Prescription Drugs: Dependence

Lord O'Shaughnessy Excerpts

Monday 19th March 2018 Lords Chamber

[Lord Hunt of Kings Heath]

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

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

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord O'Shaughnessy]

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

[Baroness Redfern (Con)]

My Lords, I welcome this major review of prescription drug addiction. Does the Minister agree that the review must also look at the provision of alternatives to prescription drugs and the culture change needed to make that happen?

[Lord O'Shaughnessy]

My noble friend is absolutely right. It is not just about getting people off these drugs who are wrongly on them, it is about making sure that they do not go on them in the first place unless that is absolutely necessary for their treatment.

[The Earl of Sandwich (CB)]

Is the Minister aware that there is a dispute between the Royal College of Psychiatrists and a significant group of academics, doctors and patients over the length of antidepressant withdrawal? Does the Minister agree that substantial research is needed quite urgently, including on withdrawal protocols, to ensure that patients can withdraw safely and slowly? I declare an interest, having experience of this in my own family.

[Lord O'Shaughnessy]

The noble Earl highlights a very important issue, and I reassure him that the review will look not only at the nature and causes of dependence on the drugs in scope, which include antidepressants, but at the correct and most evidence-based treatments for withdrawal.

[Lord Rennard (LD)]

Will the review by Public Health England be able to look specifically at alternatives to prescribing drugs, such as acupuncture, which is shown to be very effective in the relief of pain and reducing symptoms of anxiety, and perhaps also mindfulness, which has been shown to improve the mental health of very many people?

[Lord O'Shaughnessy]

I can attest to the benefits of both those courses of treatment. The review will look at prevention of dependency in the first place and in doing so will look at alternative courses of treatment. Of course, in the end there is a balance to be struck between the clinical needs of the patient and the right course of treatment. It is about making sure that clinicians are as informed as possible.

[Baroness Pitkeathley (Lab)]

My noble friend mentioned that many of the services for people who are addicted to prescribed drugs are provided by the charitable sector. He also mentioned that many of those services are under threat or have closed down because of a lack of local authority funding. Will the Minister consider what can be done to replace those vital services? Will the charitable sector, which is doing such good work in this area, be consulted in the course of the review?

[Lord O'Shaughnessy]

I completely echo the noble Baroness’s praise for the charitable sector. We have some very high-quality treatment centres in this country, provided both by the state and by charities. They do a fantastic job. In the most recently published figures, local authorities’ actual spend on funding for adults for drug misuse was about £490 million a year, so a substantial amount of money is going in. Of course, we need to make sure that it is getting to the people who are addicted to prescription drugs as well as illegal drugs.

[Baroness Gardner of Parkes (Con)]

My Lords, can the Minister explain the difference between dependence and addiction, as anyone who is on life-saving drugs is dependent upon them? Where does the definition come between that and addiction?

[Lord O'Shaughnessy]

My noble friend has just given a much better and more incisive answer than I could have given. There is a distinction; the point here is that these are drugs that people have started to take because they have needed them. I should point out one area that is not included in the review; it is not looking at cancer and terminal pain, because we need to make sure that there is appropriate pain relief for people who are in the last stages of their life.

[Baroness Meacher (CB)]

My Lords, is the Minister aware of the very powerful evidence from the United States that one of the most effective ways of reducing dependency on opioids is to legalise cannabis for the relief of pain? Cannabis is far less addictive and far less dangerous, yet it is incredibly effective for large numbers of patients.

[Lord O'Shaughnessy]

I would definitely be straying into Home Office territory by commenting on that. I would point out that cannabis remains illegal in this country and that the PHE review’s scope is to work within the drug strategy set out by the Home Office.

[Lord Watts (Lab)]

My Lords, does the shortage of mental health services in the NHS and the cuts to local authorities not mean that GPs often have no alternative but to prescribe drugs? Should the Government not address the shortages in both those areas?

--- Later in debate ---

[Lord O'Shaughnessy]

I think the link between mental illness and GP prescribing will be investigated in the review. We know that we need to do better in mental health services in this country, but it is worth pointing out that we are increasing investment and introducing new waiting-time standards, so services are getting better.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, is there not a case for a wider review of addictions in general? Public Health England did a review of alcohol and the Government ignored the report. A public health review in this area may be ignored entirely and there is nothing to make the Government do anything about it. We have just heard about what is happening with gambling; the Government have succumbed to the blandishments of the gambling industry and are not doing what many people in this House wanted on it. It is another addiction. Should we not have a review right across the board on addictions?

[Lord O'Shaughnessy]

The Government are taking steps to deal with addiction in a number of areas. We are obviously focusing on prescription drugs and the dependence on them. I hope the noble Lord will welcome the review and have the opportunity to contribute to it, as I know he feels strongly about these issues.

Children and Young People: Mental Health Services

Lord O'Shaughnessy Excerpts

Thursday 8th March 2018 Lords Chamber

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

My Lords, with the leave of the House, I will repeat as a Statement the Answer to an Urgent Question given by my honourable friend the Parliamentary Under-Secretary for Health, Steve Brine, in the other place. The Statement is as follows:

“This morning the Care Quality Commission published its report Are We Listening? Review of Children and Young People’s Mental Health Services. This is the second piece of work commissioned by the Prime Minister in January 2017 to look at this area of services. Findings include: examples of good or innovative practice, and dedicated people working in every part of the system; a number of areas with strong practice, ensuring that patients and families are involved in planning care; and concerns around join-up between children’s services.

The Government have already committed to making available an additional £1.4 billion to improve children and young people’s mental health services, to deliver on the commitments in Future in Mind and NHS England’s Five Year Forward View for Mental Health. The CQC welcomes this progress in its report.

Spend is reaching the front line. Last year we saw a 20% increase on clinical commissioning group spend for children and young people’s mental health, rising from £516 million in 2015-16 to £619 million in 2016-17. By 2021, we have committed to ensuring that 70,000 more children and young people each year will have access to high-quality NHS mental health care when they need it. But we know there is still much to do. As Claire Murdoch, the national mental health director for NHS England, said in response to this report, CAMHS services,

“are now improving, but from a starting point of historic under-funding and legacy under-staffing, relative to rapidly growing need”.

In December, the Department of Health and social care, jointly with the Department for Education, published our Green Paper Transforming Children and Young People’s Mental Health Provision. This Green Paper already responds to a number of the problems raised by the CQC in its report, and sets out a range of proposals to strengthen the way schools and specialist NHS mental health services work together, and to reduce the amount of time that children and young people have to wait to access specialist help. These proposals are backed by an additional £300 million-worth of funding. We have carried out extensive face-to-face consultation on the Green Paper proposals and have received a very high volume of responses to our online consultation. We will respond to the CQC review, alongside the Green Paper consultation, in the summer.

The report also calls for the Secretary of State to use the inter-ministerial group on mental health to guarantee greater collaboration across government departments in prioritising mental health. This recommendation is already in hand. The inter-ministerial group has already contributed to the development of the Green Paper and will continue to provide leadership on the issues that this report raises.

The report also recommends that everyone who works, volunteers or cares for children and young people is trained in mental health awareness. We are already rolling out mental health first-aid training to every secondary school and have committed to rolling out mental health awareness training to all primary schools by 2022. We are also set to launch a campaign to raise awareness among 1 million people around mental health and are a major funder of the Time to Change campaign, which has shifted public attitudes on mental health.

This Government remain committed to making mental health everyone’s business and building good mental health for all our children and young people”.

[Baroness Thornton (Lab)]

I thank the Minister for that response and Statement. What emerges from the Care Quality Commission’s review of children and young people’s mental health is the glaring finding, to which he has not referred, that children are suffering because of high eligibility thresholds. We know that 50% of mental health problems develop before the age of 14, and 75% develop before the age of 18. Does the Minister recognise that imposing high eligibility thresholds means that children and young people are treated only when their condition becomes very serious? Will he look into the referral criteria as a matter of urgency so that children and young people are getting proper treatment at the right time, thereby preventing a crisis that brings greater suffering for those children and their families, and greater expense for the health service?

