Medicines and Medical Devices Safety Review

Lord O'Shaughnessy Excerpts

Thursday 22nd February 2018 Lords Chamber

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

My Lords, with permission, I will repeat a Statement made by my right honourable friend the Secretary of State for Health and Social Care on the action the Government are taking to address public concerns regarding the safety of medicines and medical devices used by the NHS. The Statement is as follows:

“On Friday, I will host campaigners, clinicians and safety experts from around the world as part of the world patient safety, science and technology summit, which is being held for the first time outside the United States here in London. As part of that, we will release a landmark report on the extent of medication errors in modern healthcare systems, as well as the NHS’s plan to tackle them. Alongside those in the report, there are three areas of potential medication error that I wish to update the House on today where serious concerns have been raised by patients and their families.

The first is Primodos, a hormone-based pregnancy test which, it is claimed, led to miscarriages and birth defects during the 1960s and 1970s and was prescribed to more than 1.5 million women before it was withdrawn from use in 1978, partly due to more modern pregnancy tests becoming available. The second is sodium valproate, an effective anti-epilepsy drug which has been definitively linked to autism and learning disabilities in children when taken during pregnancy. Campaigners have suggested that up to 20,000 children may be affected. The third is vaginal mesh implants, often used in surgical interventions to address complications after childbirth, which have been linked to crippling life-changing side-effects.

Of course, our first thoughts are with the individuals and families whose lives have been turned upside-down by these issues. Many have endured, and continue to endure, severe complications and tremendous pain, distress and ill health, alongside a strong sense that their concerns have not reached a satisfactory resolution. I pay particular tribute to those who have responded to such experiences not just with understandable anger, but with resolute determination to campaign for change on behalf of others. Many of them have met Ministers and Members of this House to share their concerns, and I thank everyone who has written to or spoken to me personally to raise these concerns on behalf of their constituents.

We must acknowledge that the response to these issues from those in positions of authority has not always been good enough. Sometimes the reaction has felt overly focused on defending the status quo, rather than addressing the needs of patients, and as a result patients and their families have spent too long feeling that they were not being listened to, making the agony of a complex medical situation even worse. So today, in addition to practical steps for each of the three cases, I am setting out plans to establish a fairer, quicker and more compassionate way to address issues when they arise, bringing different voices to the table from the start and giving individuals and their families a clear path to answers and resolution.

Immediate action is being taken in each of the three cases. On Primodos, I have asked my ministerial colleague Lord O’Shaughnessy to drive forward, and where possible accelerate, the recommendations of the expert working group, further strengthening our systems for monitoring the safety of medicines in pregnancy. That will include: offering the families of the Association for Children Damaged by Hormone Pregnancy Tests a full and up-to-date genetic clinical evaluation; better information for pregnant women and their families; better training and support for obstetricians; better evidence around dosing recommendations; making electronic yellow card reporting easier for both women and clinicians throughout pregnancy; and stronger and more joined-up messages on safety.

On valproate, the issue is broader than the UK, and the outcome of the EU review, expected in March, will strengthen our regulatory position. In preparation, we have tasked system leaders with delivering a rapid, co-ordinated response. Directly responding to calls from patients, we are introducing a new warning symbol on valproate packaging; updating NICE guidance on valproate; pushing for valproate to be contraindicated for women of childbearing potential not using effective contraception; strengthening alerts across all GP systems and community pharmacy systems; and, for those women for whom valproate is an effective treatment, offering stronger and more tailored advice on risks and contraception.

On vaginal mesh, I have asked the Chief Medical Officer for advice in the light of calls for a full ban. She has been clear that clinical experts here and abroad agree that, when used appropriately,

“many women gain benefit from this intervention”,

hence a full ban is not the right answer in the light of the current evidence available. However, that is not to minimise the suffering many women have experienced, which is why today I can announce that we will be publishing a retrospective audit to investigate the links between patient-level data to explore outcomes, and investing £1.1 million to develop a comprehensive database for vaginal mesh to improve clinical practice and identify issues.

These actions will improve the way regulators and the NHS deal with issues related to vaginal mesh and valproate, as well as improve monitoring of the safety of medicines in pregnancy. But the fact that it has taken so long to surface these issues also raises much bigger questions. It is an essential principle of patient safety that the regulatory environment gives sufficient voice to legitimate concerns reported by patients, families and campaigners, works alongside them and responds in a rapid, open and compassionate way to resolve issues when these are raised. My view is that that did not happen in the way I would expect in these three cases.

To do better in the future, we need to ensure that patient voices are brought to the table as systematically and consistently as other voices in the system, so today I have asked Baroness Julia Cumberlege to conduct a review into what happened in each of these three cases, including whether the processes pursued to date have been sufficient and satisfactory and to make recommendations on what should happen in future. She will assess, first, the robustness and speed of processes followed by the relevant authorities and clinical bodies to ensure that appropriate processes were followed when safety concerns were raised; secondly, whether the regulators and NHS bodies did enough to engage with those affected to ensure that their concerns were escalated and acted upon; thirdly, whether there has been sufficient co-ordination between relevant bodies and the groups raising concerns; and fourthly, whether we need an independent system to decide what further action may be required either in these cases or in the future.

This is because one of the judgments to be made is whether, when there has been widespread harm, there needs to be a fuller or even statutory public inquiry. The noble Baroness, Lady Cumberlege, will make her recommendations as to the right process to make sure that justice is done and to maintain public confidence that such decisions have been taken fairly. While I am deliberately leaving the terms of this model open for the noble Baroness, Lady Cumberlege, I have asked that she consider how we can strike the right balance on the criteria or threshold for a ‘legitimate concern’; how best to support patients where there might not be a scientific or legitimate concern, but they may still have suffered harm; how we can be more open to the insights that close attention to patient experience can bring, including whether a patients’ champion could help to act as a point of contact for people or families raising legitimate concerns, ensuring that these are heard and responded to; and how any new entity interacts with the existing bodies, including NHS Resolution, the Health and Safety Investigation Branch and the ombudsman. Recognising that this is an issue that many honourable Members have been concerned about, I have asked the noble Baroness, Lady Cumberlege, to meet with the relevant all-party parliamentary groups and campaign groups early on in the review process.

We are rightly proud of the NHS and all it has achieved and will achieve in the future. Much of this has been built on the strong connections between scientific discovery and medical progress, but innovation requires safeguards, including a culture of learning to protect against the unintended consequences of new technologies and treatments, and a clear focus on the experience and treatment of patients and their families affected by these consequences. From Mid Staffs to Morecambe Bay to Southern Health, patients and their families have had to spend too much time and energy trying to access, lobby and influence NHS leaders and Ministers to get a hearing for their concerns. The stress and frustration of campaigning, sometimes in the face of closed ranks and a defensive system, has added insult to injury for too many families. We need to establish a fairer and quicker way to resolve such concerns when they arise in the future.

Our regulatory system is in many respects world-leading, but it too needs to adapt to a changing environment and to draw intelligently on multiple sources of feedback to protect the safety of patients. Today’s announcement will build a system that listens, hears and acts with speed, compassion and proportionality, strengthening the commitment to patient safety which is at the heart of this Government’s and this House’s priorities for our health and care system. I commend the Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Baroness Brinton (LD)]

From the Liberal Democrat Benches, I am very grateful and thank the Minister for the Statement. I am particularly pleased about its tone, which moves on the Government’s debate with campaigners, families and clinicians about these very serious issues. It makes a break with the past.

I am particularly concerned that there should be regular assessments and updates for people with problems from Primodos and sodium valproate, because we know from our experience with thalidomide that everybody thought that everything had been sorted from the initial diagnosis of the children, but as they entered adulthood and more mature years further medical issues appeared. It will be important to recognise that we need to make sure these young people—and adults as they are now—get that protection.

The yellow card system was not available in its current format for these two drugs. One of the things that concerns me most about the Statement is the assumption that the only people involved with the yellow card are clinicians. Speaking as a patient who has been on a drug that has very serious yellow card incidents, I have been trained to recognise that if I get a side-effect I do not just go back to my hospital; I report it to the pharma company. The pharma companies are notable by their absence in this Statement. Will there be specific links back for clinicians and patients on some of the side-effects of drugs? That is easy to say for those who are formally expert patients. I absolutely accept the point made by the noble Lord, Lord Hunt, that some patients are inexpert for all the right reasons.

There needs to be a real focus on all the other health professionals that these patients come into contact with. Reporting a yellow card incident to a GP when it is very difficult to see your own GP these days means that it could quite often be missed. In the case of sodium valproate this certainly needs to include midwives and people involved in the obs and gynae departments as well. What training is to be provided for these non-specialist healthcare people to make sure that they understand, when a patient talks about a problem, that this may need to trigger a yellow card response? To that end, I welcome the proposal for an electronic yellow card. That will be extremely helpful. Printing out a yellow card, filling it in and sending it in is an absolute deterrent to it happening.

On Primodos and sodium valproate, will the longer-term effects also be covered by the Cumberlege review? It is important to have a reference back there. I am also concerned about the vaginal mesh issues, specifically those reported in the Statement. It would be useful to know what percentage of those who have had vaginal mesh implants have faced problems. It is fine to say that many have benefited. I completely accept that, but one needs to understand what the ratio is between those facing problems and those for whom it has benefited them, to understand whether a ban should be in place. What is the date for publishing the retrospective audit? It is fine to say that it will be done. I have no idea how far along the line the process is. Then there is the timescale for creating that computer database for vaginal mesh to improve clinical practice. When will it be not just commissioned, but completed and used in analysis? Will interim reports go to the noble Baroness, Lady Cumberlege, by the people doing this review if evidence emerges that she will need to take account of?

I am concerned about the idea of the creation of a patients’ champion. We already have panels and expert groups. Yet another person that patients may or may not know about, and may or may not be able to turn to, seems problematic. I urge the noble Baroness, Lady Cumberlege, to look at what is available now rather than creating yet another body.

