible, including for oncology drugs, through the new Project Orbis route, as has been the case with the secondary breast cancer drug, Trodelvy. Have the Government assessed whether the system is fit for purpose in achieving the objective which the noble Lord has articulated: to deliver quick patient access to new, clinically effective treatments? What concrete steps have been taken so far to address any concerns?

[Lord Kamall (Con)]

Both NICE and MHRA are aware of the concerns, particularly regarding the delay between approval and licensing. That is why they are having conversations with NHS England and NHS Improvement to make sure, as far as possible, that they can discuss co-operation to ensure the speedy approval of drugs.

[Lord Robathan (Con)]

My Lords, regarding the efficacy of cancer treatment, so far this year, six friends of mine have died from cancer; all were under 80 and three were younger than me. I know of many more who have terminal cancer, regrettably. I also knew one person who died from coronavirus aged 55. She had leukaemia, or blood cancer, which destroyed her immune system, and she caught the virus while she was being treated in hospital. To put cancer in perspective, how many people under the age of 80 have died this year from cancer and how many people under the age of 80 have died in this terrible pandemic, which has shut down society, damaged our children’s education and mortgaged their future for decades to come?

[Lord Kamall (Con)]

I thank my noble friend for his question. The focus was on fighting Covid and making sure that people were vaccinated as quickly as possible. As noble Lords know, economics is about the allocation of scarce resources and there are always trade-offs. Sometimes there are unintended consequences of focusing on one condition rather than another. I will write to my noble friend with an answer to his specific question.

[Baroness Stuart of Edgbaston (CB)]

My Lords, so far, we have spoken about England. The drugs are licensed for the whole of the United Kingdom and NICE regulates what happens in England. Wales is aligned to some extent and Northern Ireland much more closely; Scotland applies a different system. Will the Minister undertake to look at whether other parts of the United Kingdom are dealing with this more efficiently? As he does so, will he also take care that NICE is not being used as a back-door way of rationing?

[Lord Kamall (Con)]

The noble Baroness raises an important point, especially given that health is devolved to the devolved Administrations. As much as possible, we work England-wide, but we also ensure that we co-ordinate UK-wide and that Ministers and officials regularly meet with those from the devolved Administrations.

[Lord Hannan of Kingsclere (Con)]

My Lords, some of the territories in the world which have the cheapest, safest and widest choice of medicines do not have their own regulators. Instead, they automatically recognise the decision made by globally acknowledged licensers. Does my noble friend agree that one way of addressing the question of expedition that the noble Lord, Lord Hunt of Kings Heath, and others raised would be for global Britain to work for the consumer as well as the drugs companies and to recognise automatically drugs licensed by the FDA, the European Medicines Agency and other equivalent bodies?

[Lord Kamall (Con)]

I thank my noble friend, who has been an advocate for free trade, for his question. Sometimes in the conversation about recognition, there is a debate between harmonisation and mutual recognition but also unilateral recognition. One of the concerns often raised when looking at unilateral recognition is that negotiators feel that, sadly, they are losing a bargaining chip. The other thing to recognise is that one country’s standard is often another country’s non-tariff barrier. MHRA is the UK regulator and I have been told that it thinks it important that we have our own arrangements in place for the regulation of medicines.

NHS: Fracture Liaison Services

Lord Kamall Excerpts

Monday 8th November 2021 Lords Chamber

[Lord Black of Brentwood (Con)]

I beg leave to ask the Question standing in my name on the Order Paper and note my interest as co-chairman of the APPG on Osteoporosis.

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

I thank my noble friend for raising this issue and for the work he has done as part of the all-party group. I look forward to reading the report it is writing on this important service. The NHS has prioritised the fracture liaison service as a key part of its elective recovery plans, after this was a recommendation from the best musculoskeletal health pathway improvement programme. NHS England is working closely with integrated care systems to support the implementation of this and other services.

[Lord Black of Brentwood (Con)]

I thank my noble friend for that Answer. He will be aware that fracture liaison services are vital for the identification and treatment of osteoporosis. That silent disease, as it is known, causes over half a million broken bones each year—one every minute—and as many deaths, resulting from fractures, as lung cancer and diabetes. The FLS is the world standard for fracture prevention, yet too many suffering from osteoporosis are unable to access the service. Is my noble friend aware that, when the Royal Osteoporosis Society surveyed NHS trusts in England, only 51% confirmed they provided the service and many of those are underfunded? Can he tell us what action the Government will take to reduce such clear health inequalities and make sure that fracture liaison services are available to all?

[Lord Kamall (Con)]

I thank my noble friend for highlighting the importance of this issue. There are MSK leads in local regions who have the ability to focus on what is best for their local region, with the incorporation of key performance indicators related to the FLS within the national clinical audit. NHS England has also convened a group of key clinical opinion leaders to develop an evidence-informed integrated secondary fracture prevention pathway for sharing with integrated care systems. There are many other issues that I could mention, and I would be happy to write to my noble friend.

[Lord Brownlow of Shurlock Row (Con)]

My Lords, I declare my interest as a donor to and patron of the Royal Osteoporosis Society and a member of the osteoporosis APPG. As my noble friend said, fracture liaison services are the world standard for secondary fracture prevention. According to the Royal Osteoporosis Society, for every £1 spent on FLS in the United Kingdom, the taxpayer can expect to save £3.28. By levelling up FLS provision to cover everyone over the age of 50 in the United Kingdom, we could prevent just under 5,700 fragility fractures every year, saving the taxpayer £65.7 million. Could the Minister confirm that the Government will invest further in prevention as well as cure?

[Lord Kamall (Con)]

I very much agree with my noble friend that the prevention of illness is as important as the cure. In conversations I have had with the NHS and other healthcare professionals, there is a focus on prevention. Some noble Lords may remember the debate we had a couple of weeks ago, focusing on the prevention of obesity rather than treating its symptoms. The NHS is prioritising FLS and similar services when it comes to prevention, understanding that this benefits not only patients but taxpayers.

[Baroness Bull (CB)]

My Lords, I declare my interest as an ambassador for the Royal Osteoporosis Society. Vertebral fractures are the most common osteoporotic fractures, but with 70% of these going undiagnosed, the opportunity for early identification of osteoporosis is missed. Does the Minister support the recommendation of the Royal Osteoporosis Society that all diagnostic imaging services should be required to routinely look for and report on vertebral fractures in any spinal imaging they undertake, whatever its primary purpose? Does he agree that this reporting should be unambiguous and actionable, via the FLS where possible, so that patients are put on the right pathway for osteoporosis assessment and care as soon as possible?

[Lord Kamall (Con)]

The department and the NHS continue to work with interested groups to expand the understanding of the wide-ranging needs of people across the country. One example is NHS England’s Covid-19 MSK—musculoskeletal—stakeholder group, which is advising on the impact that lockdowns have had on the physical and mental health of those with MSK conditions. Collaborating with NHS England were the British Orthopaedic Association, the British Society for Rheumatology, the Chartered Society of Physiotherapy, the Arthritis and Musculoskeletal Alliance, and Versus Arthritis. Self-managed resources for patients are being developed. I will write on the specific question that the noble Baroness asked.

[Baroness Walmsley (LD)]

My Lords, could the Minister say what research is being carried out to establish the extent to which universal provision of fracture liaison services could relieve the pressure on hard-pressed GPs, ambulance services and A&E departments?

[Lord Kamall (Con)]

NHS England and others are well aware of the need to reduce the pressure on GPs and other services that the noble Baroness mentioned. That is why they very much welcome the investment in 100 community diagnostic centres, not only on NHS premises but in places such as football stadiums, shopping centres, and so on, making sure that there is more access to these services and that patients can be seen quicker and more speedily.

[Baroness Merron (Lab)]

My Lords, there is no inevitability about osteoporosis and broken bones as the result of getting older, and yet osteoporosis affects 50% of all women, with those going through the menopause and after menopause experiencing it at a higher rate of incidence due to the reduction in oestrogen levels. Does the Minister acknowledge that two-thirds of women are not getting the treatment that they need, and that this was the case even before the pandemic? What steps are the Government taking to improve access by women to HRT and treatment for osteoporosis?

[Lord Kamall (Con)]

The noble Baroness raises an important point. A number of people are still waiting to be seen; NHS England is very much aware of the backlog and wants to address it. As a key part of the elective recovery plans, NHS England is working with a number of local integrated care systems to establish a greater number of clinics, as well as with community diagnostic centres, and is developing business cases. NHS England is also working with experts in the field of musculoskeletal health to improve patient pathways and to find new opportunities that, over time, will improve patient care and access.

[Lord Lexden (Con)]

Do the Government accept the estimate provided by experts that some 90,000 people a year are missing out on the bone-strengthening medication that they need? What is being done to tackle this problem?

[Lord Kamall (Con)]

My noble friend raises an important point. We accept this estimate; we are working hard to remedy it and to provide the healthcare that people need. The NHS has established the Best MSK Health national improvement programme, which is focused on improving the whole pathway for those with MSK conditions. That programme will include identifying and tackling variations in access, outcomes and experiences. I am also encouraged to see that the NHS is keeping FLS as a priority in its recovery plan, which includes plans to deliver more of these services across the country. On top of that, the Office for Health Improvement and Disparities is looking specifically at the issue of disparities, not only for MSK conditions but for others.

[Baroness Masham of Ilton (CB) [V]]

Can the Minister ensure that people living in rural areas who are at risk of osteoporosis will be able to be diagnosed by a DEXA scan? Is he aware that this opportunity has been turned down for the local hospital at Northallerton, despite the wishes of the consultant and the Friends of the hospital who raised the money to buy one? What can be done about that?

[Lord Kamall (Con)]

I am not sure about the specific case that the noble Baroness raises, but I will write to her. However, generally, there is an investment of £2.3 billion to increase the volume of diagnostic activity and to roll out at least 100 community diagnostic centres, to make sure that we are taking diagnosis closer to patients in their communities.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I do not understand. The noble Lord and his Ministers are taking powers in the health Bill going through the Commons at the moment to issue directions to NHS England. So why on earth can he not issue a direction to NHS England to simply say that every integrated care system must have one of these services, given the evidence that noble Lords on his side of the House have given about the benefit of doing so?

[Lord Kamall (Con)]

The Government recognise the importance of FLS, as does the NHS. That is one of the reasons why they are looking to roll out these community diagnostic centres, to make sure that the technology and the scanning is as close to the patients as possible. Just this morning, I had a meeting with one supplier who is talking about a partnership with a number of integrated care systems to make sure that they roll out the systems as close to patients as possible.

[The Deputy Speaker (Lord Faulkner of Worcester) (Lab)]

My Lords, the time allowed for this Question has now elapsed. That concludes Oral Questions for today.