[Lord O’Shaughnessy]

I thank the noble Baroness for those questions. On the issue of high eligibility thresholds, we are grappling with a need to expand the amount of mental health services that can be provided. Currently, about one in four children with a diagnosable mental health condition accesses NHS services. That is clearly not enough and the intention is to get that figure to one in three by 2021. Again, that is not enough but it would be progress. There is a need to move along the path, dealing first with those in the most acute trouble and then rolling out to those with less acute conditions. I agree with the noble Baroness’s point and recognise the issue. However, this cannot achieved overnight, not least because a huge number of new staff are needed to be trained in order to deliver that. We are looking at the issue of referral criteria. I should also point out to her that we have made big steps forward on waiting times and new standards for early intervention in psychosis and eating disorders. We are piloting a waiting time for access to specialist help and hope that that will start to move things along in terms of more children being seen more quickly, which is what we all want.

[Baroness D’Souza (CB)]

My Lords, does the Minister agree that more work needs to be done on finding out what the early warning indicators of mental health breakdown in young children are?

[Lord O’Shaughnessy]

I absolutely agree. This is why the changes that we are making to mental health awareness training in primary schools is critical. Most primary schools, through nurseries, take children from four—and even two or three—years old to make sure that staff can spot the signs in school and signpost to specialist services, where required.

[Baroness Jolly (LD)]

My Lords, I welcome the Minister’s Answer to the Question. I am sure that he will agree that mental health support teams will be critical in making all this work. However, CAMHS teams had huge problems in getting the workforce—and in getting it up to speed. What measures are being put in place to guarantee the resilience of these new teams?

[Lord O’Shaughnessy]

I agree that that is a challenge. There is a plan to create 21,000 new medical and allied posts by 2021, which would be the biggest expansion in mental health services that has ever taken place—certainly in this country but even in Europe. How we are going to achieve that is set out in the draft workforce strategy that Health Education England has published. A big part of that is the creation of mental health support teams in schools. That will take time—we need to be realistic—but it is an ambitious goal and we know that that support is wanted and needed.

[Lord Sterling of Plaistow (Con)]

My Lords, I am interested on two fronts. Motability over the next three years will be getting a quarter of a million people coming into the scheme and a large number of them will be children. This will put a major strain on the service they require. I am interested also on a personal front. I have a marvellous young grandson who is on the upper end of autism, so I take a deep interest in both. I thank the Minister for what he has read out from the other place but I disagree. I am afraid that we are lacking hugely in this country. Basically, we are short of educational psychologists. I am no expert but, as any doctor will tell you, the earlier you can identify mental health problems—at three, four or five—gives an opportunity of treating them generally. The Green Paper is interesting but could the Minister do some more work on the ground to find out whether what he is being told is actually happening in practice in local authorities?

[Lord O'Shaughnessy]

I thank my noble friend for that. I think it is a fair challenge. I hope he will be reassured that of the 21,000 more mental health professionals we intend to recruit, 1,700 are therapists—including psychotherapists, educational therapists and others.

[Lord Touhig (Lab)]

My Lords, 17 % of children excluded from school in England have learning difficulties. Will the review the Government are talking about take account of that and see whether we should be doing more, because it could well be a cause of children’s mental ill health?

[Lord O'Shaughnessy]

These are interconnected but separate issues. Anyone can suffer from mental health problems, including a high propensity of children with learning difficulties. A separate line of work led solely by the DfE is providing specific educational support for children with learning difficulties. The point of having specialist staff in all primary and secondary schools is to spot any child, whatever their vulnerability, and signpost them to services.

[Baroness Hollins (CB)]

My Lords, have the Government done any analysis of the numbers? My daughter is a child psychiatrist working particularly with younger children. She points out to me that there is little attention given to the needs of nought to two year-olds and their mental health in the Green Paper. We know that interventions are important in those early years. For the prevention of adverse childhood experiences and interventions after adverse childhood experiences, does the noble Lord consider it wise to ring-fence funds to support prevention and early intervention at that stage?

[Lord O'Shaughnessy]

The noble Baroness makes an excellent point about the importance of that age group. I will write to her giving the specifics of the support available to children and families with children of that age. A significant amount of funding is going into specialist perinatal and mental health services for mothers, which is a big part of the picture, but not the whole. Health visitors are being trained in mental health support. I will write to the noble Baroness with more details but I am sure there is more to be done.

[Baroness Wyld (Con)]

My Lords, have the Government made any analysis of the number of children living with parents who are suffering with mental illnesses more widely? Given the good projects that I have seen in primary schools, it is clear that this issue affects the whole family. It is not the child or the parents sitting in isolation but a family issue. I welcome the Green Paper but can we ensure that families know that it is for them to come forward, that they are in a safe space free of stigma, and that it is not just a child sitting in a box in a policy team?

[Lord O'Shaughnessy]

My noble friend is right. Some of the schemes that are already active in schools—I am sure she knows about and will have seen schemes such as Place2Be—not only provide support for children but invite families in to provide family therapy where it is required. It is rare that these issues are isolated; they often affect, in one way or another, all members of the family. That is what we are trying to do and deliver through the schools.

[Baroness Massey of Darwen (Lab)]

My Lords, I too welcome the Green Paper. Last November I conducted a seminar in Portcullis House of European parliamentarians, children, NGOs and academics. The most important thing there was the voice of the young people. Their concerns have been expressed already—joined-up thinking, early intervention and well-trained professionals. Does the Minister agree that these are important? Does he further agree that the voice of the child in all this is absolutely paramount?

[Lord O’Shaughnessy]

I know that the noble Baroness speaks with deep experience and passion on this subject and I completely agree; it is about making sure that those children’s voices are heard. We recognise that the picture of fragmentation described in the CQC report is not good enough and that is one of things we are trying to fix. It is a historic issue and it cannot be done overnight but we are working on it.

[Lord Storey (LD)]

My Lords, the awareness is very important. Will the Minister ensure that mental health awareness is part of teacher training and part of the qualification of special needs co-ordinators? I have to correct him: psychotherapists are not the same as school psychologists and there has been quite a substantial reduction in the number of school psychologists who are available and able to identify mental health problems.

[Lord O’Shaughnessy]

I will take the issue about the specifics of teacher training to colleagues in the DfE. I was talking about therapists in the broadest sense of the word: I think there is a recognition that we need more therapists of all kinds in all settings as we expand these services for young people.

Antimicrobial Resistance

Lord O'Shaughnessy Excerpts

Thursday 8th March 2018 Grand Committee

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

My Lords, I first thank the noble Baroness, Lady Greengross, and congratulate her on securing this debate on an incredibly important topic, which definitely performs above the graveyard slot it has been given on a Thursday afternoon. It has been a very useful and informative debate, and a good opportunity for us all to reflect on an important—indeed, vital—area of medicine and health, not least because it highlights the potential risks we face as humankind in dealing with this issue, but also to set out some of the things that are being done to deal with it. It is also worth our taking the opportunity to thank my noble friend Lord O’Neill, who is not here. In so many ways, the work that he has done has set the tone for the work that we are all doing together now. I will not rehearse the risks that have been set out very clearly by others, but I think a word the noble Baroness, Lady Greengross, used was “unprecedented”, which is the scale of what we face if we do not get this right.