Finally, I echo the concerns expressed by the noble Lord, Lord Hunt, about whether we should move to a public inquiry at this stage. I wonder whether the evidence that the noble Baroness, Lady Cumberlege, will undoubtedly turn up means that she may come back to Ministers and say, “Actually, this is the point at which this needs to go public”. Campaigners have highlighted for years that there are problems.

[Lord O'Shaughnessy]

I thank both noble Lords for their extensive, well-informed and probing questions; I will try to deal with all of them. I want first to take the opportunity to pay tribute to those involved in each of the three campaigns. They are almost exclusively women. A factor that needs consideration is not only that users of healthcare services are disproportionately women but that women seem to be disproportionately on the end of things when things go wrong—that issue needs investigating in itself. I have had the chance to meet not only the mesh campaigners but campaigners on sodium valproate and Primodos. They have gone to extraordinary lengths to raise these issues; they are remarkable women.

On the position relating to mesh, I have asked the MHRA and NICE as the two regulatory bodies to get in touch with their counterparts in Australia and New Zealand. There is some quite long, technical advice which I will not attempt to repeat, except to say that perhaps the simplified public view of what has happened in each of those countries is not entirely accurate. I shall certainly write to all noble Lords taking part in this debate and place a copy of that evidence in the Library. It is quite important. It is detailed, but it is well worth looking at.

I emphasise that collaboration is going on not only internationally but within the four corners of the United Kingdom. The CMOs of those four countries have met. I am meeting the Scottish Cabinet Secretary for Health—I think, next week—to talk about this specific issue and other things as well, so we are cognizant of the need for a joined-up UK approach.

On the scope of the review, it is very open. In the noble Baroness, Lady Cumberlege, we have an ideal chair: someone who has campaigned on safety issues, who is deeply knowledgeable, well respected and fiercely independent—as we know. She has the opportunity to look not just at issues around marketing, as the noble Lord, Lord Hunt, mentioned, but around the private sector. She will be able to look, too, at whether there should be public inquiries or other types of inquiry and to make recommendations. She will be able to look at pharma companies and gather evidence from wherever it is required. I want to emphasise that the review is very broad in scope. As the noble Baroness, Lady Brinton, said, we are trying to mark a break from the past. We know that we have not dealt with these things well. We are beginning to address that in the clinical and medical space in terms of medical practice; we now need to move on to medicines and devices, which is what we hope to do with this process.

On issues around the mesh, the audit and the registry, the audit is obviously retrospective. It will not be a perfect exercise, because the data is not always perfectly gathered, but it will be quite extensive in scope. It will be able to pick up not just complications associated by women, or indeed men, with having mesh but whether they have turned up in pain at another setting. We are confident that it will paint a much broader picture than we have had. The intention is to publish that in the spring. Obviously, if any interim reports relating to it come out, they will be shared with the noble Baroness, Lady Cumberlege, but clearly there needs to be robustness to them.

On the registry, this is an important moment. We have found the money to do this; it will be funded for the set-up and then for the first three years, which is the normal way in which registries are done. I do not yet have a timeline for how it will be delivered, but clearly we want to get it up and running as quickly as possible. It needs to be commissioned, but it is in everyone’s interest to do that.

Primodos presents a challenging issue, because it is not available on the market and has not been for 40 years, so it is not possible to carry out studies on what is happening to women now. However, new evidence has come to light which will also need to be considered and which was not available for the expert working group. Again, my noble friend Lady Cumberlege will be able to consider that as she looks at what needs to happen in each of those three cases.

One thing that we have to do—this moves on to the expert working group’s recommendations from the Primodos review, which is obviously very germane for women taking sodium valproate—is make sure that there is proper training for health professionals, not just in the yellow card scheme but for obstetricians in terms of their pharmacological advice and expertise. Indeed, that is one of the recommendations I will be taking forward, as was set out in the Statement. The valproate issue is very difficult, because it is an extremely effective anti-epilepsy drug but it can have very bad consequences for pregnant women and their children. I have met one of the campaigners; four or five of her children are affected and it is having a devastating impact on her life. We need to get to a position where no women of childbearing potential are using it. That needs to be done in the context of recognising that it does work for epilepsy.

Finally, I absolutely agree with the noble Lord, Lord Hunt, about meeting the groups to define the terms of reference. Again, we have learned from past experience that that has not always been done well and it is best done independently of government, with that degree of objectivity. I think that that is what this review will bring. As I say, the overall hope is that not only do we deal with the issues under each of these three headings, historical and current, but that we put in place a system that means that patients do not have to go through this tortuous process to get their concerns heard in future.

[Baroness McIntosh of Pickering (Con)]

My Lords, I welcome the review that my noble friend has announced—I can think of no better person than my noble friend Lady Cumberlege to do it. One of the concerns of those who are campaigning and have received what they consider to be very inferior treatment is that when the mesh was originally introduced it was done, they think, without proper research, it was inserted with inadequate training, and inadequate warnings were given of the potential risks. Will my noble friend assure us that if an alternative is sought, that will not be the case but that it will be subject to rigorous testing, that there will be rigorous training of the medical professionals and that the risks will be explained to the patient?

They have also raised concerns about potential trade under any future trade agreement with the United States, where I understand a lot of the mesh comes from. They are concerned that we will not just waive any suspect mesh through but will ensure our own rigorous testing so that it meets the highest requirements of the UK.

[Lord O’Shaughnessy]

I thank my noble friend for those points; she highlights some very important issues. Medical devices are regulated differently from medicines: they have to go through a safety procedure and they are not licensed in the same way as medicines are. They come onto the market, they are used and safety assessments are made as time goes on. We are now in the position with mesh that we will have a registry, so that every time it is used we will know what the consequences are. That will also give us a comparator, as will the audit, for effectiveness against alternative procedures. As I have said, there is still a view in the medical and regulatory communities that, when used according to guidelines in the appropriate way, it can be transformative for women. However, it can also be the wrong thing and NICE has been very clear that in some cases, in some surgeries, the risks outweigh the benefits, in which case it should not be used. It is important that there is absolute conformity with those guidelines and that is part of what the registry will ensure.

On the issue of trade, under no circumstances will our trade relationships with any country in the future dilute the regulatory rigour that we apply and have always applied in this country. We have a very well regarded regulatory system in this country but we also know that we can do better and it is absolutely our intention to continue to strengthen it.

[The Countess of Mar (CB)]

My Lords, I am very grateful to the Minister for repeating the Statement but I put on the record my severe reservations about the safety of HPV vaccines. The noble Lord knows of my concern. I have had meetings with the MHRA but it seems to think that mañana is quite rapid enough to be dealing with it. The situation he described for those patients dealt with in the Statement is exactly the same as that of young girls and their families who have suffered bad reactions to HPV vaccines. Will the Minister ensure that the MHRA deals with some rapidity on this matter, as at the beginning of the Statement?

[Lord O'Shaughnessy]

I thank the noble Countess for raising that point. We have met to discuss this issue and she has been a great campaigner on medicine safety issues. That dialogue is going on. As she knows, that view concerning the safety is not currently shared by the regulators. But I want to stress that the work that my noble friend Lady Cumberlege will be leading will try to set up a process which deals equitably, objectively and compassionately with these concerns when they arise. One of the problems in the past has been, frankly, that we have not dealt with these things in the same way. It is dependent on the strength of the lobby group, the type and strength of the Government and what is on their agenda at any one time. That is not good enough. We need a consistent and compassionate approach to listening to concerns, scrutinising them properly and dealing with the consequences, which may entail no further action or could be anything up to a full public inquiry. That is what my noble friend will be dealing with and that will be a huge step forward. It will be precisely that kind of process to which any concerns about HPV or anything else should be directed.

[Baroness Masham of Ilton (CB)]

My Lords, I thank the Minister for the support he has given to the epileptic women who have taken valproate, resulting in them having children with autism. The marking and the advice were not there for them. Does the Minister realise that many people are concerned about the European Medicines Agency, which deals with safety in medicines? It was housed in London at Canary Wharf but has now gone to Amsterdam. Will we still be involved in that agency? We were leaders when it was here in London and we still have a lot to offer.

[Lord O'Shaughnessy]

The noble Baroness makes an excellent point. Specifically on valproate safety, the MHRA has taken a leading role in pushing all the time for stronger responses to the concerns. We are pleased to see that other European countries are responding. That highlights a bigger issue, which is if you look across the entire continent and the work that our agencies do—whether it is the MHRA, the GMC or others—we are seen as a leader across Europe, and indeed globally, on patient safety issues. That is one reason why it is our desire that in our future relationship with the European Union, the MHRA and other agencies continue to play that role, for the good of patients not just here but across Europe.

Disabled People: Social Care

Lord O'Shaughnessy Excerpts

Tuesday 20th February 2018 Lords Chamber

[Baroness Campbell of Surbiton]

To ask Her Majesty’s Government whether they have plans to improve social care for disabled people below retirement age in the light of the change in title of the Department of Health.

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

My Lords, the Government are committed to making sure that everyone who is assessed as having a care need can access high-quality support to maintain their independence. While the social care Green Paper will focus primarily on care for older people, it will also address questions relevant to adults of all ages with care needs. In addition, the Government are taking forward a parallel programme of work so that issues specific to working-age adults are considered in their own right.

[Baroness Campbell of Surbiton (CB)]

I thank the Minister for his reply—but, as he will know, the Government have transferred responsibility for the social care Green Paper for older people from the Cabinet Office to the Department of Health. Will he confirm that the Government will use this opportunity to review the scope of the Green Paper to include younger disabled people, because the proposed parallel process, which is not a Green Paper, is simply not acceptable when half of social care spending now goes on working-age disabled people? Please will the Minister confirm that both older and younger disabled people will receive parity of status and attention from the Government?