Covid-19 Vaccinations

Lord Kamall Excerpts

Monday 8th November 2021 Lords Chamber

[Baroness Brinton (LD) [V]]

My Lords, from these Benches, we add our thanks to all those involved in the current delivery of vaccinations, whether they are GPs, nurses, healthcare assistants or volunteers at vaccination centres, and we thank more broadly our NHS and care-sector staff who are still working extremely hard to reduce the backlog of cases while coping with over 9,000 patients currently in hospital with Covid.

The Minister knows that the Delta variant and its subvariant, which is thought to be behind the growth of cases in the west country and Wales, remains highly transmissible. Doctors are reporting daily that double-jabbed patients are catching Covid and passing it on. Why have none of the mitigations in plan B been carried out? Many scientists, including some members of SAGE and Independent SAGE, believe that we should be operating them now to reduce the high numbers of cases and not be faced with a second Christmas being cancelled by the Prime Minister at short notice.

From these Benches, we have asked time and again for the wearing of facemasks inside and on public transport, as well as room ventilation in schools and other public venues, to be mandated, and for social distancing to remain. There are now, on average, 35,000 new cases daily, a shockingly high number. Professor Peter Openshaw, the chair of NERVTAG, said today that it was clear that immunity from the vaccines is waning. Yes, and vaccination is vital, but with cases at this level why are the Government not making mask mandates and social distancing formal?

Today, the Prime Minister once again reminded people to get their jab, whether first, second, third or booster, the ONS data showing that the risk of dying from Covid is 32 times greater in unvaccinated people. Can the Minister tell us why last week it was announced that vaccination centres are now closing at 6pm? Surely it should be easy for people to get vaccinated at a time that works for them, when they leave for work or get home from work?

The last time we spoke about Covid, I asked the Minister what the Government were doing to prevent some of the very unpleasant anti-vaxxer interventions at school gates and outside some vaccine centres. Has any action been taken on their disgraceful leaflets, which deliberately look like an NHS document but are full of direct lies and mistruths? It is important, because, by the Minister’s own numbers in this Statement, only 22% of 12 to 15-year olds have had their vaccination so far. I think Ministers now recognise that cases in this age group are driving cases in the older age groups, which is probably why hospital numbers are going up.

The noble Baroness, Lady Thornton, referred to the muddle between booster and third doses. The pandemic is far from over for immunocompromised and immunosuppressed people. I declare my interest as one of the clinically extremely vulnerable, as I have said before. I discovered by chance, reading something online, that I am now in the third-dose category. My GP did not know it and I certainly did not know it either. That is the problem. GPs and vaccination centres have not been told about the distinction. I have read the NHS guidance on the third dose, but many other clinically extremely vulnerable people are saying that their surgery or vaccination centre does not understand which category they fall into.

This is not helped by the problems with the online form which I asked the Minister about last week. Does the online form now specify the third dose, which is for around 800,000 people, according to current estimates, not for 400,000 people, as the noble Baroness, Lady Thornton, said, as distinct from the booster, which is for around 20 million? It is important, because the third-dose patients must have a booster in a further few months. If the system is not even recording the third dose, how will it know to call them back?

With the end of the shielding programme on 17 September, Sajid Javid wrote to all those on the patients’ list to inform them that it had finished, that the Government would no longer be offering specific advice and that we should go to our hospital clinicians. But many of us do not have an appointment in the diary, and there is not likely to be one because our clinicians are catching up with the backlog of cases, and those who are specialists in immune diseases are working on the Covid wards as well. So can the Minister say how on earth the clinically extremely vulnerable are meant to know what to do in the meantime?

Will the Minister ensure that the Government will work with patient organisations, clinicians and employer to produce clear and meaningful guidance that promotes safe working practices for this group and, in particular, let employers know that they have to help employees either to work from home or, if they have to go in, to make sure they do not have to go in by train or bus at peak hours? Please will the Government appoint a dedicated national lead to co-ordinate the support and guidance available to people in this group?

The news in the Statement of the approval of the Merck and Ridgeback antiviral Molnupiravir is also good news. I see that just under half a million courses of doses have been ordered. It was good to hear on Saturday of the success of the Pfizer clinical trials elsewhere, but I gather we are some way off from that being approved, because further trials of people who are clinically vulnerable are needed. Can the Minister tell the House the likely timescales of the actual delivery of both these different antivirals?

Finally, I am aware that I have asked some technical questions. If the Minister cannot answer them today, please will he write to me with the answers?

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

I thank the noble Baronesses for their questions and for raising some very important points, on which I and others have been in discussion not only with health professionals but with departments and other advisers. I will try to answer their questions in detail. The ones that I do not answer because of their technical nature—as the noble Baroness, Lady Brinton, acknowledges—I will try to answer later if I am unable to answer now.

First, I join the noble Baronesses, Lady Thornton and Lady Brinton, in praising our wonderful doctors, nurses and other healthcare staff. Also, we should not forget all the wonderful people who have supported them: the delivery staff who brought stuff to their homes and delivered food, and the local civil society projects. We saw a massive upsurge in voluntary work and volunteerism. Whatever our politics, whatever part of the spectrum we are on—whether we call it co-operative socialism, local libertarianism, community conservatism, or just humanity and people helping each other—I thought it was a wonderful expression of what we can do when we all pull together.

We also have to remember, as the noble Baronesses, Lady Thornton and Lady Brinton, reminded us, that this is not over. That is one of the reasons why the Secretary of State felt it was important to make this Statement and this point. There has been a level of complacency in encouraging people to come forward. We have not been strong enough, which is why we are pushing now and emphasising the fact that we want as many people as possible to come forward and get the booster. It was announced over the weekend that it is not necessary to wait for six months after the second dose; people can book from five months. In fact, today I tested the system and took advantage of it and was able to book my booster. I hope many others will be able to do so to.

I would ask noble Lords across the House that if anyone comes to them with experiences of not being able to use the service—we have had a couple of reports of a few technical hitches—please let me know so that I can pass them on to NHSX, so that we make sure that we are aware of problems as soon as possible. So far—I want to try to touch some wood somewhere—it seems to be working.

Let me now turn to some of the detailed questions that I was asked by the noble Baronesses. The JCVI has advised that people with severe immunosuppression at or around the time of their first or second vaccination receive a third primary dose as a precautionary measure. Some individuals who are severely immunosuppressed due to underlying health conditions or medical treatment may not achieve the same full immune response to the initial two-dose Covid-19 vaccine course. The third dose aims to bring them up to nearer the level of immunity. As with the vaccination of other at-risk individuals, eligible individuals will be identified and invited by the hospital where they receive care under a consultant and/or GPs.

If either of the noble Baronesses or any noble Lord here today is aware of that not happening, please let me know so that I can make sure that we push on this. I am told that the NHS is writing to all patients who may be eligible so that they can talk through their options with their GP or consultant if they have not done so already. Any patients who have not yet been contacted but think they may be eligible, for example because they have previously been advised to shield, can contact their consultant for an update. If noble Lords know of any problems or are aware of any issues, I hope that they will let me know as soon as possible so that I can chase on them.

On the booster, while there are many stories saying that we have not done that well, we have 12% booster vaccination. When we look at booster vaccination in other European countries, the highest is Israel with 45%, but Spain is at 2%, Italy is at 3%, France is at 4% and Germany is at 2%. This is why we are emphasising the importance of booster vaccinations. My right honourable friend the Secretary of State and others are keen to push people to make sure that they have their booster as soon as possible. It is the best defence against Covid and it is important, especially as protection wanes, that people are getting their boosters.

On plan B, I repeat what has been said previously: there is no set threshold. We consider a range of evidence and data, as we have done throughout the pandemic, to avoid the risk of placing unsustainable pressure on the NHS. For example, while the number of Covid-19 patients in hospitals is an important factor, the interaction with other indicators, such as the rate of increase of hospitalisations and the ratio of cases to hospitalisations, will also be vital.

The Government monitor and consider a wide range of Covid-19 health data. I shall go into some of them in a bit of detail. We look at cases, immunity, the ratio of cases to hospitalisations, the proportion of admissions due to infections, the rate of growth in cases and hospital admissions in the over-65s, vaccine efficacy and the global distribution and characteristics of variants of concern. We also look at the risk to the NHS. One of the issues, as many noble Lords will know, is about making sure that the NHS is not overwhelmed. In assessing the risks to the NHS, the key metrics include hospital occupancy for Covid-19 and non-Covid-19 patients, intensive care unit capacity, admissions in vaccinated individuals and the rate of growth in admissions. The Government also track the economic and societal impact of the virus to ensure that any response takes into account those wider effects.

On some of the measures that are being proposed in the potential plan B, clearly a number of people with other health conditions, including mental health conditions, would be incredibly concerned were we to go to some of the more severe measures under plan B. We always have to balance them up. As noble Lords will be aware, questions have been asked about those awaiting elective surgery and the unintended consequences of focusing on Covid-19, for example whether it has led to a disproportionate number of deaths from other diseases or conditions.

Covid booster jabs have been delivered or booked in almost nine in 10 care homes as the NHS vaccination programme accelerates ahead of winter. Around 6,000 care homes have already been visited, while a further 3,700 homes have visits scheduled in the coming days and weeks. The new figures also show that residents in more than half of care homes have received their booster jab. When I asked about the discrepancies in the small proportion that have not yet been booked or vaccinated, I was told that there may well be cases of Covid in those care homes and they are waiting for the delay after the positive test to ensure that it is safe to go there.

I was asked about the breakdown of different types of care home. Based on the latest CQC annual report on care, we can say that the CQC inspects a number of these care homes.

To answer some of the other questions, as I said, the NHS is writing to all patients who may be eligible so that they can talk through their options. On the issue of whether to make NHS staff take their vaccinations, we have consulted on vaccination as a condition of employment in wider health and social care; I am told that my right honourable friend the Secretary of State will set out the position very shortly. The important thing to remember is that we want people to take the booster, and we want to make sure that we reach those communities and demographics who have not had even their first or second vaccine yet.

I have had a number of conversations with noble Lords from across the House—I thank them for their advice and suggestions—about how to reach out to some of these communities. For example, I was in conversation with one right reverend Prelate about how we could work in conjunction with interfaith communities in local communities, for example in certain parts of London where there is a low uptake. Sometimes people may not be of faith, but they respect faith leaders—vicars, imams, priests et cetera. We are looking at how we can work on this, and I very much hope that we will be able to roll that programme out further. If any noble Lords are interested in or have any suggestions on that area, I would welcome them.

I apologise if there are technical questions that I have not answered; I will make sure that I write to noble Lords.

[Lord Pannick (CB)]

The Minister mentioned the importance of the booster dose. Can he explain why the valuable NHS app does not prominently display that the individual has received a booster jab, as is the case with the first two doses? The information is hidden away on the app and cannot be downloaded. This is a serious defect because some foreign countries—the Minister mentioned Israel, which is one example—now require proof of a jab in the past six months, given the waning effect of earlier doses. There are many domestic contexts where the ability to prove easily that you have had a booster dose would be valuable.