I thought it would be useful to rehearse a little of the action that the Government have been taking over the last few years—if nothing else, to emphasise the seriousness with which we take the issue. Noble Lords will know that the Chief Medical Officer used her annual report in 2013 to highlight the risk of antimicrobial resistance. Later that year, a five-year antimicrobial resistance strategy across human and animal health was published. Following that, my noble friend Lord O’Neill was asked to forward a globally facing independent review, which was published in 2016. That report produced the truly alarming figure we have heard of 10 million extra deaths a year, with a potential economic impact of $100 trillion. A very powerful point was made by the noble Baroness, Lady Suttie, namely that up to one-third of those statistics is driven by drug-resistant TB. I did not realise that until she said so. It is truly alarming, hence the focus on TB in this debate. AMR was also added to the national security risk assessment in 2015 as a tier 1 risk for our country: that is how important it is.

As for what the UK’s strategy includes, we have an acronym of the three Ps: prevent infection occurring in the first place; protect the antibiotics we have through good antimicrobial stewardship; and promote the development of new drugs, which, as noble Lords have said, is incredibly important.

On prevention, the noble Baroness, Lady Greengross, mentioned urinary tract infections. They are a huge driver of both the use of antibiotics and the development of antimicrobial resistance. There are very interesting, and very simple, things going on such as the good use of catheters, which can have a profound effect both on infection occurring in the first place and the knock-on impact on the benefit of the antibiotics that we still have now. All this work is underpinned by our world-leading R&D base in this country.

The Government’s response to the review by the noble Lord, Lord O’Neill, set out new ambitions, including halving healthcare-associated gram-negative bloodstream infections and inappropriate antibiotic prescribing by 2021. We welcomed the emphasis in the review on the use of diagnostic tests, which was brought to the fore by the noble Baroness, Lady Masham, in her speech.

I do not know whether noble Lords had a chance to see it, but only last week Public Health England published details of the modelling work it has done to look at inappropriate prescribing. The work found that, using a conservative approach, around 20% of current antibiotic prescribing is inappropriate, and therefore the ambition should be to reduce that by 10% from a 2016 baseline. Between 2012 and 2016, we had already reduced our use of antibiotics by 5%. Clearly, though, to some extent that was the low-hanging fruit, and now we need to take on the more difficult areas. In doing so—I think back to debates we have had about wound care and sepsis—we must never forget that these drugs are vital. Although we want to reduce inappropriate prescriptions, we also have to make sure that people who need them are not being restricted access to them. It is not just about gram-negative bloodstream infections but other health-acquired infections. I was sorry to hear the story of my noble friend Lord Colwyn’s brother. That shows the horrible impact that can happen.

I have talked mainly about humans but, as other noble Lords have pointed out, we also need to set an ambition to reduce antibiotic use in livestock and fish farmed for food. The good news is that we have met our ambition two years early: sales of antibiotics for use in food-producing animals dropped by 27%. In answer to the noble Lord, Lord Hunt, that is good progress. Perhaps it is an answer to the noble Baroness, Lady Suttie, about whether awareness campaigns work: it is evidence that they do. New sector-specific targets were published in October 2017 and we will be reporting against them in the months to come.

As all noble Lords pointed out, AMR is ultimately a global issue. This Government helped to secure the UN declaration on AMR in September 2016. We are committed to working not just with the global health community but with the finance community to create a system that rewards companies that develop new, successful antibiotics and, critically, make them available to all who need them.

Noble Lords will, I hope, know that the UK has been a leading advocate at the G20 for the piloting and rollout of global solutions that incentivise new antibiotic development. We continue to promote the need for global action. Noble Lords will also be aware that our Chief Medical Officer is a driving force in these efforts; she really is a wonderful and zealous advocate of this agenda. They will also know that she is totally unbending in her desire to keep this at the top of the global agenda.

AMR is embedded in all relevant strategies, particularly the sustainable development goals agenda. I also want to point out that the UK has helped to create the Fleming Fund, which is a £265 million commitment over five years, as a development project dedicated to AMR globally. It focuses on increasing capacity and capability for diagnosis and surveillance of AMR in low and middle-income countries. The noble Baroness, Lady Sheehan, made a very important point that the people who are most likely to suffer from the consequences of AMR, although spread across the world, are focused on those communities that are likely to be the poorest.

Noble Lords have asked about that incentivisation and pulling through the new drugs. There is the £50 million Global AMR Innovation Fund, which looks to develop neglected areas. The noble Baroness, Lady Sheehan, asked about China; a new partnership is soon to be launched on that although I do not have details now. When I do, I will certainly write to her. In the UK, we are channelling investment through the National Institute for Health Research, Research Councils, Innovate UK and so on to attract high-quality research proposals. As the noble Baroness, Lady Greengross, said, there is some cause for cautious optimism on drug development in this area. Not only do we need to get the drugs developed but we need to find ways to pull them through. My noble friend Lord Colwyn talked about the accelerated access pathway; that could be one route by which these drugs come through.

I want to spend a little time talking about vaccination, because it has been mentioned by all noble Lords. I absolutely agree that it is an important part of reducing the need for antimicrobials and a key weapon in slowing down antimicrobial resistance. We have a world-class vaccination service that reduces the overall burden of disease in this country. Uptake is among the best in the world: about 90% of the population get childhood vaccines, for example. However, it is fair to say that we need to do better, not only in making sure—in this era of fake news—that rumours and false information about the dangers from vaccines are firmly rebutted, but in using every opportunity and channel we have to promote the uptake of vaccines in families and other groups. That is something that the health family, as we sometimes describe it, is working on, to better understand local variation; there is huge variation from area to area, as pointed out by the noble Baroness, Lady Greengross.

It is worth saying that, from an R&D perspective, we have a great strength in this country in the development of vaccines. It was a major focus of the life sciences industrial strategy. Research Councils have just invested just over £9 million in five new vaccine networks, and the Government have invested £100 million in focusing on vaccines of epidemic potential. A lot is being done but, as noble Lords have pointed out, the task is growing because antimicrobial resistance is growing.

Specifically on pneumococcal immunisation, our expert group—the Joint Committee on Immunisation and Vaccination, as noble Lords will know—has been consulting on its advice on the number of doses. It would not be appropriate for me to pre-empt that decision at this stage. My honourable friend in the other place, the Minister for Public Health and Primary Care, will, of course, give its advice due consideration, but I will pass on the concerns that have been expressed in this debate about that, so that they understand—as we do—that there is deep concern about any dilution of our vaccination programme.

I want to quickly deal with the issues I have not dealt with. My noble friend Lord Colwyn asked whether the AAP will focus on antimicrobials. It will suggest a new suite of products in April. I have tried to leave the expert group to it; it will come to us, but that is certainly a route forward, and I would be happy to meet with the company that he mentioned to talk about its work.

The noble Baroness, Lady Suttie, asked about the UN high-level meeting, which marks an important moment to secure a political commitment to TB control. She will be pleased to know that the Government are engaging closely with the WHO and taking a lead on that. There is some benefit coming from raising awareness, but clearly there is more to do to ensure that the UK is fully engaged. On the development of new anti-TB drugs, DfID is contributing to the Global Alliance for TB Drug Development, which I hope is to some extent a reassurance that we are playing our part.

I should congratulate the noble Baroness, Lady Masham, who is a woman of many firsts. She led the first debate on the issue of MRSA in the House. We have made some really good progress on controlling MRSA and C.diff in hospitals but, of course, that is the only part of controlling infection. We are making some progress and better diagnostic techniques now exist. She also asked about the diagnosis of TB. I made a fascinating visit to a Find & Treat service in Camden which was doing on-street work. Unfortunately, it is one of only a few services of this kind, and we certainly need to do more of that sort of work.

Finally, the noble Baroness, Lady Sheehan, asked about the Rohingya community. I am not familiar with those issues, but I shall certainly take her concerns to DfID and I understand the seriousness of them.

The final and very major point to make is to ask how we break the link between price and the cost of drug development, which was raised by the noble Lord, Lord Hunt, and the noble Baroness, Lady Sheehan. The truth is that this is not an issue that faces drug development in this area alone; it concerns drug development in every area, as drugs and medicine become more stratified. The answer lies in partnership but, to be honest, we do not yet have the model for doing that. However, we are developing it, and we have a good relationship with industry to help us to do that.