[Lord O'Shaughnessy]

I thank the noble Baroness for her question. She is quite right to highlight the importance of reform for this group of people. We are talking about 250,000 people now, but that is projected to rise to 400,000 working-age adults in the next 15 years. I want to reassure her that, while the Green Paper itself is focused on care reform for older people, a parallel programme of work is going on. There is an important round table coming up which is being chaired by both the new Minister of State for Care, Caroline Dinenage, and the Parliamentary Under-Secretary for Communities and Local Government, with Mencap, Scope and others. We are giving the issue equal seriousness, as it deserves.

[Baroness Brinton (LD)]

My Lords, the charity Together for Short Lives last year put in a Freedom of Information Act request and found that one in five local authorities and one in six CCGs have absolutely no provision for respite care short breaks for the most seriously ill and disabled children. Since then we have received reports from across the country of more and more centres under threat or actually closing, such as Nascot Lawn, which I have raised in your Lordships’ House before, which is in court again tomorrow to try to save it. What is happening about this social care and nursing care provision for children? Normally, for adults, there is a negotiation between the NHS and the local authority about what is nursing and what is social care. But for these children there seems to be no such relationship; both local authorities and the NHS just point fingers at each other, and the result is children and their families not getting breaks.

[Lord O'Shaughnessy]

I am very aware of this issue. Indeed, we have had the opportunity to speak about it in specific cases. Local authorities of course are obliged to provide respite care. The noble Baroness highlights an important point about care, which seems in a way to slip between the boundaries of the two. I shall write to her about the general policy work that is going on, but I know that we need to solve this because we have children who are now living longer who before might not have lived so long and who require care, as do their families. It is essential that they get the care that they deserve.

[Baroness Thornton (Lab)]

My Lords, I know that the Minister will tell me and the House again about the extra billions that the Government are putting into social care. However, when everyone else says that there is clearly a social care crisis, we have some dissonance here. The evidence of this crisis is the regression of opportunity and care for young disabled people, which is there to see in personal cases where people are not receiving the sort of support that they need. I am not convinced about the Green Paper looking at social care for older people. The noble Baroness, Lady Campbell, is right—that makes me more concerned, and I join her in that concern. Will the Minister explain how the Government will achieve their target of 1 million more disabled people being in work by 2027 if they cannot get out of bed and travel to work without help because of this combination of cuts and the stalling of a coherent support policy to make that possible?

[Lord O'Shaughnessy]

I do not want to disappoint the noble Baroness, but she is aware that more money is going in. To address the specific issue that she talks about—and I obviously can talk about it only from the point of view of the Department of Health—we want and are seeing more disabled people going into work. I would point to one big investment that the Department of Health is making, which is the disabled facilities grant. That is about making sure that disabled people can live at home and have their independence, which of course is critical to maintaining their physical health and confidence to make them, in a way, ready to go into work. I know that there are other programmes being put through job centres and the Department for Work and Pensions to make sure that they are supported, too.

[Lord Patel (CB)]

My Lords, I take this opportunity to thank the Minister for laying before Parliament today the government response, 11 months after the report was produced, to the House of Lords Select Committee report on the long-term sustainability of the NHS. We will now get an opportunity to debate the report and the Government’s response in due course. One recommendation that was accepted was the renaming of the Department of Health as the Department of Health and Social Care. Attached to that was the recommendation that the budgets should be amalgamated so that we can provide social care to all those who need it—both care for the disabled and adult social care. Would he like to comment on that?

[Lord O'Shaughnessy]

I am glad to be able to publish the response at last, and apologise again for how long it has taken. I am pleased to report that we have not just changed the name of the department but given the strategic direction for social care policy back to it. That also includes strategic direction of funding—but the actual funding settlement happens through the local government funding settlement. I have to disappoint the noble Lord on that because there are no current plans to change it.

[Lord Cormack (Con)]

My Lords, in his Answer to the noble Baroness, Lady Campbell of Surbiton, my noble friend referred to a forthcoming round table that will address some of the issues that provoked the Question. Can my noble friend assure me that the noble Baroness will be invited to participate in that round table?

[Lord O'Shaughnessy]

My noble friend makes an excellent suggestion. It is not my round table, so the invitation is not mine to extend, but I shall certainly be seeing my colleague the Minister of State this evening and shall do everything that I can to encourage that invitation to come.

NHS: Winter Crisis

Lord O'Shaughnessy Excerpts

Wednesday 7th February 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what assessment they have made of the effectiveness of their planning for the winter crisis in the National Health Service.

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

My Lords, planning for winter started earlier than ever before to ensure that robust plans were in place to support NHS delivery during the challenging winter months. Despite the NHS being extremely busy and flu rates being at the highest level for years, hard-working staff treated more than 55,000 people within four hours every day in December—more than 1,200 more than last year. NHS England and NHS Improvement will publish their review of winter by summer 2018.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply. As he knows, NHS spending has risen by an average of 4% each year in real terms since its inception in 1948. Since this Government took over in 2010, that 4% increase has fallen to an average of between 1% and 1.5% in real terms. Can the Government not accept that some of their meanness is one of the major causes for the crisis the NHS finds itself in?

[Lord O'Shaughnessy]

I totally reject the accusation of meanness. If noble Lords look at the spending on the NHS, not only has it gone up in real terms every year while a massive fiscal retrenchment has had to take place to deal with £150 billion of borrowing bequeathed by the previous Government, but it now accounts for the highest percentage share of public spending that has ever been in place. We have found the money in difficult circumstances. We all agree that more is needed. More was found in the Budget; I am sure more will be found in the future.

[Baroness Brinton (LD)]

My Lords, in 2015 the King’s Fund warned the Government that the NHS would experience a “full-blown crisis in care” if the Government did not act early enough. That crisis has now materialised, with the additional funding announced in November’s Budget having arrived too late for hospitals struggling to cope with the accepted increase in demand from patients at that time of year. If the planning is to be published in July, when will the announcement about money to support that planning also be announced?

--- Later in debate ---

[Lord O'Shaughnessy]

As the noble Baroness knows, last year we had two significant spending announcements —there were two Budgets—in the March Budget on social care and in the November Budget for NHS funding, with billions extra being put into the service to meet very quickly rising demand. The review that will come out in summer will be a retrospective review of planning and the success of planning for winter. There will also be important lessons to be learned from it I am sure.

[Baroness Finlay of Llandaff (CB)]

Are the Government planning to ask NHS England to review the number of beds available, given that staff at the moment are starting shift after shift with no beds available and having patients who need IV therapy or even ventilation in their departments who cannot possibly be sent home? Staff morale is inevitably being undermined because they just do not know where they can put these patients.

[Lord O’Shaughnessy]

The noble Baroness is quite right to highlight the issue of bed occupancy; it is very high. The service managed to get it down below 85% before Christmas but inevitably it has risen since then. There is a big improvement in delayed transfers of care; we need that to continue to happen, and it was welcome that the Secretary of State for local government announced more funding for social care so that we can increase those transfers into social care and free up space in hospitals.

[Baroness Thornton (Lab)]

My Lords, following the noble Baroness’s question about bed occupancy, it is absolutely true that in 30 of the last 70 days in the winter period occupancy has been above 95%, which is dangerous. Some hospitals are at 100%. Was that part of the winter plan that the Minister assures us was timely and thorough? Will he accept that the winter plans have now been compromised in the light of pressure on beds, lack of staff and the fact that at least 23 trusts are now on black alert, which means that they are under very severe pressure?

[Lord O’Shaughnessy]

I agree with the noble Baroness that bed occupancy is higher than we want it to be and in some hospitals it is far too high. The question, of course, is what we do about that. It necessitated the difficult decision, for which the Prime Minister apologised, to cancel non-urgent elective surgery. Happily, that has not been repeated and rolled forward into February. We think and hope that the situation with flu, in particular, has stabilised and that that will start to relieve the pressure. I absolutely understand the hard work that staff are having to put in under tremendous pressure and I know that we all appreciate that.

[Baroness Altmann (Con)]

My Lords, I congratulate the Government on finding extra money for the National Health Service but does my noble friend agree that just putting more money in is not going to solve the crisis? Until we manage to sort out the social care system and the care of elderly people in our population the crisis will continue. We need convalescent places for older people who do not need to be in hospital in order to free up beds. I would also welcome an update on the thinking on integration between health and social care, which I so much endorse.

[Lord O’Shaughnessy]

My noble friend is absolutely right to highlight integration. I point to two things, one that is happening now and one for the long term. In the short term, the better care fund is a pot to which local authorities and the NHS contribute and it has more money than ever before, precisely to make sure that that interface between NHS care and social care is as good as possible and people can be discharged safely home as soon as possible, which is of course what they want. We also know that we are going to have a social care Green Paper this summer. It is a really important moment; we know how many missed opportunities there have been in the past to reform care in this area and I know that noble Lords are really keen to contribute to this. I urge them to do so and in that way we can build a consensus for change.

[Lord Bassam of Brighton (Lab)]

My Lords, the Minister says there are billions extra for the health service, but the East Sussex Healthcare Trust has just announced a £21 million increase in its deficit, making it £57 million for the rest of this financial year. This is now 14% of its total budget. The finance director says that it is necessary to achieve clinical stability for this ambitious deficit reduction. Is this not just a euphemism for cuts to services? What advice can the Minister give to patients using hospitals in Hastings and Eastbourne who are waiting for treatment?

[Lord O’Shaughnessy]

I am not familiar with the specific circumstances around the hospitals that the noble Lord has pointed to, but of course we know that there is huge pressure on services. If you look at the performance data, the NHS is seeing more people in A&E, more people being diagnosed, more people being referred to treatment, and that is why additional funding went into the budget, not just for this winter but for the next two years as well.