[Lord Kamall (Con)]

I thank the noble Lord for that question. I have been made aware of this by more than one noble Lord today. I contacted NHSX; it said that it is looking into it and trying to work on a fix as soon as possible. If the noble Lord is aware in a couple of days that that has not been fixed, I hope he will remind me so that I can prompt NHSX.

[Lord Campbell-Savours (Lab) [V]]

My Lords—[Inaudible]—very closely to the wise words of Gordon Brown on the need to distribute surplus vaccines internationally. Vaccine expiry is inexcusable. Gordon has made it his life’s work to defend, promote and support the interests of those in need. The third world is in need; if we fail to meet the challenge then not only it but we will lose out. I urge the Minister to listen to him and take this call back to the department for action.

[Lord Kamall (Con)]

I thank the noble Lord for that point. I think noble Lords agree that it is really important that we make sure that we vaccinate as much of the world as possible. There is no point in us being vaccinated if we then travel to areas in the rest of the world where people are exposed. We are co-operating on a number of international programmes, including COVAX and others. One of my portfolio roles in the department is on international agreements and liaison. I have been speaking to a number of Health Ministers from a number of different countries about how we can help more. I have also been talking to some of the suppliers of the vaccines about how we can make sure that, where we do not order domestically, we can redirect some of those orders for international help. I completely agree with the sentiment of the question from the noble Lord that it is really important that we play our part in helping the international community.

[The Deputy Speaker (Baroness Henig) (Lab)]

My Lords, there are four remote speakers. I shall now call the second of them, the noble Baroness, Lady Harris of Richmond.

--- Later in debate ---

[Lord Kamall (Con)]

I am afraid I am going to have to repeat the answer I gave earlier to the noble Lord. We were made aware of this only today and as soon as I heard, I got hold of NHSX and asked what was happening because, clearly, a number of people are experiencing the same issue. We have chased NHSX and I hope that NHSX will fix it as soon as possible. If it does not, please chase me up.

[The Deputy Speaker (Baroness Henig) (Lab)]

My Lords, the noble Baroness, Lady Masham of Ilton, is taking part remotely and I invite her to speak.

[Baroness Masham of Ilton (CB) [V]]

My Lords, what is the situation with vaccination against coronavirus for inmates and staff in UK prisons? Prisoners often get transferred to other prisons and they move in and out when released and recalled. Many live chaotic lives, but it is important that they all get vaccinated. Is there a system to see that this process is safeguarded, so that jabs are fully completed? Prison health must not be forgotten.

[Lord Kamall (Con)]

The noble Baroness raises a very important point. As far I am aware—I will confirm this—the population of prisons is being treated the same as the wider population in terms of encouragement to take the vaccines and the booster. I will double-check and write to the noble Baroness.

[The Deputy Speaker (Baroness Henig) (Lab)]

My Lords, the noble Baroness, Lady Thomas of Winchester, is taking part remotely and I invite her to speak.

[Baroness Thomas of Winchester (LD) [V]]

My Lords, will the Minister look into booster vaccines for vulnerable people such as me who need to be vaccinated at home? There is never any information about this cohort of people who are at the mercy of there being a healthcare professional from a local surgery available. There is a danger that they may be overlooked by surgeries, some of which might be overwhelmed at this time.

[Lord Kamall (Con)]

The NHS is writing to all patients who may be eligible so that they can talk through their options with their GP or a consultant if they have not done so already. I understand that that includes the option to be vaccinated at home, but I will double-check and write to the noble Baroness.

[Baroness Andrews (Lab)]

My Lords, two questions were put to the noble Lord that he has not had time to answer. First, I should say that, like him, I have received my booster invitation for Thursday and I am absolutely delighted. Two questions, which I do not think were technical, were asked by the noble Baroness, Lady Brinton. One was about why centres are closing. Clearly, with this big push now, spearheaded by the Government, we need to keep as many open as possible. The second relates to something the Minister said that surprised me: he talked about a level of complacency. It is indeed possible, I think, to see the failure to make masks mandatory as an indication of complacency. Will he say a little more about what he meant by the level of complacency and how making masks mandatory might help to meet that?

--- Later in debate ---

[Lord Kamall (Con)]

On the noble Baroness’s first point, about the centres closing at 6 pm, this is the first time that I have been made aware of that. I welcome any feedback about what is working and what is not. This is not necessarily political; we all want it to work, so I welcome any information on that. I will double-check it.

The noble Baroness referred to complacency. It is very interesting when people say that most people are in favour of measures on masks. It is quite often like polling, when we see a difference between stated preferences and revealed preferences. It is claimed that a number of people are in favour of masks and want to wear them, but, when it comes to public transport and the revealed preferences, we see that it depends on the mode of public transport—sometimes take-up is less than 50%. I have said to people, “Make sure you get your boosters”, but maybe we have to take some responsibility for not making it clear that the boosters were important and for not pushing them as much as possible. The first and second vaccines were taken up with such enthusiasm because people wanted to return to as close to normal as possible, but when it came to the booster, it really needed all of us to push it to make sure that more people took it.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a nurse. Would it be helpful to reinforce the message that some of the most vulnerable people should contact their specialist nurse practitioners, who in many cases are much more obtainable than both consultants and general practitioners? I would really like the Government to emphasise that.

Turning to 12 to 15 year-olds, I declare my interest in that my daughter is a secondary schoolteacher in south London. Anti-vaxxers outside schools are creating a real problem. I understand that the Government have powers to reduce their access within the area of a school. Is this being seriously considered? The uptake of vaccines in the 12 to 15 year-old age group requires the consent of an adult. Therefore, it is imperative that schools are part of that system.

[Lord Kamall (Con)]

I thank the noble Baroness for that really important point: it is about not only consultants and GPs but nurse practitioners. When you go to book a booster jab and look at availability, you might well expect it to be at a hospital or a surgery, but many community pharmacies are offering it. It is important that we have those conversations. I agree with the noble Baroness on the advice that she has given.

I also share the noble Baroness’s concerns about the anti-vaxxers. It is a difficult balance: I believe in freedom of speech, but they should not inhibit people. It is really important that we make the case. As of 2 November, 24% of 12 to 15 year-olds had received their first dose. They will have received it through school. The NHS is also working closely with schools to offer vaccines to young people as soon as parents or guardians consent. We are also expanding our programme of walk-in centres to make sure that we can provide parents with extra choice over where and when their children are vaccinated. The vaccines are safe and will protect children from Covid-19. We repeat this. The current advice is to give the majority of children a single dose, which means that they will be afforded a high level of protection.

On people protesting outside schools, the Government have explained their concerns about that. At the moment, I have no further information. As soon as there is further information, noble Lords will be informed.

[Baroness Uddin (Non-Afl)]

My Lords—

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, is the Minister aware of an article in the Health Service Journal today in which a highly respected chief executive of a highly rated acute trust said that his hospital was struggling on every front and that it was far worse than in January? He said that the emergency department was at record levels and elective referrals were increasing as exhausted staff turned down extra shifts needed to reduce the growing backlog. One in five of his beds is filled with medically fit people who cannot be discharged because they cannot find a care package. There have been more than 65,000 Covid admissions to English hospitals in the last three months; that is double the same period last year when, of course, there were no vaccines. Does the Minister agree with this chief executive when he said, “This time the vaccine hasn’t saved us”?

[Lord Kamall (Con)]

The most important thing is getting the third vaccine. The Government are monitoring and considering a wide range of factors, including cases and immunity, but also advice from the NHS as to whether it is feeling overwhelmed. That is the situation at the moment. We continue to monitor it; it is not a static situation. We are trying to get the booster out as much as possible and are really driving home the message that the booster is the most effective way to fight against Covid. We are making sure that we get as many people as possible vaccinated and taking up the opportunity of a booster.

[Baroness Uddin (Non-Afl)]

My Lords, the Minister talks about mask hesitancy in public spaces. It would be extremely helpful for the Government to take direct action and actually mandate masks. That would be very helpful for members of the public.

In the past eight weeks our family members have directly experienced the NHS, with Covid remaining a severe threat. Ward-based mental health services are in dire straits and lack sufficient funds for essential support and care. Are they also receiving vaccinations? The other thing is the incredibly outstanding services of the Medway Maritime Hospital intensive care unit, where a family member lies critically ill and is really struggling with their care.

--- Later in debate ---

[Lord Scriven (LD)]

I do; you went on for two minutes.

[Lord Kamall (Con)]

I thank the noble Baroness for her question, I think. To be fair, she has made a number of points, especially about disparities and inequalities. It is quite sad that there is low uptake of the vaccine in a number of communities. I know that the noble Baroness has done a lot of good work in the past in Tower Hamlets and other areas with minority communities.

The most important way we can tackle this issue is to encourage people to be vaccinated. We want to roll out the booster as quickly as possible and, sadly, too many people have still not taken their first and second vaccines yet. I know that noble Lords across the House have many contacts in many communities, so it is important, please, to come to me with suggestions and ideas. I have spoken to a number of noble Lords across the House about how to tackle this and how best to reach people who are hesitant and who may not trust authority, and encourage them to take the vaccine. I thank the noble Baroness for her question.

[The Duke of Somerset (CB)]

My Lords, many other countries have introduced a form of green pass as a proof of vaccine to gain entry to places for public gatherings, such as restaurants and theatres. This has resulted in a higher take-up of the vaccine, as people have been encouraged to have these passes to access the things they want. Surely we should introduce a similar mandatory proof of vaccine, either paper or electronic, which will help to drive up rates of vaccination.

--- Later in debate ---

[Lord Kamall (Con)]

Apart from the technical hitches in getting data on to it, which a number of noble Lords have referred to, the NHS app has a record of vaccination, which is important. The measures to which the noble Duke refers are being considered as part of plan B, but at the moment the advice is not to move to plan B but to focus on getting people vaccinated. The Government are concerned that other messages may confuse the picture somewhat. The message is simple: get vaccinated—vaccine one, vaccine two or booster. If there are any problems, please let me and others know so that we can push. Sometimes people do not always talk to each other—let us put it that way—so let us make sure that this is as joined-up as possible.

[Viscount Stansgate (Lab)]

My Lords, I ask the Minister about the latest advice received by the Government from the Scientific Advisory Group for Emergencies. First, has SAGE advised the Government that Covid is moving into its endemic stage or does it continue to advise the Government that we are dealing with a pandemic, which needs additional measures? Secondly, does the Minister regret the resignation of Sir Jeremy Farrar, the director of the Wellcome Trust and an eminent scientist, from membership of SAGE?