In conclusion, once again I thank the noble Baroness for initiating this fantastic debate and all noble Lords for their contributions. I think that we are making good progress, but there is a long way to go. The lodestar here is Sweden, which has succeeded in reducing antibiotic use by 40%, although it has taken the country 20 years to do that. We are a few years down the track in the process, and I hope that we can learn from Sweden and others to accelerate our progress. I finish by wishing to make sure that noble Lords understand that keeping antibiotics working lies at the heart of the Government’s strategy, and our job is to keep the issue at the forefront of everyone’s mind.

Committee adjourned at 5.52 pm.

Nurses: Training

Lord O'Shaughnessy Excerpts

Wednesday 7th March 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what specific proposals they have to increase the number of fully trained nurses working in the National Health Service and the associated care services.

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

My Lords, there are record numbers of nurses working in the NHS in England, including 13,900 more acute, elderly and general nurses. To increase the future supply of registered nurses, the Government are funding over 5,000 more student nursing places for those entering training each year from September 2018. We are opening up new training opportunities to increase the number of professionally qualified nursing staff across the health and social care workforce through the apprenticeship route.

[Lord Clark of Windermere (Lab)]

I thank the noble Lord for his reply, but I do not think the Government really grasp the seriousness of the shortage of nurses. In the last two years, 33% fewer students came forward. We have a shortage of 40,000 nurses and it will take years to put that right. Can I make a suggestion to him? The best and quickest way to increase the number of trained nurses is for the Government to drop their opposition to the bursary scheme for postgraduate students. These two-year courses are cheaper; it would cost the average funder £33,500 for the two-year course, which is half as much as the average trust would pay simply to employ an agency nurse for a year to fill the gaps. Why will the Government not follow that route?

[Lord O'Shaughnessy]

My Lords, we take very seriously the need to train more nurses. There are 52,000 nurses in training and, as I have said, there is a commitment to increase the number of training places by 25%, which is obviously how we get to a long-term solution. On the issue that the noble Lord has raised about postgraduate bursaries, the policy intention is to bring these courses in line with other courses. I know that this is an issue of great concern. The Royal College of Nursing has expressed its concerns and we take those seriously. I also know that the regulations have been prayed against in the other place; they are also being looked at in the Secondary Legislation Scrutiny Committee and we await its report. I reassure him that the issue is being considered and we will respond once the committee has reported.

[Viscount Hailsham (Con)]

My Lords, as someone who is frequently involved in regulatory work involving nurses, I ask my noble friend what is being done to ensure a proper standard of clinical performance and a proficiency in languages on the part of nurses trained abroad and, most especially, on the part of those trained outside the European Union.

[Lord O'Shaughnessy]

I thank my noble friend for highlighting that important issue. A very stringent language test is imposed by the Nursing and Midwifery Council—indeed, it is perhaps so stringent that it has excluded some nurses who are perfectly capable of practising in this country. A review of that is going on at the moment to make sure that a proper line is drawn—ensuring professional competence, including in technical language, while not excluding people who would be perfectly capable of practising well in this country.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that the vacancy rate for nurses in social care settings has doubled over the last four years? Given the other pressures on nursing homes, will the Government take specific action—perhaps grants for placements—to relieve this problem, which the NAO has described as dangerous?

[Lord O'Shaughnessy]

The noble Baroness has highlighted an important issue, which is the number of nurses in social care. I recognise that to be a problem, as does the department. A specific social care workforce consultation will get under way and is linked to the overall draft workforce plan that Health Education England has published. This is something that we are looking at. We can solve it to some extent by increasing the overall number of nurses, but we need to find ways of attracting them into the social care profession.

[Lord Patel (CB)]

My Lords, does the Minister agree that the lack of NHS nurses and other healthcare workers is due to the lack of a long-term sustainable workforce plan, as identified by the House of Lords committee report? If, following that report, the Government now have a long-term workforce plan for the NHS, when might it be published?

[Lord O'Shaughnessy]

I congratulate the noble Lord on his committee’s work in this area and on making a proposal, which we have followed in putting forward a 10-year draft plan. I hope that he will have had the chance to see that—it will of course firm into a concrete plan. It is fair to say that it is honest about both the successes and the challenges that we face in needing to train more nurses. We are trying to find new ways of doing that, not just through the university route but through apprenticeships.

[Lord Bassam of Brighton (Lab)]

My Lords, yesterday evening I went home and turned on my local news to find that the Royal Sussex County Hospital was calling on people who might otherwise use its services to keep away. The hospital has some 900 vacancies. How can the noble Lord come to the Dispatch Box and tell us about the wonderful figures that suggest that all is well and good in the health service regarding nursing vacancies, when the reality on the ground is somewhat different? My local hospital is facing a crisis.

[Lord O'Shaughnessy]

I do not pretend that all is well and good; I merely state what has happened. We know that there are challenges from increasing demand in the health service. We need more staff, which is why we are committed to training more staff. Unfortunately, I am not in a position to comment on the challenges of the noble Lord’s trust but I will be delighted to look at them with him. However, as we know, there is more demand and we have an ageing population. We need more staff and we are trying to train those staff.

[Baroness Rawlings (Con)]

My Lords, I declare an interest which is not in the register. One of my first jobs was as a VAD nurse, which some of your Lordships might remember—it was a long time ago. What do the Government think of bringing back VAD nurses, or, as they are called today, auxiliary or volunteer nurses, to help in the nursing crisis?

[Lord O'Shaughnessy]

I thank my noble friend for that question. I think that we need to diversify the routes into nursing and this is probably how we do it. One way in which that is happening is through the creation of nursing associates, which is a level 5 apprenticeship programme. To be clear, these are not nursing positions—they are not registered nurses—but they provide an opportunity for those who have a desire to get into that career and want to learn on the job but who do not yet have the skills to start working towards a full-time registered nursing position.

Emergency Hospital Admissions

Lord O'Shaughnessy Excerpts

Wednesday 7th March 2018 Lords Chamber

[Lord Bird]

To ask Her Majesty’s Government what steps they are taking to reduce and prevent avoidable emergency hospital admissions.

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

My Lords, NHS England and NHS Improvement are implementing a number of national programmes to transform NHS services so that, where clinically appropriate, a patient’s care is managed without the need for a stay in hospital. This is being achieved through services becoming better integrated across health and social care, as well as managing hospital care differently, so that more patients are treated as day patients in A&E or streamed to see a general practitioner.

[Lord Bird (CB)]

I thank the Minister for that Answer. The recent report of the National Audit Office stated that nearly 25% of people who go into hospital do so in an avoidable situation, which could be sorted out in the community. This is a clear case of why we need more prevention. What extra thinking and resources will the Government bring into the community so that we do not have the ridiculous situation of such people going into hospital, where we have the problem of a shortage of nurses and all the other things that knock on?

[Lord O’Shaughnessy]

The noble Lord makes an important point. It was good to study the report and the noble Lord is right about avoidable hospital admissions. Two changes are happening. One is GP extended access, which now has 95% coverage across the country—that is, evenings, weekends and so on—as primary care. We also have interesting results coming from the new models of care programme. I highlight one that is happening in mid-Nottinghamshire. It is called PRISM and it is a virtual ward for at-risk patients which enables multidisciplinary teams to look at vulnerable people before they come to hospital. It has reduced A&E attendance for those aged over 80 by 17%, which is significant. It is precisely this kind of thing that will make the difference that we need.