Health: Pelvic Mesh Implants

Lord O'Shaughnessy Excerpts

Tuesday 6th February 2018 Lords Chamber

[Lord Hunt of Kings Heath]

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

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

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

[Lord Hunt of Kings Heath (Lab)]

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

--- Later in debate ---

[Lord O'Shaughnessy]

I am grateful to the noble Lord for raising this issue, because there is certainly a complication rate. I know that a lot of women are suffering as a result of complications from this procedure. As he will know, we have asked the MHRA, NICE and NHS England to have a look at the correct use of this kind of mesh. They have all concluded that they do not support a complete ban. They propose a range of restrictions on usage. Indeed, the most recent interventional procedure from NICE on prolapse said that it should be used only for research purposes and not as a front-line treatment. However, I am aware that Australia and New Zealand are implementing bans for particular usage. I have asked NICE and MHRA to investigate why they have done that and to report to me urgently so that I can see the grounds for the ban. We have different regulatory systems, but I want to know what is happening there.

[Baroness McIntosh of Pickering (Con)]

My Lords, will my noble friend explain to the House what the alternative might be if pelvic mesh implants were to be stopped? Is it not appropriate to be absolutely sure that any alternative is fool-proof and that there are no consequences?

[Lord O'Shaughnessy]

My noble friend makes an excellent point. This is one procedure, and for some women it can be positive and life-enhancing. But we also know that it carries a risk of complications. That is one reason why we wanted to carry out the audit, because it will look not only at areas and procedures where there have been problems and complications but at where it has been successful, so that we can have a proper understanding of what the complication rate is and therefore what the safety concerns are.

[Baroness Jolly (LD)]

My Lords, the NICE guidelines that the Minister just referred to conclude that:

“Evidence of long-term efficacy is inadequate in quality and quantity. Therefore, this procedure should only be used in the context of research”,


as he said. But will he tell the House how confident we can now be that that is the case and that the information has been effectively disseminated? What is the mechanism for informing clinicians and women about this NICE guidance?

[Lord O’Shaughnessy]

The noble Baroness is quite right to say that it is not just about having the guidelines but making sure that clinicians follow them. Professional standards demand that clinicians do follow them, and indeed a clinician would need to be strongly justified in using mesh implants outside of the guidelines. They include things like gaining consent, providing information and registering operations that have been carried out. The guidelines are very strict and we expect clinicians to follow them.

[Lord Patel (CB)]

My Lords, does the noble Lord agree that, while we cannot be sure why New Zealand and Australia have suddenly announced total bans on the use of mesh implants, the evidence suggests that of the 20% of women who suffer from complications, most of them had been treated for pelvic floor prolapse, not stress incontinence? Banning their use completely at this stage for women with certain conditions who may benefit from them would, without further evidence, be completely wrong.

[Lord O’Shaughnessy]

The noble Lord speaks with great experience. Obviously, a number of procedures are involved, and NICE is now looking at extra procedures to provide the guidance. It does look like it is not the right thing to do in cases of prolapse, but it can be a very successful course of treatment for other conditions. It is important to take a differentiated approach.

[Baroness Tonge (Non-Afl)]

My Lords, does the Minister share with me a sense of puzzlement that this subject was brought to the House in the first place? I find it very odd given that we have royal colleges and NICE with people to assess the efficacy of particular treatments. Many treatments, both medical and surgical, carry a risk of complications. Are they all going to be brought to the House of Lords for discussion?

[Lord O’Shaughnessy]

Our job in this House is to scrutinise the decisions that are made in our publicly funded health services. I think that it is absolutely right that we do scrutinise these issues and make sure that the care being provided in this country adheres to the highest and safest standards.

NHS Winter Crisis

Lord O'Shaughnessy Excerpts

Monday 5th February 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 response to an Urgent Question given by my honourable friend the Minister of State for Health in the other place. The Statement is as follows:

“Winter is challenging for health services worldwide. With a high number of flu cases this year, we have seen an increase of around 35% in A&E attendances from flu—triple what it was last year—with around 3,000 hospital beds occupied as a result of flu, and a further 700 because of norovirus. The NHS saw 1,200 more patients a day in A&E compared to this time last year. The guidance issued by the national emergency preparedness panel sought to free up capacity for emergencies given the high number of flu cases, including two dominant strains of flu co-circulating this year.

It is important to remind the House that the deferment of operations referred to in that guidance applied to around 13% of hospital beds dealing with elective patients, of which around half were protected within the guidance in respect of cancer and other urgent elective treatments. That guidance was updated on 26 January to confirm that further deferment of hospital operations was no longer needed. In terms of the impact that the guidance has had on operations, we will not know this until mid-March, when that data will be published and placed in the Library for the benefit of both sides of the House”.

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for that Statement. Before I ask my questions, I also thank the Secretary of State and the Prime Minister for their responses to the United States President’s bizarre attack on our NHS.

Over 95% of hospital beds were full last week, leaving just one bed in 20 available. We saw the highest number of accident and emergency diverts for any week this winter, with 43 incidents across England. I pay tribute to our NHS staff, who have gone the extra mile in very challenging circumstances. We know that 50,000 elective operations were planned to be cancelled, but it would seem that some urgent operations have been cancelled, too. Will the Minister explain to the House why those operations have been cancelled, despite NHS England’s advice to the contrary?

It would also now seem that the accident and emergency targets that are enshrined in legislation and the constitution have been abandoned until March—that is, March 2019. Will the Government bring forward legislation to amend the constitution? Finally, will the Minister accept that the winter plans that have been outlined are now being compromised in the light of the fact that at least 23 trusts are now on black alert, which means that they are under severe pressure?

[Lord O'Shaughnessy]

My Lords, I thank the noble Baroness for her questions. I agree with her that we are all proud of our NHS, on all sides of this House, and I am sure that we all have great pleasure in stating that through whatever means we are required to. I also join with her in paying tribute to the staff, who do such a fantastic job, often in challenging circumstances.

She asked first about urgent operations. It is clear in the guidance that they should not be cancelled when it would negatively affect patients’ outcomes. If that has happened, NHS England is investigating and reinstating those operations. The guidance is quite clear and NHS England has followed that up.

As for A&E targets, we know that they have not been achieved recently. It is important and instructive to look at the extraordinary increase, not just in winter but overall, in the number of episodes that are happening. They really are increasing at a very high rate. Demand is very high—higher than I think could have been anticipated—and it is a credit to the NHS that it has produced the performance that it has. The aim now, with funding given at the Budget, is to get us back to the four-hour target that we all agree ought to happen. That is what will be happening over the coming year.

[Baroness Jolly (LD)]

My Lords, this morning I visited a suburban hospital in London, with an almost brand new A&E unit and a well-managed winter crisis. But despite all that, it has still had to face a bed occupancy rate of 97% on several days, which is stretching its ability to make this work. Money was clearly an issue—the hospital was quite anxious about what its end of year accounts might look like. Today, the Liberal Democrats launched a report looking again at a different way of funding the NHS through the creation of an office of budget responsibility for health and care, long-term health and care funding, and a ring-fenced tax to replace national insurance. Also, there is a clear need for some sort of short-term fix, and we have suggested that £2 billion should be raised by adding a penny to our income tax. Has the Minister looked at this report and will he agree to meet with me to discuss it?

--- Later in debate ---

[Lord O'Shaughnessy]

I thank the noble Baroness for her questions. I am glad she had a positive experience this morning at the hospital she mentioned. She is quite right that bed occupancy is very high at the moment. A good job was done in getting it down below 85% across the system in the run-up to Christmas, but of course it has filled up subsequently. An important part of dealing with this is the social care side, as we know, and the extra funding that has gone in is having some impact on these so-called DToCs—delayed transfers of care—and freeing up a number of beds.

The noble Baroness is right of course that money is important, particularly as we have the demands of a growing and ageing population. More money was of course announced in the November Budget for the short term. As for the long term, there is obviously a very informed and lively discussion going on not just among the Liberal Democrats but across the system and across politics about what is the right long-term solution. Obviously, as I have said before, issues of taxation are for the Chancellor and not for me, but I would be delighted to meet her to discuss those plans. What I can say, on behalf of the Secretary of State, is that we understand that there needs to be sustainable, long-term increases in NHS funding. We have to find the right way to do that.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise the concern of the Royal College of Emergency Medicine that the revised way of collecting data by NHS England does not allow meaningful comparisons because it includes walk-in and minor injury units, some of which are off site from the level 1 major emergency departments? Its concern is that this may be giving an overoptimistic impression of throughput and does not reflect the huge pressures on level 1 units. Will the Minister undertake to meet the president of the Royal College of Emergency Medicine with me to discuss some of its concerns?

[Lord O’Shaughnessy]

This is an afternoon of agreeing to meetings—but, yes, I would be delighted to do so. I am not knowledgeable enough about the issue that the noble Baroness mentioned but, while of course there is a huge difference in the kinds of workloads of those different types of A&E, the target incorporates all of them. They all have the obligation to reach the four-hour waiting time standard and we want to make sure that, whatever the situation and whatever the venue, we can do that.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister explain how, five years after the Francis inquiry, there is a lack of investment in the health and care nursing workforce in England, as outlined in the RCN report published today? That report, Left to Chance, shows that even if we had more beds we would not be able to staff them. In comparison, Wales has invested heavily in new nurses and continued professional development, and is doubling the number of district nurses that it intends to train this year. In England we currently have 4,400 qualified district nurses, but in 2010 we had 7,500. How can we resolve this quickly and ensure that we have more district nurses in training by this September?

--- Later in debate ---

[Lord O’Shaughnessy]

This is a really important point about nursing numbers. I think the particular accusation was about the Francis report and the follow-up to it. Of course, a lot of that was about nurses in NHS hospitals and indeed on wards. The latest figures from October 2017 show that, when compared to May 2010, there has been an increase of more than 14,000 in acute, general and elderly. At the same time, that has meant that some other areas of nursing have been impacted; we have talked about mental health before as well as district nursing. I say to the noble Baroness that the big increases in nurse training places ought to mean that there are more nurses going through not just into acute, general and elderly but into mental health and community nursing as well.

[Lord Campbell-Savours (Lab)]

My Lords, despite the increase in population over the last 30 years, the number of beds in the National Health Service is half what it was 30 years ago. Germany has eight health service beds per 1,000 and in France the figure is six, but in the UK it is two and a half. Is it not about time that we revisited the whole question of the number of beds available in our National Health Service?