[Lord Kamall (Con)]

The Government welcome advice from a range of stakeholders and have listened to SAGE and others throughout to balance their different views. In fact, I remember that when Jeremy Farrar was resigning he insisted that his departure should not be interpreted as a fresh disagreement with the Government. The Government listen to a range of views and balance them all.

[The Deputy Speaker (Baroness Henig) (Lab)]

The time for Back-Bench questions has now elapsed.

Public Health Grant to Local Authorities

Lord Kamall Excerpts

Tuesday 2nd November 2021 Lords Chamber

[Lord Scriven (LD)]

My Lords, in begging leave to ask the Question standing in my name on the Order Paper, I declare my interest as a vice-president of the Local Government Association.

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

Since 2016, the local authority public health grant has decreased by 2% in cash terms, but we increased the grant in 2020-21, and in 2021-22, and it now stands at over £3.3 billion. We are maintaining the grant in real terms over the next three years to enable local authorities to deliver preventive and front-line health services which will improve the health and well-being of their communities.

[Lord Scriven (LD)]

My Lords, even with the recent cash increases, the public health grant has been cut in money terms since 2016 by £1 billion, curtailing services such as smoking cessation, healthy families, and sexual health clinics. If the Government really are committed to preventing poor health, why did the Chancellor not restore in the Budget the £1 billion to improve public heath, rather than prioritising giving banks a £4 billion tax break?

--- Later in debate ---

[Lord Kamall (Con)]

The public health grant will be maintained in real terms over the spending review period, and we will confirm local authority allocations in due course, but this is not the only money going to public health. In addition to the grant, the Government are investing £300 million over the SR period to tackle obesity and £500 million over the SR period to improve the “best start in life” offer available to families. The NHS is spending over £1.3 billion on national public health services.

[The Lord Bishop of London]

My Lords, during my time as the Government’s Chief Nursing Officer for England I witnessed the unique value of public health nurses in the community. The pandemic has further highlighted the importance of such roles and the significance of a whole-system approach. Given this, will Her Majesty’s Government consider increasing funding specifically to build up or rebuild the capacity of public health nurses to tackle localised health inequalities?

[Lord Kamall (Con)]

The Government have allocated more money for local authorities but we think that it is best left to local authorities to decide how to spend that portion of their grant, for they are closer to the people in the communities that they serve.

[Baroness Neville-Rolfe (Con)]

Does my noble friend agree that a public health capability in local authorities is very important? I was very impressed by the work the head of the public health office did in my home town of Salisbury during the poisonings of the Skripals. I have heard reports that some of the duties of the office or its funding might be transferred to the NHS, which has enough on its plate. Is there any truth in this report?

[Lord Kamall (Con)]

It is true that some of the allocation for the National Health Service is being used for public health spending, but we want to make sure that across the health system the NHS not only focuses on prevention and therapeutics but works in partnership with the public health authorities.

[Lord Laming (CB)]

My Lords, the good news is that in the Budget last week, it was announced that local councils are to receive £1.6 billion in grants for each of the next three years. The bad news is that that does not take them close to what the councils were receiving and spending in 2010. Will the Minister do all that he can to press for adequate funding, especially for the public health services but also to meet today’s needs and not those of a decade ago?

[Lord Kamall (Con)]

There are many bodies tackling public health and raising awareness of some of the worst health problems we have—not only the Office for Health Improvement and Disparities and public health officials in local authorities but the NHS, which wants to move more towards prevention because in the long term that saves money.

[Lord Whitty (Lab)]

My Lords, the noble Lords, Lord Laming and Lord Scriven, have pointed out that the loss of £1 billion over the last decade or so from the public health teams’ budgets has impaired their ability to deal with issues, including those related to Covid. Does the Minister recognise that the increase just announced goes nowhere near to closing that gap? Does he also recognise the parallel problem that the limitation on local authorities’ support for care homes is greatly impairing their ability to care for the health of elderly and other disadvantaged people resident in care homes?

[Lord Kamall (Con)]

As noble Lords will know, the Chancellor has confirmed additional spend for public health, and the public health grant will be maintained in real terms over the spending review period, enabling local authorities to invest in prevention and front-line services such as child health visits. There will also be continued funding of £100 million per year over the period to tackle obesity in adults and children, as well as investment in a new start for life offer for families, with an additional £66 million in 2024-25. We know and recognise the importance of public health. At the same time, the NHS is committed to rebalancing between public health, prevention and therapeutics.

[Lord Young of Cookham (Con)]

Has my noble friend seen analysis by the University of York showing that expenditure on public health is three to four times more effective in terms of health outcomes than investment in the NHS? Will he take steps to ensure that we now invest in the resilience of the public health network to ensure that we are better placed for any future pandemics?

[Lord Kamall (Con)]

I thank my noble friend for that very important question. We continually assess our preparedness plans for infectious disease outbreaks and pandemics to ensure that they remain as robust as possible. This assessment includes, as appropriate, incorporating lessons learned from exercises that test the readiness of our plans and from our experience in responding to pandemics, disease outbreaks and other types of incident in the UK. The UK Health Security Agency will be dedicated to ensuring that we are protected from all future threats, including pandemics.

[Baroness Merron (Lab)]

My Lords, areas of greater deprivation have disproportionately borne the brunt of cuts to the public health grant, despite many people in these areas having poorer health. In Blackpool, ranked as the most deprived upper-tier local authority in England, the per capita cut to the grant has been one of the largest, at £43 per person per year. Can the Minister explain to the House how and why these decisions are made, and will he ensure that fairness in funding is restored for those who need it most?

[Lord Kamall (Con)]

The noble Baroness raises a very important point about needing to tackle disparities across our nations. The ring-fenced grant that we provide to local authorities to spend on public health services comes with a condition that they consider the need to reduce health inequalities in their areas. Also, the grant’s distribution is heavily weighted towards areas facing the greatest population health challenges. Per capita grant funding for the most deprived decile of local authorities is nearly 2.5 times greater than that for the least deprived. In addition, noble Lords will be aware of the new Office for Health Improvement and Disparities. The pin-light focus of that office is on health disparities and how we tackle them.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I must say that that is a rather surprising answer. The Minister will know that the Prime Minister has promised to help level up the health expectancy of the poorest areas, but I take the Minister to his answer. The Health Foundation stated in the summer that there is no sign of concerted action to do this and:

“Current plans appear to be partial and fragmented, and many deprived areas where people are likely to have poorest health have not been identified as priorities for investment.”


Will the Minister reconsider his answer to my noble friend?

[Lord Kamall (Con)]

The noble Lord raises a very important point about how we tackle these disparities. This is one of the reasons. Given that a lot of powers to intervene at local level are in the form of local authority grants and local public health officials, it may well sometimes come across as fragmented. This is why the Office for Health Improvement and Disparities is very important to take an national overview of areas of disparity and target them.

Alcohol Duties

Lord Kamall Excerpts

Tuesday 2nd November 2021 Lords Chamber

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

The reform of alcohol duties will simplify duty rules and tax drinks in proportion to their alcohol content. This should create a financial incentive for manufacturers to reformulate their products, therefore giving consumers a greater choice of lower-strength products. This would support individuals to drink within the Chief Medical Officer’s guidelines. The Office for Health Improvement and Disparities plans to make an assessment of the potential impact of these proposals on consumption and associated harms.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I regret that the Minister has not actually answered the Question. All the evidence indicates that if the price of alcohol goes up, people drink less and are healthier. If the price of alcohol goes down or the duty goes down, people in fact drink more. More people go into hospital and more people die. Instead of relying on the industry to decide whether manufacturers will reformulate their drinks, as the Minister just indicated, the Government should take a firm lead and put the health of the nation first. They should not be handing out a £3 billion cut in this way. Will the Minister please go back to the Chancellor and tell him that we need a policy that will lead to better health, not worse?

[Lord Kamall (Con)]

Many public health officials, for many years, have criticised the system of alcohol taxation, particularly the EU’s system of taxation. Now that we have left the EU, we are free to set our own law in this area. Given the criticisms from the World Health Organization and many other think tanks, we can now set taxation based on the volume of alcohol.

[Baroness Hayter of Kentish Town (Lab)]

My Lords, I welcome that the duty will be related to the strength of alcohol. However, the Budget included a dozen references to wine, just as the Government were boasting that the biggest benefit of the New Zealand trade deal was cheaper New Zealand wine. This duty freeze, as we have heard, will cost £3 billion to the Exchequer over five years—money that could have been used for treatment services and for public health, since we know that deaths and illnesses will go up. It seems to me that the Government have an alcohol problem. They are scared to increase prices for the sake of all our health and are uncaring about the problems that this measure brings in its wake. Can this Health Minister go to his colleagues in the Treasury and try to educate them as to what they should be doing?

[Lord Kamall (Con)]

The noble Baroness is being a little unfair in her comments. These reforms were based on the advice of many public health officials, including the World Health Organization as well as a number of think tanks, which said that it was about time that we linked taxation to the volume of alcohol in drinks in the hope that we can encourage and incentivise manufacturers to lower alcohol content and to produce more low-alcohol and alcohol-free drinks. I am not sure whether noble Lords would accept such reformulated drinks, but it is important that we push this from a public health perspective.

[Baroness Randerson (LD)]

My Lords, real-term cuts in the price of alcohol send the wrong message also about drink-driving. We have one of the highest drink-drive limits in the world, set more than 50 years ago and well out of date. Around 2,000 people are killed and seriously injured on the roads every year, and that figure rose by 8% in 2019 alone. The British attitudes survey reveals that 77% of people support lower limits. Do the Government intend to catch up with the rest of the world and adopt this popular policy, saving lives on the road?

[Lord Kamall (Con)]

Noble Lords will know that alcohol-related deaths are not due purely to sclerosis of the liver and other direct impacts; we also know that alcohol plays a large role in, for example, drownings, 30% of which have some alcohol connection. We know that a number of murders and cases of domestic abuse are also connected to alcohol. The most important thing is to try to incentivise drinkers to drink low-alcohol or no-alcohol products in the hope that we can do that. This is why we have reformed the taxation system in a way that is linked to the volume of alcohol in drinks.

[Lord Smith of Hindhead (Con)]

My Lords, I refer to my interests as set out in the register. While the duty freeze and 5% cut on duty on draft beer was welcomed by the industry, in reality prices that consumers will experience are likely only to increase due to production and distribution costs. I do not think that measures in the Budget will lead to overconsumption since, in the highly unlikely event of the duty cut being passed on, a person would need to drink 183 pints before they got a free one. Does my noble friend the Minister agree that we should encourage people to go out, have a couple a modest drinks if they want to, support our fantastic hospitality industry and enjoy themselves?

