NHS: Nurse Retention

Lord O'Shaughnessy Excerpts

Wednesday 17th January 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask a Question of which I have given private notice.

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

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

[Lord Hunt of Kings Heath]

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

[Lord O’Shaughnessy]

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

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

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

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

[Lord Clark of Windermere (Lab)]

My Lords, the Minister has yet again repeated that there are 11,700 extra nurses on the ward, and compounded that by saying that there are more trained nurses in Britain than there were in 2010. Yet a Written Answer to me of just 10 days ago shows that we currently have 317,980 nurses, which is fewer than there were in 2010. Can he square that circle—or is he talking not about nurses but about nursing assistants?

[Lord O’Shaughnessy]

On the specific and most recent workforce data—if we are going to get into the specifics of nurses only—in May 2010 there were 273,071 nurses and in September 2017 there were 275,356, so that is an increase. I shall certainly look into the figures with which I wrote to the noble Lord. Of course, I intend always to be truthful. I am reading from the latest workforce stats.

As for nurses on wards, the noble Lord will know that the number has gone up. An important response to the scandal of Mid Staffordshire and the Francis report was to increase nurse numbers. We know that that has a consequence for other professions—I have talked about that quite openly—and in mental health and district nursing. That is why we want to increase the number of nurses in those areas.

[Lord Patel (CB)]

Does the Minister agree that the real issue is the lack of long-term workforce planning of all health professions, including social care? That planning should address the changing demography of citizens and the changing pattern of disease—and involve flexible training. Does he agree that that is what is required, and that what we have now is too many individuals or organisations trying to address the workforce? While he is at it, could the Minister also put on record when the Government will respond to the Select Committee of this House’s report on NHS long-term sustainability, which was published 10 months ago?

[Lord O’Shaughnessy]

The noble Lord speaks with great wisdom and experience. He is quite right about the need for long-term workforce planning. I hope that is why he will welcome the 10-year strategy that Health Education England is launching. It is looking at diversifying the working population—for example, through the growth in the number of nursing associate training places.

On the report, I can only apologise again for the delay. I hope that at least the noble Lord will welcome the fact that in the reshuffle the health department gained social care policy. That was one of the issues on which he wanted to promote greater integration.

[Baroness Jolly (LD)]

My Lords, in the past 12 months, more than 6,000 nurses have gone on long-term sick leave, related to stress. How are nurses being helped to cope by the occupational health departments of their employers, and do the Government acknowledge that the problem is exacerbated by a 1% cap on their pay rise?

[Lord O’Shaughnessy]

I acknowledge the importance of looking at pay, which is why it was so welcome that the issue was dealt with in the Budget, with the cap being lifted for nurses and other health professionals on Agenda for Change contracts. I agree that long-term sickness is a big concern and undoubtedly having an impact on some nurses leaving. That is why the return-to-practice programme that we have is so important. Several thousand nurses have been through it; it is about providing opportunities to come back into the profession in a supportive way for those who want to do so.

[Lord Tebbit (Con)]

My Lords, can my noble friend tell me how many of these nurses who have left the NHS are now working for agencies and still in the same hospitals, on the same wards, doing the same work but costing the taxpayer rather more money?

[Lord O’Shaughnessy]

In the last few years there has been an increase in agency spend. Of course, per nursing hour that tends to be more expensive. We have managed to reduce agency spend by increasing the availability of nursing banks. Those are the people employed on flexible contracts, which is very welcome for many nurses who are looking for—as they say in staff surveys—greater flexible working arrangements.

[Lord Watts (Lab)]

My Lords, how did the Government get their planning so wrong? The demographics were known, and yet the Government have failed to plan to provide the sorts of numbers of nurses that we need. What went wrong?

[Lord O’Shaughnessy]

We know that we have a growing ageing population—I do not doubt that. We have been increasing real-terms funding for the NHS, which is going on more staff. Nurse numbers have increased and I should point out that there are more doctors and ambulance staff. There have been about 40,000 more clinical staff in general in the NHS over the past few years and more to come in the future.

[Lord Willis of Knaresborough (LD)]

Does the Minister accept that roughly 10% of our nursing workforce has left the profession this year? Many of them are new recruits or not long into their careers. It takes about £80,000 to train a nurse. Any employer with any sense would want, first, to retain them and, secondly, when they leave, to know why they have left, where they have gone and how to get them back. What are we doing to track people who leave and what are we doing to attract them back?