[Lord O’Shaughnessy]

The noble Lord raises a very interesting issue. As he rightly points out, that number has been dropping over a long time. It has plateaued in recent years, but it has been falling. This is a difficult situation. We all agree that more care should be delivered in the community, but we also understand that at certain times of year you do need beds in hospitals. I will point to two things: first, making sure that bed capacity is more efficient so that people can stay safely for less time and can spend more time being treated in their homes—which often is where they want to be, and that is why the extra funding for social care is important; and, secondly, the reconfiguration test that has been introduced by NHS England, which is about stopping reductions in bed numbers—which, as the noble Lord said, has happened under successive Governments—where it cannot be proven that any reduction is for the benefit of patients in terms of their overall care.

[Baroness Masham of Ilton (CB)]

My Lords, I declare an interest as president of the Spinal Injuries Association. Is the Minister aware that at Stoke Mandeville’s national spinal centre, a ward that is absolutely necessary has been taken away from the spinal unit and used for general patients? There are waiting lists in the seven spinal units all over the country, affecting seriously ill patients who need specialised treatment. Will the Minister look into the situation?

[Lord O’Shaughnessy]

I was not aware of that but I shall certainly investigate and write to the noble Baroness.

Dental Care

Lord O'Shaughnessy Excerpts

Thursday 1st February 2018 Lords Chamber

[Baroness Kennedy of Cradley]

To ask Her Majesty's Government what action they are taking to improve dental care in England.

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

My Lords, the Government are committed to increasing access to dentistry and improving oral health outcomes, particularly for disadvantaged children. Across England, access to NHS dentistry is improving. We are also reforming the current dental contract to increase dentists’ focus on preventing, as well as treating, disease and oral ill health. Alongside this, NHS England’s Starting Well scheme will help children in high-need areas to access appropriate dental care.

[Baroness Kennedy of Cradley (Lab)]

I thank the Minister for that reply, but dental care in England is in crisis. Charities now provide emergency dental care. A quarter of all five year-olds have tooth decay. More than half of dentists plan to leave the NHS within five years and government spending on NHS dentistry has fallen by £170 million since 2010, meaning that patients pay more and more. The NHS dental contract that the Minister mentioned needs urgent reform—something that Labour recognised back in 2009. Why, despite running pilots since 2011, are the Government now saying that they need more time—a couple of years, perhaps—before wider rollout can even be considered? By what date, therefore, do the Government expect to deliver reform to these urgently needed NHS dental contracts?

[Lord O'Shaughnessy]

I am afraid I do not recognise the picture that the noble Baroness paints. She is quite right that 25% of five year-olds are not decay-free; obviously, that is not good enough, but that figure has been increasing over the past 10 years. I should also point out that there are more dentists practising in NHS dentistry than ever.

The noble Baroness is quite right that a pilot has been going on in 75 dentists’ surgeries. An evaluation report will be produced by the deputy Chief Dental Officer in the next few months. That will set out the path toward the full reform of the dental contract.

[Lord Colwyn (Con)]

My Lords, dental care would be improved by the addition of fluoride to the water supply. This has been agreed by my noble friend and his department, but not all water authorities are prepared to take this step. In the last decade, dentists’ average earnings have gone down by a third in real terms. This is of great concern to dentists, who do not receive any government funding and have to cover all costs—equipment, staffing and training—unlike medical general practitioners. I declare an interest as vice-president of the British Fluoridation Society. According to a recent BDA survey, more than half of all dentists intend to leave NHS dentistry in the next five years. Perhaps my noble friend could start by looking at the current salary structures and contractual arrangements.

[Lord O'Shaughnessy]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord O'Shaughnessy]

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

[Baroness Hollins (CB)]

My Lords, I am sure that the Minister is aware that adults with learning disabilities are also at considerable risk of tooth decay, in part because of difficulties in maintaining their dental health. What measures are being taken to improve their dental health? I declare an interest here because I published a book on the subject. I am concerned too about excessive sugar consumption as a major cause of tooth decay. This is a risk for children and adults with learning disabilities. Will the Government consider introducing a ban on advertising high-sugar products on television before the watershed?

[Lord O'Shaughnessy]

The noble Baroness might send me her book so I can get her ideas on reaching adults with learning difficulties. Most adults with significant learning difficulties are likely to be on a range of benefits. That means that their dental care is free, if not for all, I suspect, then for some. She is absolutely right to point to sugar. We now have the sugar levy, which has had a really big impact. About 50% of drinks that would have been affected have been reformulated to either reduce or remove the application of that levy. That is a really good impact. On her point on advertising, we have very tough advertising rules in this country, including the banning of advertising of sweet drinks, sugary products and so on in children’s media. That is one of the reasons why we are seeing some hopeful signs on, for example, the number of extractions falling in primary care year on year.

[Baroness Janke (LD)]

My Lords, is the Minister aware that 41.5% of children have not visited the dentists for the year up to September 2017 and that many of these children are in the poorest communities of the country, many of which, as the noble Baroness, Lady Kennedy, said, are now dependent on charity for dental care? What action will he take to ensure that all children have proper access to NHS dentistry, wherever they live throughout the country?

[Lord O'Shaughnessy]

The noble Baroness is right. About 59% of children have seen a dentist in the last two years, but of course that leaves 41% who have not. I have to say that that is an improving picture. On her two particular issues, there is NHS England’s Starting Well programme, which is targeted on 13 local authorities that have the worst oral health outcomes for children. The range is really quite dramatic from one area to the next. It has also developed a core offer to help every local authority commission better dental health for children.

[Baroness Hayman (CB)]

My Lords, is not the issue of fluoridation of water just like the issue of adding folic acid to fortified flour, about which even more overpoweringly conclusive evidence was published this week? The Government need to take a more robust attitude towards public health.

[Lord O'Shaughnessy]

I return to the point that I have made: I do not think there is any doubt about the evidence on the benefits of fluoridation, but it is important to do it in a way that brings local people with you. I should also point out that a big programme of fluoride varnishing is going on for children’s teeth as well, so we are getting fluoride into children in other ways too.

NHS: Clinical Negligence

Lord O'Shaughnessy Excerpts

Wednesday 31st January 2018 Lords Chamber

[Lord Sharkey]

To ask Her Majesty’s Government what progress they have made in reducing (1) the amount set aside in NHS budgets for clinical negligence claims, and (2) the annual level of payment for such claims.

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

My Lords, the Government are committed to tackling clinical negligence costs. To do so, we have proposed to fix the amount that legal firms can recover from clinical negligence claims, proposed a scheme so that families whose babies experience severe, avoidable birth injuries have an alternative to lengthy court proceedings, and brought forward our ambition to halve maternal and neonatal deaths, brain injuries and stillbirths from 2030 to 2025.

[Lord Sharkey (LD)]

I thank the Minister for that Answer. Last year, the NHS paid out £1.7 billion in settlements for negligence claims—a 15% increase on the year before. A substantial part of that enormous amount was intended for the provision of private sector care. That is because Section 2(4) of the Law Reform (Personal Injuries) Act 1948 requires claims to be calculated on the basis of private healthcare, not the NHS. Allowing claims to be made on the basis of costs to the NHS would dramatically reduce costs. Does the Minister agree that repealing Section 2(4) would save the NHS an enormous amount of money?

[Lord O'Shaughnessy]

I recognise the issue the noble Lord has raised; it has been raised by a number of people who are concerned about and interested in this issue, as we all are. The problems are significant. The annual costs of dealing with these injuries and other issues has quadrupled over the last 10 years. That is the scale of what we are dealing with. We have to act—indeed, the National Audit Office has implored us to act. It is one of the issues we are considering as part of a cross-government strategy that will report in September. I am not in a position to give more detail at this stage, but it is an area we are looking at.

[Lord Faulks (Con)]

My Lords, I have acted for the NHS and the MDU on a number of occasions. However, perhaps the Minister will help me. One of the reasons why these claims have increased in value is because of the rather mysterious decision by the Government to alter the discount rate, which has often resulted in the doubling of the size of claims. Can he tell the House whether the Government are seriously considering placing a cap or tariff on damages, as is often done in other jurisdictions? That would not only clarify the amount of damages obtained, but significantly reduce the legal costs involved in such disputes.

[Lord O'Shaughnessy]

The noble Lord knows more about this issue than anyone in the House, I think. The issue of reform to tort law is difficult. We have to be very careful when stepping across the idea of full compensation. It is one of the issues we are looking at. Other countries, such as Australia, have looked at this and we are considering it as part of the cross-government strategy. As I said, we will report by September this year on our plans in this area.

[Baroness Brinton (LD)]

My Lords, it is estimated that a relatively small number of clinical negligence cases end up as claims filed with the NHS. Has the NHS undertaken additional efforts to understand what factors cause certain cases to be escalated, in particular the attitude of lawyers in the NHS and trusts? How can escalation be prevented and, if so, when might the results be published?

[Lord O'Shaughnessy]

I point the noble Baroness in the direction of a five-year strategy that was published by NHS Resolution, the body that acts on behalf of what used to be the NHS Litigation Authority. The strategy looked at many issues, not only how we can prevent escalation. One of the drivers of cost is unsuccessful claims; more of those are going on. It also looked at how we can reduce incidents in the first place and learn from deaths and injury throughout the system, so that we can start to reduce the burden overall.

[Baroness Thornton (Lab)]

My Lords, it is telling that if you google “clinical negligence”, the first four or five pages that come up are companies offering their services to support people making claims. According to the Medical Protection Society report last year, the annual costs to the NHS in England of settling clinical negligence claims was equivalent to training 6,500 doctors. That is expected to double by 2023, so the noble Lord is quite right that this is a terrible drain. I am very pleased to hear that the Government have plans to reduce the number of claims. Have they included taking into account the recommendations in the PAC report published at the end of last year?