[Lord Kamall (Con)]

The noble Lord makes an important point in looking at the various factors that have to be balanced up. Clearly, we want to encourage consumers or drinkers to move towards low-alcohol and no-alcohol products, while balancing that against the wider economic climate and the hard two years that the hospitality sector has faced, which is why we announced the freeze to some alcohol duties. On encouraging people to go out and drink alcohol, I am afraid I am the wrong person, because I am teetotal.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest, having chaired the Commission on Alcohol Harm. Our report published last year cited the data, then 10 years old, which showed that the cost from alcohol to the NHS was £3.5 billion a year, while the Home Office’s own estimates were that the cost to society was £21 billion a year. In the decade since then, the number of alcohol-related hospital admissions has risen by 19%, and there has been a rise, too, in alcohol-related hospital admissions and deaths, which increased by 20% last year alone. Given the rising cost to the NHS, what contingency plans have the Government made should this drop in duty fail to decrease alcohol harms, and what other methods do the Government plan to use to decrease alcohol consumption?

--- Later in debate ---

[Lord Kamall (Con)]

The Office for Health Improvement and Disparities, as well as many other bodies, will continue constantly to review the impact of this change in taxation. In addition, the Government remain committed to supporting those who are most vulnerable and most at risk from alcohol misuse. Alcohol is a cross-cutting issue affecting several government departments. A strong programme of work is under way to address alcohol-related harms and their impact on life chances, including an ambitious programme to establish specialist alcohol care teams in hospitals and support for children of alcohol-dependent parents. There are a number of other alcohol harm reduction strategies that are too numerous to list now, but I am happy to write to the noble Baroness.

[Baroness Merron (Lab)]

My Lords, alcohol-misuse experts have warned that the Government’s reforms of alcohol taxes are undermined by their failure to address the issue that alcohol from high-strength beverages may remain cheaper, in many cases, because the price per unit of alcohol is lower in many of those high-strength beverages. What plans do the Government have to introduce minimum alcohol pricing? Does the Minister share my concern that the Chancellor, in the Budget, appeared to be investing more in Prosecco than in the public health budgets that we need to see to cover the cost to society of alcohol harm.

[Lord Kamall (Con)]

The World Health Organization and a number of other organisations have criticised the current system of taxation of alcohol, and urged the Government—and the EU when we were a member of it—to move toward taxation based upon the volume of alcohol. To answer the noble Baroness’s specific question, there are no current plans to implement minimum unit pricing in England, but the Government continue to monitor the impact of minimum unit pricing as evidence emerges from Scotland and Wales. It has been in place in Scotland for more than three years, and the Scottish Parliament will not consider its extension until April 2024. In all my conversations with various public health experts, one of the things that they make quite clear is that this has to be evidence-led, and we want to look at evidence from elsewhere.

[Baroness McIntosh of Pickering (Con)]

I declare my interest as chairman of the PASS Proof of Age Standards Board. I also chaired the Select Committee on the Licensing Act 2003. Does the Minister agree with the Committee when it said:

“It is in our view unarguable that an increase in the price of alcohol will decrease consumption.”?


Does he further agree that, by increasing the taxation on stronger alcohol as the Budget aims to do, that will have a better chance of reducing alcohol intake and dependency than the minimum unit pricing that we have seen in Scotland?

[Lord Kamall (Con)]

I thank my noble friend for that very important point. This is why the new system of taxation has been introduced. It will more directly align the volume of alcohol with the taxation on it. That will feed through to higher prices for drinks with higher alcohol content.

Smoking Cessation: Prescription of E-cigarettes

Lord Kamall Excerpts

Tuesday 2nd November 2021 Lords Chamber

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

I thank the noble Baroness for her questions. It is really important that we look at how we can reduce smoking in this country. The point about the e-cigarettes and the MHRA’s wish to licence products is that it wants to move smokers on to a pathway away from smoking cigarettes and on to e-cigarettes since they are seen as a safer option. It does not want to encourage people to smoke e-cigarettes, but to move them off cigarettes and on to e-cigarettes. At the moment, the MHRA does not feel comfortable licencing any of the existing products, and therefore wants to have conversations with manufacturers and others to see if there can be a product produced that it feels comfortable licencing so that it can be available for prescription. Moreover, by having that MHRA stamp of approval, it may well encourage others to buy it over the counter.

[Baroness Walmsley (LD)]

My Lords, it is three years since the change of rules that allowed medicinal cannabis to be available on NHS prescription, but there have been only three NHS prescriptions in that time. How confident is the Minister that smokers will be able to benefit from regulatory change when children with intractable epilepsy cannot? Do not both of these situations require further training for doctors to ensure their confidence to prescribe?

[Lord Kamall (Con)]

The hope is that we will be able to move current cigarette smokers to e-cigarettes, but I am afraid that I will have to write to the noble Baroness on her specific question.

[Earl Cathcart (Con)]

My Lords, I used to smoke over 50 cigarettes a day but, in 2014, I transferred to using e-cigarettes. I have not had a puff of tobacco since, and I find that my health and breathing are so much better now. This is surely a very good thing; it should be encouraged.

[Lord Kamall (Con)]

I thank my noble friend. He is indeed looking incredibly healthy and is a living advert for the path away from cigarettes to e-cigarettes. Noble Lords across the House are keen for this to happen. The MHRA has advised that it is 18 to 20 months away from approving a medicinal licence for e-cigarettes in the UK. However, I take the points of many noble Lords; I will push the MHRA, and I hope that they will too.

[Lord Patel (CB)]

My Lords, it is correct that only MHRA-approved e-cigarettes should be available on prescription. The reason for that is that many e-cigarettes currently sold on the market contain dangerous products; there have been reports of deaths occurring due to lung complications. So is it not right that the sale of e-cigarettes not approved by the MHRA should be banned?

[Lord Kamall (Con)]

E-cigarettes are a pathway out of cigarettes; these e-cigarette products exist now, even before we have one approved via the MHRA. It is important not to ban existing products because we need to make sure that people move along that pathway. The hope is that, once there is an MHRA-licensed product, people will be encouraged to buy it, both on prescription and over the counter.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister has mentioned the MHRA a considerable number of times, which is a great tribute to the work that it is doing. Can he tell us why it is facing budget cuts at a time when we need our independent regulator in this country to be doing all it can to regulate and encourage new innovative products, including pharmaceutical products, to the market?

[Lord Kamall (Con)]

As the noble Lord will know, some of the issues are related to leaving the EU, but it is interesting to learn from conversations with the MHRA that it is hugely excited about its ability to be more global in its outlook and to be a centre of expertise that many people across the world will want to learn from. With respect to international engagement, as well as making sure that it updates its guidelines to take account of medical technology there will be ongoing reorganisation and changes, and it hopes to be fit for purpose for many years to come.

[Lord Naseby (Con)]

My Lords, is the Minister aware that, as I understand it, there is a problem with the MHRA budget? This is important work. Furthermore, is it not a fact that the industry itself is supporting this work?

[Lord Kamall (Con)]

It is very important that we get the MHRA to approve these e-cigarette products. The MHRA is seen as a jewel, to which many experts from other countries look. One of my roles is international health diplomacy, and many people I talk to from other countries are very impressed with the work of both NICE and the MHRA. We can use that in our international health diplomacy.

[Lord Mackenzie of Framwellgate (Non-Afl)]

My Lords, does the noble Lord believe that encouraging and giving the green light to e-cigarettes may well send a signal to youngsters who might think it is cool to start inhaling foreign gases into lungs which are not designed for them?

[Lord Kamall (Con)]

The noble Lord raises a very important concern about e-cigarettes. From conversations I have had with the MHRA and others, I understand that, at the moment, there is no evidence in the UK that young non-smokers are adopting or taking up smoking e-cigarettes. Most users of e-cigarettes use them as a pathway away from cigarettes.

[Lord Vaux of Harrowden (CB)]

My Lords, to follow up on that point, e-cigarettes are sold using flavours such as dragon berry, bubblegum, gummy bears and unicorn juice, in colourful packaging with cartoon characters—all clearly aimed at children. If we are considering licensing e-cigarettes, could this also be an opportunity to tighten up the packaging and branding rules to ensure that that stops?

[Lord Kamall (Con)]

There are a number of factors that will be looked at when licensing e-cigarettes, including incentives to customers—flavours, et cetera—to take up these products. I will have a discussion with the MHRA to ask that question in more detail, if the noble Lord would like to write to me.

[Lord Rennard (LD)]

My Lords, e-cigarettes are undoubtedly part of the way forward to achieving a smoke-free Britain. But why has it taken so long to get to this point and to begin fulfilling what was in the 2017 tobacco control plan and to adopt the recommendations of the 2018 Select Committee, chaired by Sir Norman Lamb, which highlighted the significant benefits of having medicinally licensed e-cigarettes which could be prescribed? How do we know that licensing will now proceed in a timely manner?

[Lord Kamall (Con)]

The MHRA has been quite clear that it wants to be in a position to license a product as soon as possible—it says 18 to 24 months. Noble Lords may well want to push the MHRA on that, and that is part of your Lordships’ role. But it is important that we make sure that, when we license a product, both consumers and public health experts can have faith in it.

[Lord Cormack (Con)]

My Lords, I understand from my noble friend Lord Patel that some of the devices and products to which he referred do not bear health warnings on their packaging. Why is that so? Surely that at least should be on all of them.

[Lord Kamall (Con)]

I thank my noble friend for pointing that out, and I will investigate. Not being a user of e-cigarettes or cigarettes, or of any sort of narcotics or alcohol, I am afraid that I am not really an expert myself. I will look into that and write to my noble friend.

[Baroness Finlay of Llandaff (CB)]

Can the Minister confirm that the nicotine levels will be looked at, given that the nicotine level in some e-cigarette products is very high and that nicotine is the addictive substance both in cigarettes and in the continued use of e-cigarettes? The commercial incentive for tobacco producers to produce flavoured, palatable and highly addictive products should not be pandered to.

[Lord Kamall (Con)]

The noble Baroness raises an important point about nicotine itself being a very addictive substance. I am sure that the MHRA will be looking at the guidance, but if the noble Baroness would like to write to me, I can confirm that.

Health Protection (Coronavirus, Restrictions) (Self-Isolation) (England) (Amendment) (No. 3) Regulations 2021

Lord Kamall Excerpts

Tuesday 2nd November 2021 Lords Chamber

Moved by

[Lord Kamall]

That the Regulations laid before the House on 22 September be approved.

Relevant document: 15th Report from the Secondary Legislation Scrutiny Committee. Considered in Grand Committee on 26 October.

Motion agreed.