[Lord Brooke of Alverthorpe (Lab)]

Is the Minister aware that in 2016-17, 30% of admissions to A&E of people aged 65 and over were alcohol-related? Is he further aware that, given the need for the services of psychiatrists to look after those people, training for psychiatrists has reduced dramatically in the past 10 years and we have no facilities available to look after them? Turning to a longer-term public health policy, when will the Government do something about the increasing number of people going into hospital due to alcohol problems?

[Lord O’Shaughnessy]

It is now the case that thousands of GPs and hospital staff have been trained to screen for the signs of alcohol abuse and to provide intervention. So not only are there dedicated staff and dedicated public health programmes, but hospital and primary care staff have now been specifically trained to look for the signs and to signpost people to care when they need it.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that one of the causes of the recent pressure on acute hospital beds is that young people and children who are waiting for scarce specialist mental health beds are frequently put into inappropriate adult wards because there is no room for them anywhere else? Would the Minister look into that again?

[Lord O’Shaughnessy]

I thank my noble friend for making that point. Unfortunately, we have a growing prevalence of the kind of mental illness he is describing. We are in the process of increasing the number of in-patient beds available for young people going through those kinds of episodes. That is the right thing to do. It means that they will not have to travel so far from their homes and has the benefit of relieving the impact on adult acute beds.

[Baroness Finlay of Llandaff (CB)]

Is the Department of Health and Social Care, in conjunction with NHS England, monitoring the completeness of 24/7 nursing coverage in the community? Even though the pilots, which will have a virtual ward, will help determine the most vulnerable patients, those patients will still need hands-on nursing at the time they need it. If it is not available, they will inevitably end up being transported to hospital.

[Lord O’Shaughnessy]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord O’Shaughnessy]

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

[Lord Rennard (LD)]

My Lords, does the Minister accept that part of the problem with emergency hospital admissions is the difficulty people have in accessing their GPs? Some of this is perhaps because of the high levels of stress among GPs, but there is also recent evidence suggesting that it is because of the £1 million pension cap imposed on GPs, which means many more of them are retiring before the age of 60. Surely, in the interests of the NHS, this particular cap should be looked at again.

[Lord O’Shaughnessy]

Although the number of early GP retirements has been rising, the number of total GP retirements has been falling, which is encouraging. It is also important to point out that, while the pension cap obviously applies to everybody, it has not had the impact that the noble Lord described on dentists or consultants, so there is something more to it. It is to do with how GP services are structured and providing support for that partnership model. That is what we are trying to do at the moment.

General Practitioners: Workforce

Lord O'Shaughnessy Excerpts

Monday 5th March 2018 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I refer to my registered interest.

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

My Lords, in the 2016-17 pension scheme year, 721 GPs took early retirement, representing 62% of all GP retirements. However, it should be noted that many GPs who take their NHS pension then return to service. Early retirement does not necessarily mean a loss of skills and experience to the NHS. We recognise, however, the need to increase the general practice workforce, which is why the Government remain committed to delivering an additional 5,000 doctors working in general practice by 2020.

[Baroness McIntosh of Pickering]

My Lords, we appear to be in a vicious cycle of doctors retiring early and then coming back and working part-time and fewer EU doctors coming to work here. What can my noble friend do to increase the number of doctors wishing to enter GP practice as opposed to other specialties, and what will the certification procedure be for EU doctors to be recognised as doctors to practise post Brexit in this country?

[Lord O’Shaughnessy]

I thank my noble friend for her question. It is interesting to note, looking at the figures, that the total number of retirees from general practice has been falling in recent years, which is very welcome, even though in the past few years there has been an increase in the number taking early retirement. As for entering general practice, that is how we need to get more GPs. The number of training places has increased to a record 3,250, which is an 18% increase over the past three years. Finally, on certification, mutual recognition of professional qualifications is of course a matter for negotiation as part of our future relationship with the EU. However, I can tell my noble friend that the Government are committed, under whatever circumstances, to recruit 2,000 international GPs in the coming years.

[Baroness Thornton (Lab)]

My Lords, I declare an interest as a lay member of a CCG. GPs are indeed retiring before the age of 60; in fact, last year, twice as many retired as three years ago. More GPs are leaving the profession than are joining it, and soaring numbers of junior doctors are leaving the NHS after their two-year foundation training. How do the Government intend to fill the failing pipeline of junior doctors, and would the Minister care to speculate why there is a flood of departing junior doctors right now? Could it be due to junior doctors’ rock-bottom level of morale after their shabby treatment by the Secretary of State?

[Lord O’Shaughnessy]

The noble Baroness might be interested to note that in 2014, the number of GPs in specialty training was 2,671, and in 2017, it was 3,157—an increase of nearly 400. That is how we are filling the places.

[Lord Carlile of Berriew (CB)]

Is the Minister aware of the increasing number of inner-city general practices where the entire GP workforce consists of locum doctors because of recruitment problems? Does he agree that that is an expensive way to provide GPs, and one which diminishes the doctor-patient relationship?

[Lord O’Shaughnessy]

I agree with the noble Lord: we need to crack down on agency and locum spend. That has been falling in recent years. The way we will fix this issue and the demand for general practice in a sustained way is to increase the number of GPs coming into the service, and, as I said, that is exactly what we are doing.

[Baroness Jolly (LD)]

My Lords, there should be a move to recruit newly-qualified doctors to general practice and to prevent GPs retiring earlier and earlier, but that is not as easy as it sounds. Can the Minister therefore tell the House what work has been done to enable job-sharing, so that part-time GPs balancing a family life can partner with older GPs who want a less full-time commitment?

[Lord O’Shaughnessy]

I shall have to write to the noble Baroness with the specifics on GP flexibility. However, one of the reasons that GPs take early retirement to take advantage of their pension is that it enables them to work flexibly afterwards.

[Baroness Redfern (Con)]

My Lords, regarding the workforce, having pharmacists in GP practices means that GPs can focus their skills where they are most needed: diagnosing and treating patients with more complex needs. Does the Minister agree that this not only helps GPs manage demands on their time but helps to ease their workload, while patients have the convenience of being seen by the right professional, improving quality of care and ensuring patient safety?

[Lord O’Shaughnessy]

My noble friend is absolutely right. As well as our commitment to increase the number of GPs by 5,000, we also have a commitment to increase the number of GP practice staff by 5,000, including 1,500 pharmacists, who provide exactly the kind of support she outlined.

[Lord Turnberg (Lab)]

My Lords, one of the reasons why general practice is less attractive than it used to be is because of the enormous bureaucratic load that is placed on GPs nowadays. They have to sit on committees and on CCGs, and they rush around doing non-clinical work. Is there any way to reduce this non-clinical workload?

[Lord O’Shaughnessy]

That is an important issue. We know that workload is a problem. I point the noble Lord and other noble Lords to NHS England’s 10 high-impact actions. These are actions which all GP surgeries can take; for instance, using technology such as e-booking and e-prescribing to reduce the kind of workload he is talking about.

[Lord Forsyth of Drumlean (Con)]

My Lords, does my noble friend not acknowledge that one reason that GPs are retiring after the age of 55 is that their salaries are such that their pension exceeds the limit, which the previous Chancellor reduced from £1.8 million to £1 million, and they find themselves having to pay tax on their pension contributions at 55%? Would not the simple solution be to raise the threshold, thereby allowing GPs to continue in practice and not be taxed on their pension contributions unfairly?

--- Later in debate ---

[Lord O'Shaughnessy]

My noble friend is quite right—there has been anecdotal evidence that that is the case. Of course, any policy changes are well above my pay grade, but I should point out that that does not seem to have affected early retirement among dentists and consultants, so it is possible that another critical factor is at work.

[Lord Patel (CB)]

My Lords, it is suggested that part of the reason for the failure of junior doctors to be recruited as GPs is the nature of GP contracts, which treat them as independent contractors. I know that several are now employed as salaried doctors, but do we have figures for how many salaried GPs, as opposed to principal general practitioners, are employed by the NHS?