[Lord O'Shaughnessy]

We absolutely have. Indeed, the PAC investigation and the National Audit Office report on this issue are very thorough and looked at the causes and drivers behind it. One is increased NHS activity—not worse safety but the fact that the NHS is doing more. The investigation also looked at the legal environment and some of the changes that have occurred. The noble Baroness is right: a number of firms offer these services. That is important for access to justice but we also need to fix the costs that they can claim so that we get this budget under control.

[Lord Patel (CB)]

My Lords, the statistics show that 46% of the litigation cases involve misdiagnosis and 34% involve surgical errors. However, the largest settlements are for obstetric cases, particularly those related to babies who have suffered brain damage at birth. The important thing is to prevent these accidents occurring. The key issue here is better and continuous training in interpreting foetal heartrate patterns during labour. That is what we should focus on—preventing these cases happening.

[Lord O'Shaughnessy]

I completely agree with the noble Lord and make two points in response. He will know of the Secretary of State’s great passion for this area and of the maternity safety training funding and other training funding. From April, we will introduce the healthcare safety investigation branch, which will investigate each of the 1,000 incidents noted by the Each Baby Counts project which occur at birth, whether brain damage or neonatal death, precisely so that we can learn from that experience and make sure that those who provide these services are properly trained to avoid these incidents wherever humanly possible.

[Lord Ribeiro (Con)]

My Lords, we need to do something to tackle this issue much more urgently as the total cost of the litigation in the pipeline is some £65 billion—half the NHS budget. Until and unless we do something about changing Section 2(4) of the relevant Act we will have a continuing problem with patients claiming for private care when they should have their care provided by the NHS.

[Lord O'Shaughnessy]

I agree with my noble friend; this is an issue, not least because, when that Act was brought in, the NHS was a very different creature and did not offer the extensive range of care that it does now. We need to make sure that we are not effectively paying twice. However, this is a difficult and complex legal issue. It is important that we take our time to investigate how we tackle it properly so that those who are unfortunately affected by poor care are not put at a disadvantage for the rest of their lives.

NHS and Social Care: Winter Service Delivery

Lord O'Shaughnessy Excerpts

Thursday 25th January 2018 Lords Chamber

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

My Lords, I begin by congratulating the noble Baroness, Lady Wheeler, on securing this debate and bringing very welcome attention to the interaction between the NHS and social care systems. I am of course speaking on behalf of the newly minted Department of Health and Social Care and I promise that a focus on service integration is one that the Secretary of State and I, as well as Caroline Dinenage—who is Minister of State for Care, just to clarify that question—welcome and embrace. That is not, as we have discussed today, solely to deal with the winter pressures the NHS and social care systems face, but in order to provide a truly world-class health and social care system. Before answering the question that the noble Lord, Lord Hunt, asked about social care policy, this means that the department, through the Secretary of State and the Minister of State, are driving the reform process through the Green Paper, which was previously under the control of the Cabinet Office.

I congratulate all noble Lords on their contributions. I fear that there is sometimes a tendency in these debates—rightly, because we all want to solve problems—to focus on negatives. It was good to hear from the noble Lord, Lord Brooke, and I hope that the family member concerned is in good health now and having a positive experience of their care, even though the situation he describes is rather alarming; it is certainly something I shall look into. We know that the vast majority of care being delivered is of a high quality and of course, that is because of the wonderful health and care staff to whom we all owe so much.

I start where the noble Lord, Lord Desai, started—in the less controversial part of his speech—by recognising that many of our challenges stem from the fact that people are living longer, which of course is very welcome. It is a global phenomenon: worldwide, the population aged 60 or over is growing faster than all younger age groups. In developed countries the proportion of the population aged 65 and over is expected to rise by 10% over the next 40 years. What that means in England is that by 2026 the population aged 75 and over is projected to rise by 1.5 million, from 4.5 million to 6 million, and by 2041 to have nearly doubled to 8.3 million.

Funding social care and health services is of course a challenge that all developed countries face. One issue, as we have said, is longevity; the other is the likelihood of multiple health conditions. An arresting fact is that by 2025, the number of older people living with a disability could increase by 25%, while the number of people with dementia will increase by 50% over the next 10 years. That is one reason why the solutions we come up with in the social care system need to deal with some of the arbitrary distinctions in the way that older people with different conditions get dealt with by the current set-up.

As noble Lords have pointed out, that inevitably means that we must change the way we provide services. The traditional model of healthcare was reactive, set up to deal with infectious diseases. Now, we are dealing with long-term, complex conditions that incorporate not just physical illness, but mental illness, as the noble Baroness, Lady Hollins, pointed out. Equally, the traditional model of social care relies on admissions to care homes, whereas we know that people increasingly want that care to be delivered in their own home. That in itself brings challenges, as the noble Baroness, Lady Watkins, said regarding loneliness and that horrifying statistic of older people suffering malnutrition in the home. These traditional models need to change. They are expensive and tend toward silo working. We need to move to a system in which care is individually tailored to people’s needs.

I will come on to talk about winter, but I want to address the situation regarding social care funding, which has been the topic of so many noble Lords’ speeches today. We know and admit that local authority budgets have faced pressures in recent years. They account for about a quarter of public spending and they had to play their part in dealing with the historic deficit inherited by the coalition Government in 2010. That meant that social care funding was inevitably impacted during the last Parliament, but with the deficit under control, we have turned a corner. There were two Budgets last year. In the March Budget, the Government announced that councils in England would receive an additional £2 billion for social care over the next three years. I understand noble Lords saying that is not enough, but it is important to recognise that that, combined with other measures, gives councils access to over £9 billion over three years in dedicated funding for social care. That gives local authorities the ability to increase spending on adult social care in real terms to support and sustain a more diverse care market. As noble Lords have pointed out, that is incredibly important. The 2014 Care Act places obligations on local authorities and this extra funding is designed to enable them to meet those standards. The funding will also inevitably help to ease pressure on the NHS, including—as many noble Lords have pointed out—by supporting more people to be discharged from hospital as soon as they are ready. That is always important for patient welfare and safety, but never more so than at this time of year.

Winter is always challenging for the NHS in all four countries of the United Kingdom—not just this year, but in other years too. That is of course because cold weather and an increase in flu and other viruses place additional demands on the service. This year, preparations began earlier than ever before. I quote Sir Bruce Keogh, NHS England’s national medical director, who said:

“I think it’s the one that we’re best prepared for. Historically we begin preparing in July/August. This year we started preparing last winter.”


I was pleased to hear the noble Lord, Lord Kerslake, recognise that that preparation—as called for by the right reverend Prelate the Bishop of Carlisle—had taken place. Of course, that means we need to start preparing for next winter now; and indeed, we are.

Ahead of winter, NHS England and NHS Improvement also asked international experts from five leading countries to review how well prepared the NHS was for winter. They complimented the NHS on its state of readiness. In practical terms, they meant that just before Christmas—on Christmas Eve—bed occupancy had been reduced to 84%, helping to free up capacity to deal with the increased demand on services seen following the new year. Similarly, as my noble friend Lady Eaton pointed out, the 20% reduction delivered by local authorities has freed up over 1,400 beds a day.

I should also take this opportunity to reiterate the apology made by the Prime Minister for the cancelling of elective care. It was a difficult but planned-for decision to deal with extra demand as it arose. I should also emphasise that it did not include urgent treatments or treatments related to cancer.

Noble Lords will I hope know, as we have discussed it before, that there has been an unprecedented system-wide push on flu vaccination, including an expansion of the winter GP and national pharmacy programme. For the first time, workers in care homes have been able to access the vaccine free of charge. This has meant over 1 million extra people have been vaccinated, with the highest ever uptake among healthcare workers at 59.3%.

We know that doing things efficiently is one approach but we also know that more money is necessary. The Budget provided an extra £337 million-worth of funding for winter. The noble Baroness, Lady Wheeler, challenged me on whether that money came too late. It is important to point out that at least half that money went to fund plans that were already in place. It is simply not the case that it could be implemented only once it had arrived. I should also point out in response to, the noble Baronesses, Lady Wheeler and Lady Barker, and others that, NHS England will at Easter be reviewing the impact of all the funding and the measures it took to deal with winter. The consequence of that funding is to have helped the NHS to open over 1,300 beds in December. That is on track to rise to 2,700 in February; the latest data shows 3,000 additional beds have been made available since the end of November.

However, I recognise that the preparations and investment have not fully been able to mitigate the enormous pressures on services, including ambulance services, and that in some cases this has led to unacceptable care being delivered. In particular, the rate of flu in hospitals is higher than the peaks reached in the previous seven seasons. The latest data in December showed that emergency admissions had risen by 4.5% compared to last year, so services are extremely busy. Despite that, the NHS treated 55,328 patients every day in A&E within four hours in December—over 1,200 more every day compared to the previous December. Let me use this opportunity to pay tribute again to the incredible work that our NHS workers do in emergency departments across the country.

As the noble Baroness, Lady Barker, reminded us, there have been many well-meaning actions by successive Governments over the years intending to improve our health services, but they have sometimes got in the way of delivering a truly joined-up system. I believe we all know and agree that the only sustainable solution to short and long-term pressures on the NHS is the integration of health and care services. That is the goal set out in NHS England’s five-year forward view, which this Government endorse. Integration is already happening on the ground. Now in its third year, the better care fund is a mandatory, national programme for integrating health and social care, which joins up services so that they are designed around people’s needs and enabling them to manage their own well-being, and to live as independently as possible. By mandating the pooling of funds, the better care fund has helped to join up health and care services, and to incentivise local areas to work together, with increasing amounts of funds used within this process.

The challenge now, which all noble Lords alluded to, is that we need to take that model and spread it into all corners of the health and care system, taking advantage wherever possible of the huge potential of technology to transform the way that care is delivered. The noble Baronesses, Lady Watkins and Lady Jolly, made suggestions about particular pilots and the use of community hospitals for integration. Schemes such as the vanguards scheme and new models of care are doing that, but I shall certainly take away their ideas and write to them to see whether we could do more to hasten that integration.