Health Incentives Scheme

Lord Kamall Excerpts

Thursday 28th October 2021 Lords Chamber

[Lord Scriven (LD)]

My Lords, from these Benches I thank the Minister for coming to answer questions on the Statement. These Benches welcome anything, including innovation, that targets the poor health and loss of life years that obesity brings. However, this is really the emperor’s new clothes, because it has to be set in the wider context of the detriment of poor health, public health budgets and poverty. Public health budgets have been decimated, so that many issues connected to the determinants of health cannot be dealt with. Low pay has become the norm for so many in our country. School budgets for extra activities, such as physical activity, and timetabling have caused problems, and food and drinks industry standards also have to be addressed. Tackling obesity is about tackling the lack of opportunity and tackling poverty. Innovation with a wristband is like asking somebody to learn the Green Cross Code they have a motorway to get across. It is not going to be successful.

As a country, we have to start early: we have the second-largest child obesity problem in the whole of Europe. So what are the Government doing to ensure that daily sport as an activity is available in every state school, so that every child has some daily activity? What is the Government’s response to the report by the Association for Physical Education with regard to children’s health and, in particular, with regard to swimming?

Diet at home and in school is important. The Jamie Oliver Foundation Bite Back report basically found that healthy options in schools were more expensive. What are the Government doing to ensure that fresh, healthy food is available at an affordable price in every school in the country? How are the pilots being chosen? The correct areas are the areas of deprivation, because that is where the highest incidences of obesity are. What are the criteria? How are they being selected? How are areas being offered the chance to become part of the pilot? This must be seen as a healthy eating and exercise approach, and not a weight-loss problem. There are far too many citizens in our country who suffer with eating disorder issues. So what are the Government doing to ensure that it is this framework of healthy eating and healthy lifestyles, rather than being seen purely as weight loss?

With regard to the wristband and the data, who will have access to the data? Where will it be stored? What precisely will the data be used for? Will any private sector organisation have access to the data and its interpretation, and, if so, what conditions are in place to ensure that we do not have the problem that we had with DeepMind, where it was used for purposes over and above what was anticipated?

Finally, talking of the private sector, HeadUp Systems is noted in the Statement. This is a company that has a £30,000 turnover and made an £11,000 loss last year. So how, and on what criteria, was HeadUp Systems chosen? What role will it have? Which other private sector organisations were asked to provide the support that HeadUp Systems is doing? What Ministers or officials did members of HeadUp Systems approach or have access to? If there is a contract, what is its value and on what basis was it given to HeadUp Systems?

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

My Lords, I start by thanking the noble Baroness and the noble Lord for their questions. This is a good story in terms of how we tackle health in the modern day. The noble Baroness mentioned the IPPR. I am not sure how well the name “Tony Blair” goes down on the Benches opposite these days—

[A Noble Lord]

Very well.

[Lord Kamall]

I am pleased to hear that, because the Tony Blair Institute has actually recommended more of these schemes using wearable tech to ensure that we have a healthier population. So this is not politically motivated in any way; it is led by a desire to do the right thing, and to learn lessons from previous schemes about what works and what does not work. One problem, as many noble Lords have said in the past, is that some of these schemes have not worked. We need to make sure that we have evidence, and that anything that we roll out is evidence-based. On that basis, it is absolutely right that we pilot a scheme rather than do a one-size-fits-all scheme, only to find where the errors are.

Also, as Hayek has said, we have limited knowledge. Some people express the conceit of knowledge and think they know everything, and sometimes—in economics and in politics—quite often we become aware of consequences, both intended and unintended. It is important that, when piloting a scheme such as this, we are able to identify potential unintended consequences that would not have been foreseen. I know that the noble Lord, Lord Scriven, can already predict the outcome and has infinite knowledge, but what is really important is that we see what works and what does not work, rather than predicting in advance that something will fail—and I acknowledge that the noble Lord, Lord Scriven, was asking a question, as he is entitled to do.

I will try to answer a few of the specific questions. One of the things that we are seeing is that obesity is costing our health service and healthcare system more than £6 billion a year. Clearly, schemes have been attempted in the past, and some have worked and some have not. We looked around the world to see what we could learn from the rest of the world. In particular, we looked at the Singapore health challenge, and also the Amsterdam programme, to see what we could learn. One of the things that I noticed when I worked on projects in the past in one particular area was that, just because they worked in one area, it did not mean that they would necessarily work in another area. We have to understand the local factors that might make a project a success or not.

In addition, it is really important that we do tackle disparities, and I am very pleased that many noble Lords have brought up the issue of disparities. We now have the Office for Health Improvement and Disparities: the clue is in the title. “Disparities” means that we want to identify these disparities—all sorts of disparities: sometimes they are gender disparities; sometimes they are based on ethnic minorities; and sometimes within communities there are different disparities. It is always far more complex than we can predict in advance. One of the best ways of tackling things is to look at pilot schemes.

Let me see if I can now answer some of the specific questions. This is based on understanding what incentives people respond to. Many noble Lords will have read of schemes in the past that simply have not worked. We need to work out what works with certain communities and certain demographics. One of the bits of academic research that has been found to be quite helpful is that, quite often, people from lower-paid communities respond better to price incentives or reward systems, and we are going to put that to the test. We are not saying that this is definitely the case: we are saying that we are going to pilot this to see if what we think is going to happen will happen—and, if it does not happen, why does it not happen and what can we learn from that in the future?

The noble Baroness, Lady Merron, asks what assessment the department has made of the changes in the level of the public health budget. Public Health England has monitored and published data on trends, with a wide range of indicators of public health, set out in the Public Health Outcomes Framework. That function has now transferred to the Office for Health Improvement and Disparities, which shows the fact that we want to identify those disparities and see how we can tackle them.

The ring-fenced grant that we have provided to local authorities to spend on public health services comes with a condition that they consider the need to reduce health inequalities in their areas. The grant’s distribution is heavily weighted towards areas facing the greatest population health challenges. Per capita grant funding for the most deprived decile of local authorities is nearly 2.5 times greater than that for the least deprived.

What is the breakdown, as we go over this? The publicly available information will contain the contract value, inclusive of £3 million to be spent on rewards for participants. The budget will be managed through standard contract procedures and there will be provisions in place to prevent overspend.

I shall go over the timescales. There was open procurement for the pilot, which closed on 16 August. The contract was awarded and unsuccessful bidders notified on 27 September. The pilot mobilisation period that we are looking at is 11 October to 31 December. The press release announcing the pilot provider was issued on 22 October. The pilot launches in January 2022 and closes in June 2022 with an evaluation report. That is critical. We want this to be evidence led; it is about time that we pushed for more evidence-led research. Before I came here, I had read reports from think tanks that had analysed government programmes, only to find that the evidence always backed it up. We want to make sure that this process is clearly evidence led and also to be aware of unintended consequences.

In terms of whether people can afford to eat a healthy diet, the Eatwell Guide represents government recommendations on a healthy, balanced diet to promote long-term health at the population level. Analysis by Scarborough et al in 2016—I shall not give a Harvard reference here—of the cost of achieving a diet in line with the Eatwell Guide concluded that in some cases it was 3p cheaper than the current diet.

In terms of audience and location, the pilot will target adults over the age of 18 in a chosen local authority. The approach will be tested to ensure that it combines wide appeal across the adult population with an ability to engage those who could get the most benefit from adopting healthier behaviours for physical activity and diet, such as those not meeting recommended guidelines. The pilot will take place in one local authority in England where there is a high proportion of our target groups. I hope that the information will become available publicly, or I will be able to update the House. We will be releasing further information in due course on the pilot location and on how residents can sign up to take part in the work. The scheme will be for England only but we will continue to work across the devolved nations to learn shared best practice. One of the things that we need to do is to make sure that we learn from what works well and what has not worked so well.

How will we safeguard data and privacy? I am sure that the noble Lord, Lord Scriven, will have recognised that I come to this post as a bit of civil libertarian, and perhaps civil liberties is one of the few things that we agree on. All data will be collected, stored, shared and used in alignment with all applicable law regarding the processing of personal private data and security standards, including the UK Data Protection Act and the UK General Data Protection Regulation. Full data collection and processing requirements will be shared with potential pilot users as part of the sign-up process. Consent to take part in the pilot is, I stress, voluntary. The Department of Health and Social Care is the data controller for the pilot, with HeadUp Systems as a limited data processor that collects data on the department’s behalf.

The noble Lord asked about the supplier. We contacted HeadUp Systems to deliver the pilot, and it has partnered with a number of organisations to deliver the requirements, including the Behavioural Insights Team. The advice of Sir Keith Mills who successfully launched and ran the Air Miles and Nectar programmes has also been sought. We are therefore trying to work with the best experts out there, including the Behavioural Insights Team, to bring knowledge and expertise on behavioural economics. I am sure that many noble Lords have read many interesting works on behavioural economics over the years. If the pilot does not work, we will work out why and how we can improve the scheme to make sure.

Given that obesity costs this country over £6 billion a year, surely it is worth a little investment, experimentation and discovery to see if we can make sure that we nudge our citizens, wherever they come from, whatever their background, towards healthier living.

[Lord Balfe (Con)]

My Lords, perhaps I may first apologise to the Opposition Front Bench for my confusing an Urgent Question with an Oral Statement. I thought that we had only 10 minutes for all of us.

My reaction is that this system will be quite easy to game. One cannot measure fruit and vegetables, and size of portions, by wearing a wristwatch; one can only use it to input data. That is the same for step counting, which, on a wrist counter, is well known as being not as accurate as elsewhere. I hope that the Minister and his officials will look carefully at the possibilities for gaming the system. If they are collecting the data remotely, they should be able to tell whether it is being gamed.

As a former president of the British Dietetic Association, I ask the department to look carefully particularly into the obese and overweight category. There is evidence that a BMI of around 26 does no harm to people, and I should like to see more medical evidence produced on that. I invite the Minister to ask the department to look at that.

Finally, will the department look at producing an app for all citizens, not with rewards attached but just an app of good practice that could be made available for free through the App Store so that we can all share in the wisdom of the department?

[Lord Kamall (Con)]

I thank my noble friend for those important questions, which are exactly those that I would have asked—and, in fact, did ask the briefing team when I was getting more details on this matter.

Of course, one of the most obvious things that we have to ask is: how do people game the system? Often, when one analyses a scheme, sometimes there are unintended consequences whereby people are able to game it. Someone asked me—I think and hope that it was in jest—“If I ate 75 cream cakes and blamed my metabolism, would I be able to get on to the scheme?” We have to make sure that our data is robust. The pilot will include robust anti-fraud measures in relation to users’ activity and access to incentives.

What is interesting about the scheme is that it is voluntary, but it will also make sure that the users input the data. There has been a lot of research around that, because it has seemed to be a potential weakness, if users were inputting the data, regarding whether they can game the system. We have been assured that measures have been put in place to avoid that sort of gaming but, once again, the evidence will tell. That is why the system is not national but is a pilot to test all these questions to the limit.