[Lord O'Shaughnessy]

That is an evolving model, as the noble Lord has pointed out, and I will write to him with the exact figures. The partnership model has an enduring popularity and importance, which is why the Secretary of State has asked for a review of it. However, as we see new models of care develop, I am sure that salaried GPs will become more of a feature of the system.

[Lord Roberts of Llandudno (LD)]

My Lords, many refugee medical trainees are coming over. Is there no way that we could help them finish their medical courses and then deploy their skills in this country before it is safe for them to return to their country of origin?

[Lord O'Shaughnessy]

The noble Lord has asked that question before. He will be pleased to know that there is specific help for refugees and others through waiving fees for language courses and other elements of the professional qualification process, and we can bring those into practice as soon as possible.

Alcohol: Minimum Unit Pricing

Lord O'Shaughnessy Excerpts

Wednesday 28th February 2018 Lords Chamber

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

My Lords, data from the Sheffield University alcohol policy model in 2015 estimated that, in 10 years, minimum unit pricing could on an annual basis reduce alcohol-related deaths by 356, alcohol-related hospital admissions by 28,515, and crime by 34,931 crimes. Minimum unit pricing remains under review and the Government will consider the evidence of its impact once it is available.

[Lord Rennard (LD)]

My Lords, figures issued today by the Institute of Alcohol Studies suggest that, for each hour worked, it is possible to buy three times as much supermarket beer as was the case 30 years ago. Given the statistics which the Minister cited from the University of Sheffield, is it not urgent that we act to prevent the sale of perhaps four cans of beer in a supermarket for as little as £1?

[Lord O’Shaughnessy]

As I said, the Government are looking at this issue and, following the Supreme Court judgment, the Scottish Government can move ahead with their plans. The issue is not about the lack of evidence on whether reducing drinking has health benefits, but about making sure that any new system is implemented in a way that is fair on those who drink sensibly, particularly those on low incomes. The approach we have taken up to now is to use the tax system judiciously, including high duty levels for drinks such as white cider. As we move ahead and look at the evidence, we have to consider not just the health benefits but the economic costs that could be imposed on perfectly sensible drinkers.

[Lord Ribeiro (Con)]

My Lords, liver disease, unlike cancer, is the only major cause of premature death that has increased since 1970. As the Minister rightly says, the Scottish Government have this week introduced minimum unit pricing. Would the Minister be willing to meet me and the chairman of the Alcohol Health Alliance to discuss what we in this country can do to follow the Scottish lead?

[Lord O’Shaughnessy]

I would be very happy to meet my noble friend and the colleague he mentioned.

[Baroness Watkins of Tavistock (CB)]

In terms of austerity, can the Minister justify neglecting the £3.2 billion cumulative reduction in alcohol-related harm over five years that the Public Health England evidence review into the policy cites with an MUP of 60p? That is what would be generated.

[Lord O’Shaughnessy]

As I have said, and reiterate to the noble Baroness, we will look at the impact of minimum unit pricing. We must not just take into account any revenue that we generate and the health benefits that could accrue, but make sure that it provides a fair deal for those who drink sensibly.

[The Lord Bishop of Southwark]

My Lords, the report of the University of Sheffield referred to earlier said that the top 30% of drinkers consume 80% of all alcohol consumed, as measured in pure ethanol; and that, of the beer sold in supermarkets, a disproportionately high amount is sold on promotion—and much of that well below 50p per unit. Does the Minister agree that a floor in the unit price of alcohol would help to yield a more orderly, content and healthy society by bearing down on demand?

[Lord O’Shaughnessy]

The statistic mentioned by the right reverend Prelate is in a way even more alarming because 4.4% of the heaviest drinkers account for a third of all alcohol drunk. A lot of people are drinking sensibly, within the guidelines. We need a system capable of targeting those who are sensitive to both price and health interventions, among those drinking in a way that is very deleterious to their health. We are doing that for a range of interventions—public health and taxation. As I said, we will look at the progress of minimum unit pricing in Scotland as it takes place.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, has not the Minister just made the case for minimum unit pricing? Could I remind him to cast his mind back to all the arguments advanced by his side against changes to tobacco and smoking—that everybody was going to be hurt by it if we increased the price? We had to increase the price for the benefit of everyone, and the same now applies to alcohol. All the evidence that he is getting from all his senior medical advisers is that he should introduce a minimum unit price. Why will he not move on this?

[Lord O'Shaughnessy]

I do not recognise the picture of obstruction about tobacco and smoking. This Government have done a huge amount, and smoking levels have never been lower. In terms of increased pricing, history tells us, if you go back hundreds of years—think about “Beer Street” and “Gin Lane”—that taxation has a really important role to play in promoting better drinking habits. That is the approach that we have taken with changes in duty for drinks that are particularly problematic, such as white cider. As I have said, we will look at how minimum unit pricing in Scotland progresses.

[Baroness McIntosh of Pickering (Con)]

Is the Minister aware that Scotland has banned or tried to reduce BOGOF—buy one get one free—at supermarkets? That is the evidence that we heard on the ad hoc committee, which I had the honour to chair, on the scrutiny of the Licensing Act 2003. Changing behaviour is a good way forward, rather than the potentially regressive tax of MUP.

[Lord O'Shaughnessy]

My noble friend speaks with great wisdom about making sure, not just with alcohol but with other health issues around food and drink, that we have a look at making those kinds of promotions not possible.

[Baroness Jolly (LD)]

My Lords, the Minister has acknowledged that the evidence is absolutely there and that he will look at it in the near future, but when might a decision be made? How long does he need the Scotland experiment to last before he actually makes a decision?

--- Later in debate ---

[Lord O'Shaughnessy]

The evidence is there, and it is strong—but there is disputed evidence. The coalition Government carried out a consultation in 2013 and found that the evidence was not entirely conclusive. However, we will have a live experiment going on in Scotland, and we expect in two to three years to see evidence of its impact.

National Child Obesity Strategy

Lord O'Shaughnessy Excerpts

Monday 26th February 2018 Lords Chamber

[Baroness Benjamin (LD)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare an interest as the co-chair of the All-Party Group on a Fit and Healthy Childhood.

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

My Lords, all reports and data published on progress in delivering our childhood obesity plan will be open to scrutiny. This includes all research evidence produced by the Obesity Policy Research Unit, which will be published as projects are completed, and Public Health England’s assessment of progress on sugar reduction, which will be published in the spring. We will use this to determine whether sufficient progress has been made and whether alternative actions need to be taken.

[Baroness Benjamin]

I thank the Minister for that Answer but five year-olds are now eating their own body weight in sugar every year. Obesity is the second-largest cause of cancer and it reduces life expectancy by up to 10 years. Voluntary action cannot combat the obesity epidemic that the country faces. What is needed are mandatory reformulation targets for reductions in added sugar, fat and calories across all products, as well as common-sense policies directed at early years, which includes oral health initiatives. Can the Minister confirm that there will be a more robust mandatory element in future stages of the national obesity strategy?

[Lord O’Shaughnessy]

The noble Baroness is right to highlight the importance of this issue; we have seen more research today highlighting not just the prevalence of obesity among younger people but the catastrophic health risks that attend that. I would say, though, that the actions in the obesity plan—including the reduction of sugar by 20% by 2020, with a 5% interim target, and the sugar levy—have led to serious action. Fifty per cent of the drinks that would otherwise have been captured have now reduced their formulation, so we have seen action. We will see in the spring the evidence of whether that has had the desired effect and if it has not, we have left all options open to take further action if required.

[Baroness Wyld (Con)]

My Lords, health visitors play a key role in helping parents to tackle and prevent obesity. Is my noble friend the Minister confident that all health visiting teams have the resources and the support they need to do this?