We all acknowledge that the health and care systems have to work collectively to transform themselves for the future, both in the interests of patient care and to put the system on a financially sustainable footing. The key process for delivering that is through the sustainability and transformation programme. The noble Lord, Lord Hunt, asked whether we were still as committed as we were before to that programme. I can promise him that we are and that it is now evolving into the creation of accountable care systems, which bring every actor in the local area’s health and care system together to deliver the kind of care that we want to see. That was backed by significant capital funding in the Budget.

The first group of designated accountable care systems have agreed to deliver their fast-track improvements as set out in the next steps on the five-year forward view, including taking the strain off A&E, investing in general practice to make it easier to get a GP appointment, and improving access to high-quality cancer and mental health services.

We know that the burden of care cannot simply continue to fall on hospitals. We need to move care into the home and the community. It was instructive to hear from the noble Lord, Lord Smith of Leigh, about how Wigan, as part of devo-Manc, is taking the lead in that initiative. Service integration needs to be underpinned by a joined-up workforce, as many noble Lords have said. That is why it is welcome to see the draft workforce plan launched by Health Education England. It includes the social care workforce, recognising the interdependencies between the two workforces. Many noble Lords, including the noble Baronesses, Lady Watkins and Lady Barker, asked about total staffing numbers. It is a topic we talk about a lot in this House, and I hope they will welcome the increase in training places for doctors and nurses. I should point out to the noble Lord, Lord Smith, that it also includes increased training places for emergency doctors.

I turn to the social care Green Paper. I use this opportunity to reiterate the Government’s commitment to publish a Green Paper by the summer of this year setting out their proposals for the reform of social care. It will be broad in scope and will look at the full range of issues relating to older people’s social care. To answer the noble Lord, Lord Pendry, it is intended to lead to a lasting solution. In developing the Green Paper, it is right that we take the time needed to debate the many complex issues, listen to the perspectives of experts and care users and try to build consensus, which has too often eluded us, so that the reforms can succeed. I look forward to engaging with all noble Lords in that process to take advantage of the golden opportunity to achieve lasting reform, as the noble Lord, Lord Pendry, said. The Green Paper will include action on carers. Many noble Lords asked about that. There will also be a carers action plan. I am not able to give a date on that, but I will write to all noble Lords when I am able to do so.

As well as reforming care, we also understand that the NHS needs to change. The Secretary of State for Health and Social Care said that,

“as we come to the end of the five year forward view, we need to seek consensus on the next stage for the NHS. We will need significantly more funding in the years ahead, and we need to build a national consensus on … that funding”.—[Official Report, Commons, 10/1/18; col. 346.]

The Secretary of State’s view is that we should try to do that for a 10-year period and not a five-year period. He is clear that he is open to all discussions with colleagues about the best ways to do that. I know that he is making that case in government, but we are clear that NHS spending will continue to rise to meet the demographic challenges that we face.

The noble Lord, Lord Macpherson, provided some interesting and well-considered ideas, which were backed up by the noble Lord, Lord Desai, and others, about how things could change. We can and must speculate about different ways of raising revenue for various spending priorities. Of course, taxation is a matter for the Chancellor and the Treasury, but the last Budget shows that when we have been given the opportunity to increase funding for the NHS, we have done so. Indeed, the proportion of public spending taken by the NHS has been increasing over time.

Building a sustainable health and care system will require some big and urgent decisions, but getting this right promises a better service, where people understand their responsibilities, can prepare for the future and know that they will receive care of a high standard that will help them maintain their independence and well-being. We need to create a consensus, by whatever means, in this country behind a plan for change. That has eluded too many Governments in recent years. I hope that, when the chance comes, all noble Lords will make available their expertise and wisdom so that we can deliver a health and social care system that is truly fit for the future.

NHS: Cancer Treatments

Lord O'Shaughnessy Excerpts

Thursday 25th January 2018 Lords Chamber

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

My Lords, I begin by joining all Members of this House in paying fulsome tribute to the noble Baroness, not just for securing this debate today but for the extraordinary character she is showing by leading it. It has been a rich and moving discussion and, as the noble Lord, Lord Blunkett, said, it is extremely daunting to follow her and try to do justice to the requests and speech she has made, but it is also a privilege to be able to do that on behalf of the Government.

I also praise the noble Baroness for the determination that she has shown in raising the profile of issues around cancer treatment during the course of her illness. I think it is fair to say that she has inspired us all, and many cancer sufferers too, but I suppose we should expect nothing less from the woman who brought us the most wonderful Olympic and Paralympic Games in 2012.

I am also very grateful to the noble Baroness for sharing her speech, via the noble Baroness, Lady Thornton, and I have done everything I can to address in my response today the questions that she has asked. She will forgive me if there are any stones left unturned; perhaps we can pick them up afterwards.

As we have heard, every story about cancer is a personal one, but behind those stories lie some very stark numbers. As our population ages, the prevalence of cancer rises. One in two of us will get cancer at some stage in our life. The question is not so much how we stop that happening, but how we can diagnose and treat it more quickly and effectively, so that it moves from being a life-threatening disease to one that can be managed throughout a normal and happy lifetime.

We must be honest in saying we are not yet there. Historically, we have lagged behind the best performing countries in Europe, and catching up with those standards has been a focus for successive Governments, including this one.

There is good news. Things are getting better. In the past eight years, various actions, including the establishment of the cancer drugs fund, mean that there are about 7,000 people alive who would not have been otherwise, but, as we have heard, the benefits of these actions are spread unevenly. Survival rates for certain cancers are stubbornly low. Testicular cancer has been transformed into a nearly totally curable disease, but for other cancers—we have heard about oesophageal, stomach, pancreatic, lung, liver and, unfortunately, brain cancers—very little progress has been made. There is much still to do and we need to do better.

The first step towards achieving the world-class cancer outcomes we all want and which NHS patients rightly expect is to have a plan backed by the cancer community. As noble Lords will know, that plan was provided three years ago by the Independent Cancer Taskforce, which provided a cancer strategy aimed at saving 30,000 lives a year by 2020. It was truly a landmark moment. As any Government would have, the Government accepted the recommendations of the strategy and have backed it with funding.

It starts, of course, with prevention, and we have heard about the vigour with which the noble Baroness pursued public health and prevention when she was a Health Minister. Smoking and obesity remain the biggest preventable risk factors for cancer. That is why last year the Government introduced a childhood obesity strategy and a tobacco control plan for England. The truth is that we are making progress on smoking, and rates are coming down for almost every age group. However, we have a long way to go to tackle the obesity epidemic which we have not yet done. More courage is needed, I fear.

As the noble Baroness also said, early diagnosis is critical, and there are new early diagnosis standards, including a new 28-day faster-diagnosis standard. However, we all know that it is not just about targets but about bringing the best diagnostic tools and therapies into the NHS more quickly. There are also incredibly exciting discoveries in diagnostic science happening as we speak. I am sure that noble Lords will have heard about the successful trial of a blood test for cancers by a team at Johns Hopkins University, and we want our NHS to be able to bring on these kinds of innovations as quickly as possible. I am hopeful that our new accelerated access pathway, whose team meets for the first time next week and which becomes operative in April, will be looking at these kinds of technologies and will provide opportunities for them to come into the health service for NHS patients up to four years quicker than is currently the case.

At the centre of every cancer experience is a human being, their family and friends, with all the emotional and physical needs that attend. So it is right to expect that every patient is treated with compassion and dignity. The National Cancer Patient Experience Survey shows that more cancer patients are experiencing positive care overall, which is extremely welcome. I want to use this opportunity to pay tribute not only to the amazing NHS and care staff who deliver that care for cancer patients, but to our extraordinary range of charities and voluntary organisations. It is invidious to name some, but Macmillan Cancer Support, Cancer Research UK, The Brain Tumour Charity, and others provide outstanding support to people with, and recovering from, cancer.

Of course, their illness is not what defines cancer patients; life goes on, with its usual joys—if I heard the radio correctly, I think that for the noble Baroness that includes dancing—as well as its challenges. Making sure that life can go on as normal, or as close to normal as possible, is essential. At the moment, standards of care are high but there is local variation, and that is why there is a plan to create a national recovery package that is there for every cancer patient from the moment they are diagnosed. Inevitably, where the Government can make the most difference is in providing the necessary investment. I would like to highlight three examples of that investment, and shall attempt to avoid the list that Ministers often slip in to these kind of speeches. There are two areas where investment is really making an impact for cancer patients.

Elsewhere, the noble Baroness, Lady Jowell, has spoken about the surgery required to treat her cancer, which can be highly invasive and debilitating. There is major investment, I am pleased to say, in the modernisation of radiotherapy equipment taking place across England, including two new proton beam therapy centres. Combined with new approaches to surgery, it is hoped that that will bring benefits to around 6,000 brain tumour patients a year who will get access to less invasive surgeries. The noble Baroness specifically asked about the availability of a key florescent dye, and I can tell her it is called 5-ALA. It helps surgeons to see malignant tissue, so helps to ensure a more accurate surgical margin during surgery. We have spoken to NHS England in advance of this debate, which has committed to working with the cancer alliances and the brain cancer surgery centres to drive national uptake of its usage.

I also want to highlight another innovation or change, which is a big investment in the health infrastructure through 20 biomedical research centres in England. I had the opportunity to visit one of these last year at University College London Hospital, where I met some wonderful and very brave cancer patients who were among some of the very first people in the world to trial immuno and combined therapies, and they absolutely understand the importance of giving patients a choice about the ability to take risks when the prize is extra months of life with the people they love. These centres and their clinical research networks are now recruiting or have set up around 700 trials. I am just sorry that the noble Baroness was unable to find one in this country that she could access for her particular form of cancer. I can promise her that our determination, like hers, is that British cancer patients should not have to travel abroad to be part of trials or to access the kind of treatments that they need for their cancer.