The noble Lord mentioned weight loss and obesity, which I shall come to. One of the things that we want to make clear is that the health incentives scheme is not a weight-loss programme; it is a programme for healthy living. It uses an innovative approach to rewards and incentives to help participants to adopt healthier behaviours for physical activity and diet. Of course, it will help those who are overweight. I have been on two diets in my life—no, really I have. What is interesting about this is that, when one looks at these issues, it is not just a question of consuming less but about burning off calories. That is why we want to encourage healthy living as opposed to purely tackling obesity. That is very important.

The other day, I met a young lady who was very slim. She said, “Why do you keep going on about obesity and type-2 diabetes? I am slim and I have type-2 diabetes”. So sometimes we have to make sure that we are clear about these connections.

[Lord Scriven (LD)]

The Minister has been going for about two minutes now.

[Lord Kamall (Con)]

Oh I see. I bow to the superior expertise in this House of the noble Lord, Lord Scriven, and I will sit down.

[Baroness Boycott (CB)]

My Lords, I want to ask the Minister a question based on an answer he gave earlier. He said specifically that the Government’s “eatwell plate” was as affordable as any other meal. I would like to challenge that, in my role as a member of the Food Foundation. It points out that, if you are on a low income, eating the “eatwell plate” is going to take about 60% of your disposable income. The reality of the cost of healthy food is this: if you have a pound to spend, you could get three peppers, which add up to 65 calories; six apples, which add up to about 200 calories; or a packet of sweet biscuits, which would give you 1,000 calories. If you are a mother or father struggling on a low income, and you need to feed your kids, you are going to go for the high-calorie option; this is how the food system is worked. If the Minister has data that proves that the “eatwell plate” is affordable, on whatever income you happen to have in this country, I would be very grateful for that knowledge. If he does not have it now, please could he write to me?

[Lord Kamall (Con)]

I thank the noble Baroness for that important question. When I am being briefed, I test my officials and make sure that I am able to answer as many questions as possible. I am told the “eatwell plate” costs about 3p less per adult per day than the current diet in the UK, but I will write to the noble Baroness with more detail. If the noble Baroness is not happy, she can challenge that.

[Baroness Chapman of Darlington (Lab)]

My Lords, I really think the Minister can afford to be less prickly about all this. No one is disparaging the idea of a pilot; there have been many hundreds of pilots in this space, to my knowledge, and probably many more that I do not know about. The easy thing is piloting it; the hard thing is rolling this stuff out and having an impact. It is just that we are rather underwhelmed with the scale of this pilot, given the scale of the challenge we face. But in the interest of being positive about all this stuff, a Parkrun practice pilot has been taking place in GP surgeries up and down the country—only about 20% of them are actually taking part. Early assessment looks incredibly positive. It does not actually cost anything to implement. I encourage the Minister to try to accelerate the rollout of this initiative and, if he does not already, to take part in his own local Parkrun.

[Lord Kamall (Con)]

I thank the noble Baroness. I would like to know on what basis she thinks I should take part—I hope I am not looking unhealthy. I also apologise to noble Lords if I have come across as prickly; maybe I just got too excited about this scheme. As someone who been quite critical in the past of schemes that do not work and who has looked at evidence behind such schemes, I am excited that this is a real pilot, as opposed to a one-size-fits-all national system. We can see what works and then roll it out. I also thank the noble Baroness for making me aware of the scheme in GP surgeries. Maybe the noble Baroness could do me a favour and send me some details, so I can look into it in more detail and see how we could roll it out.

[Lord Fox (LD)]

My Lords, in giving his answer, the Minister failed to answer one of the questions from my noble friend Lord Scriven on school sport. So perhaps we can give the Minister a second go at responding. When will the Government throw their full weight behind reviving, revitalising and extending school sport?

[Lord Kamall (Con)]

I have responded to questions, including the noble Lord’s question about sport in schools, which is of course incredibly important—we all benefited from that. One of the things I have to be clear about is which department it falls under. As I understand it, some of this does fall under the Department for Education, so if the noble Lord does not mind, I will write to him.

[Lord McNicol of West Kilbride (Lab)]

I want to follow on from the question on sport. Since 2010, the Government have given authorisation for the sale of over 220 school sports fields. Does the Minister see any correlation between the sale of these school sports fields and the rise in health inequalities? I understand the Minister might not be able to answer this and may need to go back, so if we could get a response from the Department for Education, that would be great.

[Lord Kamall (Con)]

I thank the noble Lord for that question. It is an interesting data point to look at to see whether it is correlation, coincidence or there is a link. As the noble Lord acknowledges, I do not have the answer at my fingertips, particularly because some of this will fall under the Department for Education. If the noble Lord will allow me, I will go back and investigate this and write to him.

Social Care

Lord Kamall Excerpts

Thursday 28th October 2021 Grand Committee

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

My Lords, I congratulate the noble Lord, Lord Lipsey, on securing this important debate and I thank him for his well-argued case for the importance of the private sector in helping people pay for care. As he rightly acknowledged, it puts a Conservative politician in an interesting place when a Labour Peer is explaining the benefits of the private sector. I acknowledge his long-standing interest in this area; he brings a wealth of experience to the topic, not least as a member of the Royal Commission on Long Term Care for the Elderly, which in 1999 began the important discussion of how people should pay for their care. We should also be clear, however, that successive Governments, even before then, have kicked the can down the road. Reports have been issued and have gathered dust on bookshelves. I worked for an economic think tank which surveyed a range of views across the political and ideological spectrum—good ideas that have just been ignored for many years.

In that spirit, whatever one thinks of the announcement made by the Prime Minister on 7 September, it marks an important step on the journey to reforming adult social care. We are no longer talking theoretically or about blank pieces of paper. We are talking about a proposal that can be critiqued and, we hope, improved. I hope that in time, with noble Lords’ experience across the House, we will be able to come up with a package that addresses many of the criticisms made today.

The Government’s view at the moment is that the £86,000 cap in England will end the worry that individuals may face unlimited care costs. In addition, anyone with assets worth between £20,000 and £100,000 will be eligible for some means-tested support, helping people without substantial assets. The Government’s view is that the reforms will bring people peace of mind from knowing that their assets will not be wiped out if they end up needing care.

Let me turn to a couple of the points made by the noble Lords, Lord Desai and Lord Lipsey. A few years ago, I read a very interesting article in the Financial Times about financial planning. The journalist asked why we plan for people to build ever larger amounts of wealth towards the end of their lives, then leave it to someone without benefiting themselves; surely we should encourage people to build large amounts of wealth that they then spend towards the end of their lives, including on their own care. That raises some substantial questions, which, I agree, the Government will need to address.

The cap marks an important step in enabling people actively to plan for the cost of their care, and agree that this is where the private sector can play a critical role. Of course, the new cap will protect people from facing unlimited costs and give greater clarity and certainty about what costs they may face. However, I take on board the point made by the noble Baroness, Lady Brinton, about making sure that we have proper publicity and public information. People will need to plan. As many noble Lords have said, to date, too few people think about the cost of care until a point of crisis when they or a family member are affected.

We believe that the financial services industry can play a critical role in helping people to meet their needs and in supporting people to pre-fund their care cost if they wish to do so. As many noble Lords acknowledged, the financial services industry already offers a range of products that can be used to help people to meet their care costs; they may not necessarily be marketed as help for care costs, but they help to build up a sum that can be used for such costs. There will continue to be a landscape of products to meet people’s needs and, we hope, to enable them to fund the cost of their care up to the cap. It is not a one-size-fits-all measure, as the noble Baroness, Lady Brinton, outlined.

Some people may prefer, for instance, to invest in a long-term savings product such as a lifetime ISA, or increase their pensions contributions to make use of their pension freedoms. Others may wish to use some of the products that noble Lords have mentioned, such as immediate needs annuities. Some people may wish to draw on their housing wealth, in consultation with their family, to pay for their care and, as such, make use of equity release products offered by either banks or local authorities through a low-interest deferred payment agreement.

No one single product or approach to planning for care will meet everyone’s needs. Therefore, as the noble Lord, Lord Lipsey, rightly pointed out, quality financial advice will be critical so that people can make informed decisions about paying for their care costs up to the cap. There is already a legal obligation on local authorities to help people to understand how they can access independent financial advice, but we recognise that more is needed. We are working with stakeholders to consider what people need and how the Government can support them.

Noble Lords may think it rather far-sighted of me that, 20 years ago, I started looking at financial products and how I could save for my future. Interestingly, when I interviewed financial advisers, one thing I was advised was that they were not necessarily financial advisers, and that they may well have been financial salespeople trying to sell products. As we ensure that better financial advice is available, we are going to have to be clear about making a distinction between independent advice and the incentive-based sale of products. In many cases, this is where mis-selling has occurred—that is, where the incentives have incentivised the so-called financial advisers to sell an inappropriate product, rather than the most appropriate product, to the person requiring help. With increased demand, and given that this sends a signal that people will have to start thinking about their social care, the Government hope that the market will evolve. I cannot say that for certain because no one can predict how markets will evolve; that is the wonderful thing about spontaneous order, with existing products adjusting and new products developing.

However, as the noble Lord, Lord Lipsey, and other noble Lords acknowledged, this will not happen overnight. We will listen to and work with partners and industry over the coming months to consider the development of financial products to help people to plan for their care costs, in line with the introduction of the cap on care costs in October 2023. The Government have also held initial discussions with the ABI. What is interesting about those conversations is that we were clear that this will not be spontaneous, and that these measures will emerge with time as people start to understand the parameters and the amounts that they need to raise for their future. We hope to continue these conversations with a broader range of sector representatives in the months to come.

I give this pledge to noble Lords across the Committee: I want to learn from the expertise in this Committee. Some very valuable points have been made in this debate. I will hope to take them back when discussing with the Government the future course of the Bill. We will be listening and there is great and deep expertise. As I indicated before today's debate, I would like to have a long conversation with the noble Lord, Lord Lipsey, and others because there are some valuable points being made.

It is important to see the reforms as a package. The noble Lord, Lord Lipsey, said—and this is something we should all be aware of—that this should not be something for the wealthy; it should be for everyone. There is not just the cap, but also a much-extended means test. It is about how we can support people with their care costs right from the beginning and be aware.

The problem with being purely private, as I think the noble Baronesses, Lady Wheeler and Lady Brinton, said, is that there might be some who cannot afford to take out some of these products—those with less or the just about managing. In that case, unless one is a complete anarcho-capitalist, one would see a role for the state to help those who are unable to make those informed decisions.

Regarding equity release schemes, the deferred payment schemes are effectively a local authority-administered equity release scheme and available in certain circumstances. The Build Back Better document says that we want to make these more accessible, better value and not necessarily for profit.

A number of noble Lords asked questions about raising awareness. We have committed to providing information. We want to make sure that those looking to prepare for their own future, or maybe helping their parents prepare for the future, make informed decisions. It is critical that we make sure that they are getting independent advice. I welcome noble Lords’ advice on how we ensure that we make that distinction between advice, objective advice and pure sales. We also want to work on how to improve access to this advice, for example through the citizens advice bureaux.