[Lord O’Shaughnessy]

My noble friend is absolutely right and as the noble Baroness, Lady Benjamin, said, it is about getting into families when children are young. My noble friend will I think be reassured, as I hope the House will, to know that not only are there more health visitors than ever but, as part of that, we have a healthy child programme looking at the prevention and identification of obesity. Health visitors are trained in critical elements such as promoting breastfeeding, nutrition and physical activity to encourage healthy babies.

[Baroness Massey of Darwen (Lab)]

My Lords, have geographical variations been taken into account in the strategy? For example, London has much higher levels of child obesity than the rest of the country.

[Lord O’Shaughnessy]

Health inequalities and their reduction are a core part of it and in talking about them I would focus, to pick one example, on breakfast clubs. We know that having a good-quality breakfast—indeed, having any breakfast as some children go without it, which causes problems, too—is important. About £26 million is being spent on extra breakfast clubs in 1,500 schools in opportunity areas and disadvantaged areas.

[The Countess of Mar (CB)]

My Lords, does the Minister consider that there is an elephant in the room? There are thousands of endocrine-disrupting chemicals that children and young people have been exposed to since they were in the womb. Nobody seems to be looking at the effects of endocrine disruptors on appetite and obesity.

[Lord O’Shaughnessy]

I must confess that I am not completely aware of the specific issue which the noble Countess talks about. I think I will have to write to her. It may be something that our obesity research unit can have a look at.

[The Lord Bishop of Durham]

My Lords, the relationship between childhood obesity and poverty is well evidenced. In the light of warnings by the Children’s Society and others that 1 million children in poverty will miss out on a free school meal under the current proposals for changes to entitlement under universal credit, does the Minister agree that all children in poverty should receive a free school meal to combat child malnutrition by ensuring that they receive a healthy meal at lunchtime?

[Lord O’Shaughnessy]

We have a free school meal policy in this country. Indeed, the previous Government introduced free school meals for all children up to the age of seven, I believe, so we have made a significant impact in this area. I talked about breakfast clubs, which will also help, particularly disadvantaged children.

[Baroness Brinton (LD)]

My Lords, the salt reduction strategy worked particularly well because all supermarkets came together and followed it. Two years ago, Sainsbury’s chief executive asked the Government to introduce compulsory targets for sugar reduction, but we have not seen them yet. After the first year of the sugar tax in Mexico, there was a 17% reduction in purchases by poor people and a 12% reduction across the board. It works. If the supermarkets want it, why will the Government not follow?

[Lord O’Shaughnessy]

We are making good progress in reformulation and in reducing sugar in drinks, which I have talked about, and in other foods. However, we have to look at the impact. We will look at that and if progress is not made—let us face it, obesity levels are unfortunately continuing to increase—clearly other actions will have to be taken.

[Baroness Jenkin of Kennington (Con)]

My Lords, last year I chaired the Centre for Social Justice’s childhood obesity report. Until then, I had not appreciated how challenging and complicated it is, not least to keep representatives from the food industry and food campaigners in the same room. Amsterdam’s healthy weight programme has helped to reduce childhood obesity by 12% since its launch in 2012. Will my noble friend confirm that the Government are studying carefully how that reduction has been achieved?

[Lord O’Shaughnessy]

I thank my noble friend for that and applaud the work that she has done in this area. The Amsterdam effect seems significant and is an area we are looking at as we consider further actions in future.

[Lord Watts (Lab)]

Does the Minister agree that it would be a good idea to reintroduce domestic science into all schools so that people have a better mechanism for preparing and eating more quality foods than fast foods?

[Lord O’Shaughnessy]

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

[Lord Hunt of Kings Heath (Lab)]

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

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

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

[Lord O’Shaughnessy]

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

NHS: Waiting Lists

Lord O'Shaughnessy Excerpts

Monday 26th February 2018 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government what plans they have to reduce the waiting lists for consultant-led NHS treatment; and to what timetable they intend to carry out such plans.

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

My Lords, the joint NHS England and NHS Improvement plans for 2018-19, published on 2 February 2018, set out how £1.6 billion of funding announced in the Autumn Budget will be spent on additional elective surgery as well as ensuring that the four-hour A&E waiting times standard is met. The guidance refreshes two-year plans already in place to improve waiting times performance.

[Baroness Thornton (Lab)]

I thank the Minister for that Answer. Waiting lists at the end of November 2017 stood at 3.72 million. The head of NHS England, Simon Stevens, says that at present waiting lists will grow to 5 million by 2021, and the Minister’s Answer is inadequate in solving that problem. Does he agree with the findings of the Royal College of Physicians research that shows among other things that 45% of advertised consultants’ posts remain unfilled, 82% believe that the workforce is demoralised and 74% are worried about their ability to deliver safe patient care in the next 12 months? What are the Government’s plans to deal with this crisis in an NHS that is underfunded, underdoctored and overstretched?

[Lord O'Shaughnessy]

It is absolutely our goal and obligation to return to the referral-to-treatment standard. It is worth pointing out that the NHS has been dealing with an annual growth in demand of around 4%, which is extraordinary when looked at historically. What we have seen in the plan set out a few weeks ago are important steps to get a grip on that, including halving the number of 52-week waits, halting the growth in the waiting list and delivering more every year. Clearly that is an interim step and more needs to be done; the way to achieve that is by continuing to provide real-terms increases, which we have done and will continue to do, and by dramatically increasing the number of staff in the NHS, which again we have done. We have also increased the number of training places.

[Lord Patel (CB)]

My Lords, does the Minister agree that imposing a mandatory time of up to 16 weeks for elective surgery, as it has recently been reported that many clinical commissioning groups are doing, is wrong, and that how long a patient should wait for elective surgery needs to be a clinical decision?

[Lord O'Shaughnessy]

The length of time to wait should always be a clinical decision; I completely endorse that. CCGs have responsibility to manage demand according to local needs, but in the end, it must be a clinical decision.

[Lord Bassam of Brighton (Lab)]

My Lords, in a written reply to me, HL 5459, the Minister said that vacancy data was not available for doctors, nurses and consultants in hospital trusts in Sussex, Surrey and Kent, whereas local recruitment advisers suggest that there is a real crisis. Why cannot the human resources element of the National Health Service provide that basic data? As the noble Lord seemed to acknowledge earlier, our chances of our reducing waiting lists are much lessened if we cannot understand where the vacancies are and put people in those jobs.

[Lord O'Shaughnessy]

Vacancy data is available. If it was not available on the particular footprint that the noble Lord asked for, I would point him in the direction of data published last week by NHS England on vacancies, which is always a topic of much interest in this House. Over the past three quarters, that shows a slightly improving picture, but clearly there is a lot more to do.

[Baroness Jolly (LD)]

My Lords, under the NHS constitution, no patient should have to wait more than 18 weeks for any treatment. However, there are no specific national standards for waiting times for CAMHS patients, only guidelines, except for under-18 year-olds with psychosis and those treated in the community for eating disorders. What proportion of those CAMHS patients are seen within the agreed times, when does the Minister expect we will see a significant improvement and is sufficient funding earmarked to achieve it?

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight this issue. There simply are not equivalent waiting times for CAMHS. As she mentioned, we have introduced the first waiting times for eating disorders and early intervention in psychosis. I think she will have been pleased to have seen in the Green Paper published before Christmas that a new four-week waiting time for NHS children and young people’s mental health services will be piloted. That will be rolled out in the near future.

[Lord Reid of Cardowan (Lab)]

My Lords, in the eight years before 2010, waiting lists and waiting times were brought down dramatically. In the eight years since 2010, waiting times and waiting lists have risen dramatically. What does the Minister think happened in 2010 to change that?

[Lord O'Shaughnessy]

I think we all know what happened in 2010, but it might be worth pointing out that 10 years ago, half of patients waited more than 18 weeks for referral to treatment and that is now only about 10%.