Before closing, I want to address a number of the other issues raised by the noble Baroness during her speech. I absolutely agree with her that more investment is needed in cancer research for brain cancer. Making that happen is a specific objective of the departmental working group that has been operating under our Chief Scientific Adviser, Professor Chris Whitty. I can confirm that this group will deliver its final report to me next Wednesday, and I can also say today that one action stemming from that will be a highlight notice from the National Institute for Health Research to encourage researchers to submit applications for funding in the specific area of brain cancer research. I hope that some of the interesting ideas and research projects going on today will look at that opportunity so that we get more funding into this important area.

The noble Baroness also talked about the importance of adaptive trials. I am again pleased to report that they form a growing proportion of the clinical research network’s portfolio and are mainly in cancer trials. We undoubtedly need to be more radical in this, and the noble Baroness has provided a specific suggestion. I would be delighted to meet the director of the ECI, and I am thrilled that he is here today to hear the debate.

There has been, as the noble Baroness pointed out, a lack of new brain cancer drugs. Again, we have been in touch with the National Institute for Health and Care Excellence—I did not know that she had a role in its founding—about this. I am informed that there are a number of drugs in development specifically for glioblastoma and NICE has committed to publishing draft guidance on these drugs before they receive a licence. Drugs recommended in the draft guidance will be funded from the point of licensing, which brings forward the opportunity to use them by many months.

The noble Baroness also talked about the importance of data and having access to data. I could not agree more. As we know, one of the wonderful things about the NHS is that it is here for all of us, all the time. One quirk of the way that it was set up—I am not sure that Nye Bevan intended it, but it is certainly a benefit—is that it has an unrivalled dataset on patients’ medical experiences and journeys, which is invaluable to the research community. We all know that we have not always got policy right in this area or brought the public with us about the benefits of sharing data, but there are some key decisions coming up in the next few months to help us to access and create that dataset for research purposes. I warmly welcome the opportunity to engage with the noble Baroness and other noble Lords to make sure that we can win the argument with the public about sharing data for the benefit of not just ourselves but one another.

There have been many questions from noble Lords, and I hope that they will forgive me for not trying to answer all of them in the interests of time. I will of course write to any noble Lords whom I have not answered specifically. I just want to highlight three other things. First, genomic medicine and its potential in combination with artificial intelligence and machine learning have been mentioned. We have a set of 5,000 whole cancer genome sequences—believe it or not, that is the biggest set in the world. But, thinking about the number of people getting cancer every year, we need to do much better on this. There are big ambitions here, and I hope to use the opportunity of the NHS’s 70th birthday to make real progress in something ambitious in this area.

Several noble Lords asked about the Lords’ sustainability report. The department is perhaps not shown in its best light in how late the response has been. It will be published very soon, I can promise that. The issue of taxation has also been raised. I hope that noble Lords will forgive me if I say that is above my pay grade. They may also have noticed, however, that the Secretary of State for Health and Social Care has been here throughout the whole debate and listening intently. So I am looking to him, as I know that he will be making a case across government.

Finally, I have been a Minister for long enough to know that you cannot have a debate without talking about Brexit—so let us make it quick and positive. Clinical trials have been mentioned, but we should also mention medicine regulation. The Government’s intention, going into that negotiation, is to have a new way to create the same kind of partnership that we have now, not just for the good of patients in this country but for those across the EU as well. That is our intention and we think that is the right thing to do.

To close, I would like to talk about a word on which the noble Baroness focused towards the end of her speech, and that word is “Hope”—it also happens to be the name of my youngest daughter. The NHS symbolises many noble ideas—reassurance, compassion and service to others—but more than anything it provides people with hope: hope of a better life and more years enjoyed, not just for themselves but for those they hold dear: hope for a better today and for a better tomorrow.

What the noble Baroness has done today is to offer hope. With her courage in calling and leading this debate, and with her ever-fertile mind making suggestions for how we can improve cancer care, she raises our sights and demands that, collectively, we work harder to offer hope to people affected by the terrible disease she suffers with such dignity. It is the right challenge, and one I am prepared to accept on behalf of the Government. In doing so, I promise her that our efforts will not waver until the scourge of cancer no longer robs us of the ones we love.

Public Health: Strength and Balance Programme

Lord O'Shaughnessy Excerpts

Thursday 18th January 2018 Lords Chamber

[Lord Jordan]

To ask Her Majesty’s Government whether they intend to provide local authorities with sufficient resources to enable them to provide universal access to the Strength and Balance Programme for adults over 65.

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

My Lords, we are providing £16 billion to local authorities to spend on public health during the course of this Parliament. It is for local authorities to determine their spending priorities, reflecting the needs of their populations. The Chief Medical Officer recommends that adults undertake strength and balance activities on at least two days a week. Most local authorities provide opportunities for these activities within their falls prevention programmes.

[Lord Jordan (Lab)]

I thank the Minister for his reply and declare an interest as deputy president of ROSPA. Will the Minister acknowledge that it is the failure to tackle adequately the chronic causes that means a quarter of a million elderly people attend accident and emergency each year with fall-related injuries, which makes an NHS crisis inevitable when seasonal illness strikes the same social group? To ease the unacceptable burden on A&E departments, will he urge the Government to give more tangible support to local authorities and to age-related and safety organisations whose work with elderly people, through what they call strength and balance exercise-based programmes, can and does significantly reduce the risk of injuries to those taking part?

[Lord O’Shaughnessy]

The noble Lord is quite right to point out the importance of preventing falls. Around 95% of hip fractures come about through falls, at particular cost and pain to the individual, of course, but also to the wider economy as a whole. I should point out that Public Health England supports a number of activities, one of which is a partnership with Sport England that has trained 5,000 health professionals in delivering physical activities, including strength and balance work. I agree that more needs to be done at local authority level, particularly as we have an ageing population, but there is good work going on at the local level.

[Baroness Jolly (LD)]

My Lords, in parts of Cornwall there has been real success with the strength and balance programme, with a huge reduction in falls. We all know that prevention is always better and cheaper than the cure. Can the Minister tell the House what work has been done to determine how much could be saved for the NHS as a result of a total rollout of this programme and why reductions to local authority public health budgets are jeopardising such programmes?

--- Later in debate ---

[Lord O’Shaughnessy]

I have not seen an extrapolation of the benefits the noble Baroness talks about but they would clearly be significant. There are a number of schemes going on at a local level, which it is important to point out. One of them, which we have discussed before, is the “Dance to Health” programme that started with six pilots two years ago. That is now a nationwide scheme across England and Wales. Local authorities should look at precisely that kind of activity. Public Health England is committed to making sure that local authorities understand the Chief Medical Officer’s targets, so that we see more of these programmes taking place.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest as president of the Chartered Society of Physiotherapy. There is evidence that every £1 spent on physiotherapy can save £1.50 on the cost of a fall along the whole trajectory. There is also evidence that targeted, multifactorial risk assessment of people at particular risk can decrease falls by 60%. Therefore, will the Minister make sure that falls prevention is viewed across the whole of the NHS and not only delegated to local authorities and programmes outside, because that would miss some of the people who are at the highest risk of falls?

[Lord O'Shaughnessy]

I am grateful to the noble Baroness for pointing out the benefits of physiotherapy. She might be aware of a scheme in Middlesbrough that is providing for people who have fallen a precise pathway from physio into community activities involving strength and balance work. As ever, one of the challenges is to make sure that all local authorities know about such programmes and put them in place. They are not necessarily expensive, but they take a bit of time. I will make sure that Public Health England is taking that attitude of spreading good practice across the country.

[Baroness Thornton (Lab)]

My Lords, NICE’s most recent and excellent quality statements in January 2017 offer guidance on falls and the importance of multifactorial risk assessments and interventions. These interventions require resources, particularly from social care specialists and public health workers, who we know are at the sharp end because of the financial pressure the Government have put on local authority funding and the successive reductions of public health budgets. Now that the Secretary of State has responsibility for social care, will he therefore ensure that strength and balance programmes are properly resourced? When will NICE next update its statistics on the uptake of guidance on this matter?

[Lord O'Shaughnessy]

I will write to the noble Baroness with specifics on the NICE guidelines, which are incredibly important because they establish best practice. Of course, it is then incumbent on professionals to follow that best practice. We know that public health budgets have been under pressure, but local authorities are still getting £16 billion over five years. That is a lot of money and they can use some of it to focus on such activities. Moreover, in the spring Budget last year, there were big increases in the social care budget, which I know we all welcomed. That money is particularly focused on older people and preventing falls, which is what we want to see as part of that programme too.

[Lord Elton (Con)]

My Lords, the noble Lord, Lord Jordan, has raised a matter that is of close interest to a large number of noble Lords. I wonder whether it would be worth considering having access to the programme to which he refers in the Palace of Westminster.

[Lord O'Shaughnessy]

My noble friend makes an extremely good suggestion and I look forward to talking to him about that. Perhaps he could lead such a class.

[Lord Lea of Crondall (Lab)]

My Lords, in addition to the suggestions that have been made, perhaps I could pass on a tip: playing tennis is quite good for this sort of thing.

[Lord O'Shaughnessy]

Indeed it is, as are other things such as yoga, tai chi and—believe it or not—carrying shopping bags.

[Lord Kakkar (CB)]

I declare my interest as chairman of University College London Partners. What assessment have the Government made of the provision of accountable care organisations to drive the integration across primary care, secondary care and social care to achieve the kinds of objectives that are the subject of this question?

[Lord O'Shaughnessy]

The noble Lord makes an incredibly important point. We know that we want an integrated health service, particularly as we have older people with comorbidities using a range of services. The five-year forward view—NHS England’s own strategy for the future—talks about how that integration will take place through what the noble Lord calls accountable care organisations or systems. We are moving ahead with these: indeed, the most recent Budget is providing significant capital to support that integration. This is the future of the NHS, and we all need to get behind it.