My noble friend Lord Balfe talked about people paying for their own care. For this Government, it is about balance. We recognise—as I said previously and many other noble Lords have said—that people do not start thinking about this until it is sometimes quite late. We agree that people should pay towards their care, but we want to make sure that they can somehow plan and overcome this issue of unpredictable costs at the same time. How do we get the balance right between personal responsibility and state support for those unable to provide for themselves?

My noble friend also talked about equity release schemes and existing equity release schemes. He made some very interesting points, as did the noble Lord, Lord Desai, on these. We should take them on board.

The noble Baroness, Lady Brinton, talked about the possibility of the insurance market. We agree that the most important point is that the cap in itself will not mean that an insurance market will magically spring up. It will take time for the industry to understand and work through the consequences—particularly the very clever minds in the insurance industry—and then to see what demand there is from the public.

We need to make sure there is a better understanding of who pays for what, as the noble Baroness, Lady Brinton, said. An extensive campaign should be launched. We very much hope once again to draw on the experience of noble Lords across the House in reaching the public. We are finding this with some other health issues. How do we reach those difficult-to-reach markets?

We will publish details of policy parameters later. I will end with a couple of points. My noble friend Lord Balfe talked about Denmark. It is important that we learn from the best and worst international experiences. If my noble friend can send me details of other international schemes, we will look into those.

The noble Lord, Lord Desai, said that women tend to look after men. My wife would probably say that that is not just in old age—I think they start rather young. As my wife says to me, she has two sons but three boys.

I apologise if I have not covered all points made by noble Lords today. If I have not, I hope noble Lords will write to me and follow up. I will try to get the answers if I can. I thank the noble Lord, Lord Lipsey, for securing such an important debate today and thank all noble Lords who have taken part.

People with Learning Difficulties and Autism: Detention in Secure Settings

Lord Kamall Excerpts

Thursday 28th October 2021 Grand Committee

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

My Lords, I thank the noble Baroness for securing this important and heart-wrenching debate, and for leading the work on the independent reviews of people with a learning disability and autistic people in long-term segregation. I also thank the oversight panel that works with the noble Baroness on this vital issue for its report and recommendations, which the Government wholeheartedly welcomed and responded to in July this year.

Some of the stories we heard were heartbreaking. I am extremely concerned to hear about the number of people who remain in long-term segregation and, in too many instances, the unacceptably poor care to which they are subject. As the noble Baroness rightly says, no one should be detained where they do not need to be and where they can live a full life in the community but, sadly, we know that this is still happening and, frankly, it is not good enough. The Government are committed to taking action, both for those already detained who can and must be discharged, and to prevent people who do not need to be admitted from being so in future. We must move away from responding to crises to ensuring that the right care and supporting legal framework are in place from the very beginning of someone’s life.

We are determined to reduce the number of people with a learning disability and autistic people in mental health hospitals, which is why we are investing more than £90 million of additional funding in 2021-22 in community services and support for discharges. The Government are also undertaking wider action, which I will set out as I address the important points raised in this debate. I aim to address as many of noble Lords’ points as possible today.

The noble Baroness, Lady Hollins, started the debate by talking about housing. There is clear evidence that the right housing arrangements can deliver improved outcomes and meet people’s preference to remain in their own home. We agree, as the noble Baroness said, that the right housing for people with learning disabilities and autism is not always available, or available as quickly as we would like. In England, we are providing funding to build specialised housing through the Care and Support Specialised Housing Fund—CASSH—for older people and adults with learning and physical disabilities or mental ill health. We have provided £71 million for the fund in 2021-22.

Also in England, we fund the disabled facilities grants to support eligible people, including people with learning disabilities and sensory impairments, in adapting their homes to make them safe and suitable for their individual needs, subject to a means test, eligibility criteria and their needs assessment; £573 million has been provided for this in 2021-22. Housing is one of the six priority work streams of the Building the Right Support delivery board, and will form part of its upcoming action plan.

The noble Baroness, Lady Hollins, and the noble Lord, Lord Addington, mentioned training and expert staff. We accept that the right workforce is critical in enabling the highest standards of care and support for people with learning disabilities and autistic people. Skilled staff, leadership and creativity can be key in supporting someone towards discharge. For those in long-term segregation, the launch of a senior intervenors pilot is vital. Senior intervenors are being recruited, and we hope that they will help to remove barriers and bring creativity to planning and moving people towards discharge. The role will bring with it the necessary expertise and experience to assist in overcoming some of the barriers to progress.

More generally, we have provided £1.4 million of funding for the development and trialling of Oliver McGowan mandatory training to improve awareness and understanding of learning disability and autism for health and social care staff. Hundreds of staff have already been trained through the trials. The Government recently announced at least £500 million over three years to fund social care professionalisation initiatives to improve workforce well-being and other issues, especially for those who work with patients with autism and learning disabilities.

As we set out in Right to be Heard:

“Our vision is that in future all professionals will, before starting their career or through continuing professional development, undertake training which covers a ‘common core curriculum’ for learning disability and autism so that we can be confident that there is consistency across education and training curricula.”


The Government are currently working with Health Education England, the Medical Schools Council, regulators and medical schools to establish the best approach to developing a core curriculum. In addition, to improve patient services supporting autistic people, we are investing £1.5 million to develop training for staff in adult in-patient mental health centres. I know that the noble Lord said that there are much wider issues around mental health, but it also includes supporting autistic people, in line with tier 3 of the core capabilities framework.

As part of the Oliver McGowan mandatory training in learning disability and autism programme, we are working with a number of people, backed by that £1.4 million investment. Subject to evaluation, this should be available to all of the 2.8 million health and social care staff on autism and learning disability. As I said, the workforce is one of our six priorities. Also, as part of the new national autism strategy, we are taking a number of steps to improve the understanding of autism among educational professionals, as well as the training that we have already announced.

There are a number of incredibly important reports and recommendations, especially those by the Joint Committee on Human Rights, the Health and Social Care Committee and the CQC oversight panel. The Building the Right Support delivery board has been established to drive further and faster progress on the exact issues that a number of noble Lords raised today. We are considering how to bring these recommendations together as part of the Building the Right Support action plan; this will require a cross-government, cross-system effort, as many noble Lords have said.

We also want to ensure better reporting on the number of people being detained. The Government are fully committed to reducing restrictive practices and poor care for people with learning disability and autistic people. Reporting on our progress on the use of these restrictive practices is an important part of that, which is why the Mental Health Units (Use of Force) Act statutory guidance, on which we recently consulted, set the reporting requirements for restrictive practices under the Act. That guidance makes reference to the mandatory requirement to report this information, in line with current NHS England and NHS Improvement requirements. We will publish the final guidance, reflecting feedback from the public consultation, later this year.

The noble Baroness will be aware of existing reporting data which is also already published. NHS Digital publishes its annual Mental Health Bulletin, a monthly public dashboard about the use of restrictive interventions and assuring transformation data about the number of people with a learning disability and autism in in-patient settings.

The noble Baroness, Lady Hollins, and perhaps one or two other noble Lords, also raised the issue of changing the rules so that care workers can enter the skilled worker immigration scheme. We should all acknowledge the valuable role that immigrants play in our economy. Within the social care workforce, nurses, occupational therapists and social workers are eligible for the health and care visa. The new health and care visa will make it cheaper, quicker and easier for eligible social care professionals from around the world to come to work in the UK. We hope to attract the best talent from around the world.

The noble Lord, Lord Addington, asked whether we have training for staff to de-escalate and minimise restrictive practice. NHS England and NHS Improvement have commissioned the rollout of the HOPE(S) model, a national training model to be delivered through NHS-led provider collaboratives to reduce the use of restrictive practices and long-term segregation and to develop positive cultures. The HOPE(S) model will follow a human rights-based approach, be person-centred and be informed by experiences of trauma. A number of noble Lords raised the issue of trauma and we think it is important that we address it. I would welcome feedback from noble Lords across the Committee who take an interest in this issue to make sure that we are on the right path.

I want to dwell on the senior intervener role, which is being trialled in response to the recommendation of the noble Baroness, Lady Hollins, for the introduction of an additional senior person to support local services to plan discharge, guide where there is challenge and agree actions to facilitate a reduction in restrictions. It is important that we do this planning and that we are planning for discharge as the ultimate goal. The project builds on the positive evaluation of the pilot of children and young people’s senior interveners. The ultimate goal of senior interveners is to establish and oversee this robust programme, making sure that we are all working towards discharge from long-term segregation and hospital.

I was asked by a number of noble Lords, especially the noble Baroness, Lady Hollins, about independent case reviews. We have accepted the recommendation made by the noble Baroness, Lady Hollins, and the oversight panel to resume independent case reviews for those in long-term segregation. We are working with NHS England and the CQC to ensure that IC(E)TRs will be restored as soon as possible. It is important that the reviews that take place are high quality and that we have the right panel of experts in place. We are trying to work on this as fast as possible in the context of the Covid-19 pandemic.

A number of noble Lords asked about Winterbourne View and targets. We have a clear target in the NHS long-term plan of a 50% reduction by 2023-24 and are taking action across several fronts to achieve this. There have been more than 10,000 discharges since March 2015 and a 28% net reduction in in-patient numbers. We accept that this does not meet the target of a 35% reduction previously set out in March 2020, but we hope to continue and to make real progress.

The noble Lord, Lord Touhig, talked about mental health issues and Mental Health Act reform. Reform of the Mental Health Act is important and a White Paper was published in January 2021. We have consulted publicly on the proposals, and we published a response in July 2021.

I will try to answer the other questions. The noble Baroness, Lady Bull, and the noble Lord, Lord Touhig, talked about limiting the scope of detaining people with learning disabilities or autistic people. The proposed reforms will create new duties for commissioners to ensure an adequate supply of community services and make every local area understand and monitor the risk of crisis at individual level.

I would like to say more about commissioners, if I may, but, if I have not answered noble Lords’ questions in the time allotted, I hope that they will write to me, so that I can give them all a more thorough response.

I end by thanking the noble Baroness, Lady Hollins, for this important debate. I think all noble Lords agree that all parts of the system must play their part and take action, so that no one is detained when they do not need to be. Hospitals must always have a therapeutic purpose and detain people only for as long as is absolutely necessary. We hope that the actions we have set out today for both the long and short term—I will write to noble Lords about our significant reforms—demonstrate the range of activity already under way or planned. We hope that this will help to ensure that we prevent people with a learning disability and autistic people being detained when they could live a full life in their community with their friends and family, as every one of us deserves.

Once again, I thank the noble Baroness, Lady Hollins, for securing this debate. I look forward to working with her in future.