[Baroness Finlay of Llandaff (CB)]

My Lords, given that many consultants report feeling demoralised and worn down by constant pressure from the number of clinical problems they are dealing with and the administrative pressures that they find themselves under, what discussions have the Government had with NHS England, and what discussions has NHS England had with trusts, on ways that consultants and their teams could have better administrative support and better ways to achieve upgrades in equipment that they may need to undertake specialised procedures? At the moment, they are having to apply and reapply for funding, which wears them down and takes away from clinical time.

[Lord O'Shaughnessy]

I shall write to the noble Baroness on what NHS England is doing about the specific issue. I think her real point is about morale. We know that NHS staff do an incredible job under a great deal of pressure, dealing with that rising demand. We are doing two things to try to alleviate that situation. One, which we have talked about, is increased numbers coming through training so that we can increase staffing. The other is pay. Getting rid of the pay cap and allowing for an Agenda for Change pay increase is a good way of saying thank you to those staff.

[Baroness Hussein-Ece (LD)]

My Lords, in response to my noble friend Lady Jolly on child and adolescent mental health services, the Minister talked about reducing waiting times for young people and children to see a clinician as something to be addressed “in the near future”. He must appreciate that for children and young people, time is of the essence to get treatment before the situation becomes acute and they reach a crisis. Could he not give a more satisfactory answer on that question?

--- Later in debate ---

[Lord O'Shaughnessy]

I said that only because I cannot give specifics and I do not want to hold out false hope. I can say that the Government are providing £1.4 billion extra so that another 70,000 children are seen every year. I think that is extremely welcome. Piloting a waiting time standard is all about making sure that we can reach the right clinical standard.

NHS: Charitable Donations

Lord O'Shaughnessy Excerpts

Thursday 22nd February 2018 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government, further to the Written Answer by Lord O’Shaughnessy on 20 December 2017 (HL4078), why they have no plans to provide patients with the costs of their treatment in order to encourage charitable donations to the National Health Service.

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

My Lords, the NHS is based on the principle of access to treatment regardless of your means and according to clinical need. As a consequence, it is important that patients should not be exposed to the costs of care as it might deter them from seeking treatment. Where costs have been provided, such as the cost of missing GP appointments, this has been in an attempt to prevent waste.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister agree that we have a great gift in the NHS and that great gifts become even greater if one can make a return contribution to the giver? Why will the Government not reveal the cost of treatment to people—after they have had it, not before, and only to those people who request it—so that in turn they may make a voluntary contribution, either in full or in part, towards the cost of that treatment? Why is there such difficulty in encouraging people to play a greater part, to give more and to get more involved with the NHS in a way that the Government are refusing to do at the moment?

[Lord O'Shaughnessy]

I agree with the noble Lord that it is a gift. I also absolutely understand the sentiment behind what he is saying, which is a desire for people to contribute back to the NHS not just through the tax system. It is important to point out that there are more than 250 NHS charities, with an annual income of £400 million. One of the other great gifts we have in this country is people’s willingness to donate time and money not just to the NHS but to a range of health causes. So we do provide an opportunity for that and those gifts are supported by gift aid. With regard to itemising the bill, we worry about deterrence. Many users of the most expensive health services are older people. Itemising a bill could put some of them off and that would be the wrong thing to do.

[Baroness Gardner of Parkes (Con)]

My Lords, I am pleased that the Minister has acknowledged the great contribution made by charities, but is he aware that councils are also providing a lot of care for people in need, both pre hospitalisation and post hospitalisation, but that they cannot use gift aid in any way? Will the Department of Health liaise with the Treasury to see whether there is some way that special council funds could be set up, where you could make a charitable donation? Gift aid is a great attraction. Yesterday I got a letter asking me whether I would like to give something to my council. I would not give anything unless it had gift aid—so it seems that we are missing an opportunity there.

[Lord O'Shaughnessy]

My noble friend makes an important point. Gift aid is a wonderful scheme that obviously has driven huge contributions. She is quite right that public sector bodies cannot provide the gift aid opportunity, which is why in the health sector those charities attached to hospitals exist. She makes an excellent suggestion for what councils should do and I shall take it up with my colleagues in that department.

[Baroness Barker (LD)]

Can the Minister tell the House whether integrated care trusts can have associated charities so that people can make donations not just to healthcare but to social care in their area?

[Lord O'Shaughnessy]

The noble Baroness asks a very interesting question. Clearly these are emerging organisations and most of the charities are attached to hospital trusts—although not exclusively: some are attached to primary care. None of these are yet quite in being. Once they are in being, this will be an excellent suggestion that we should take forward.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain why we should not at least be clearer about what care costs by publishing the tariffs within hospitals so that people understand, if not individually, how expensive some of the day-to-day treatments they get are?

[Lord O’Shaughnessy]

That is an important point. We are not yet in a position where we have mandatory collection of all that unit pricing data. That will happen from the next financial year onwards, so we will be able to publish that data. It is important, though, to resist the urge to send out to people information itemising costs, precisely for the deterrence reasons that I mentioned.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, we can all agree that the National Health Service being free at the point of use is probably the single most valued thing about it for everybody. Personally, I would not want to see that changed or compromised in any way. However, despite the Minister’s reasonable point about putting people off, does he not think that it would help people to value the health service more if they better understood the real cost of what it takes to treat what are in some cases quite minor ailments? Further, could it not help with the pressure on GPs to overprescribe certain drugs, the use of which we would really do well to reduce?

[Lord O’Shaughnessy]

I think we are getting to a sensible position here: we want that transparency about what things cost in general, but not specific to each patient because of the concern that it might put people off. There is a lot more information available now than there ever has been about what items cost. What is critical—what we have learned—is that when people miss appointments, for example, which costs about £1 billion per year, there is a good opportunity to demonstrate what that cost is. But as regards what they incur as they go through the experience of healthcare, we worry about the deterrence.

[Lord Elton (Con)]

In his Answer to the noble Lord, Lord Brooke, my noble friend said that older people might be put off. Speaking as an older person, from what might I be put off by information after I have had a procedure or treatment as to what it cost? In the same supplementary, may I ask that when my noble friend comes to remind younger people about not turning up for their appointments, he should send them a note of the cost of that as well?

[Lord O’Shaughnessy]

I reassure my noble friend that I am not trying to make an ageist point. The point I was trying to make is that the majority of healthcare costs in a lifetime occur at two points in life: in younger children and in older age. We effectively have an insurance system where we pay through our tax and use the care when it is needed. The concern is that at a point in life when people might be vulnerable and not have support around them, and not necessarily know what is required in complex care, having had the facts about one piece of care they may feel that they should not be creating a burden on society by asking for more care. I do not think that is the right approach.

[Lord Clark of Windermere (Lab)]

My Lords, will the Minister make it quite clear—loud and clear—that virtually every hospital trust has its own charity and indeed that many individual wards have one?

[Lord O’Shaughnessy]

That is precisely the point. Any of us who have spent time in hospital will know that those charities are well advertised. As I say, they have £400 million of income, which I think makes them second only to cancer research in terms of income for health charities. I agree that they are a real asset to our health system.

[Lord Dobbs (Con)]

My Lords, I have a great deal of sympathy with what the noble Lord, Lord Brooke, said, because he talked about the National Health Service being a right but also said that we have individual responsibilities. Is it not time to put much greater scrutiny on the issues of not only missed appointments but the abuse of health tourism and the Friday night nightmares of people who turn up at A&E not sick but overindulged, and expect the taxpayer to help them out?

[Lord O’Shaughnessy]

My noble friend is quite right—we of course have a responsibility to use this precious resource responsibly. On health tourism, we have introduced a number of changes to recoup the amount of money spent on non-UK citizens who have not contributed to the tax system. We have made good progress on that. I take his point on alcohol, which we are dealing with in a couple of ways. One is obviously by taxing alcohol through the tax system but we also have to do much more preventive work so that people drink less.