--- Later in debate ---

[Lord O’Shaughnessy]

The point about understanding the reasons that people leave is very important. Some hospitals use exit interviews for that; I do not know if it is a nationwide programme but I shall certainly write to the noble Lord about that as it is a good idea. As for attracting staff back, I mentioned the return-to-practice programme. I think my noble friend Lady Chisholm took advantage of a similar programme when she returned to work after having children. I come back to the issue of pay. We know that pay is important, which is why lifting the cap will make an important difference to showing how much we value these staff.

[Baroness Masham of Ilton (CB)]

My Lords, does the Minister agree with me that, if the National Health Service provided reasonable housing for nurses and flexible working for those with children, it would help to retain them?

[Lord O’Shaughnessy]

The noble Baroness is quite right. We know that housing costs are an issue, particularly in the south of England and cities, which is why we want to use the sale of surplus NHS land to deliver more homes specifically for nurses and other similar professionals. She is also right to talk about flexible working, which comes up time and again in staff surveys. The use of nursing banks can be very helpful in that regard, and we have seen a big switch away from agencies towards using such banks for those places that need to be filled temporarily.

[Baroness Symons of Vernham Dean (Lab)]

My Lords, the Minister talked about the number of nurses on wards; can he say something about the numbers in accident and emergency departments? I had occasion recently to go with somebody to accident and emergency. The person in question was in dire straits and, when I spoke to the sister in charge, she said that there were waits of six, seven, eight hours every night in accident and emergency in that hospital in a major town in Wiltshire. Can the Minister tell us whether accident and emergency is being properly addressed and when he last had occasion to speak to a sister in charge about what is really happening?

[Lord O’Shaughnessy]

The kind of waits that the noble Baroness has pointed to are clearly unacceptable. People should not have to wait that long in A&E and that is why we have the target. I accept that it happens but it is unacceptable. We know that the NHS is under huge pressure at this time of year. There have been, as I pointed out, more nurses in A&E and in wards in general—indeed, there are more emergency doctors as well. But we accept that there is a need for more, because of the growing needs of the population.

NHS: Winter Funding

Lord O'Shaughnessy Excerpts

Thursday 11th January 2018 Lords Chamber

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

My Lords, in the Autumn Budget, we allocated £337 million to be available immediately for trusts to use this winter. This package funded more hospital beds, community services, mental health services and urgent GP appointments to manage the expected surge in demand. After Easter, the NHS, as last year, will undertake a full review of this winter and identify any lessons for the future. We expect that that will include an assessment of the impact of this funding.

[Baroness Wheeler]

I thank the Minister for his response. He will have seen the BMA’s stark analysis of one week between Christmas and new year. In just those seven days, bed occupancy rose to 91.4%, 39 ambulances were diverted from A&Es that were too busy to cope, 731 beds were closed due to diarrhoea or vomiting, and by the end of the week, 3,400 escalation beds had to be opened because hospitals were full. Today’s figures and the warnings from NHS Providers tell the same sorry story. Does the Minister accept that announcing extra funding in November/December was far too late to prevent the worst period across the winter so far or the Government having to announce the bombshell of 550,000 cancelled operations? Can he also tell the House how the Prime Minister’s plan will now be revised to reflect these everyday realities and come up with the urgent action and funding that is needed to help the NHS cope with its worst winter crisis in two decades?

[Lord O’Shaughnessy]

I would hope that the noble Baroness would welcome the money that was set aside in the Budget. It is important to point out that in addition to that £337 million, half of which has gone to support plans that were already in place and being actioned before the Budget, there was a further £100 million to support A&E streaming, which is also a way of taking pressure off emergency services. That has had an impact, so I do not accept the accusation that the money came too late, and indeed there is still money in the pot as services come under pressure.

As regards the future, the noble Baroness will know that it was also announced in the most recent Budget that another £2.8 billion would be allocated to the NHS to help it get through the next few years. We know that the pressures are increasing because of the ageing population. The idea of that money is precisely to help the NHS get back on target on A&E waits as well as referral to treatment.

[Lord Clark of Windermere (Lab)]

My Lords—

--- Later in debate ---

[Lord O’Shaughnessy]

I shall certainly take that interesting idea to the new Minister for social care. The noble Baroness will be pleased to note that the number of delayed transfers of care actually fell in the run-up to winter as a result of the extra money that went into social care. However, she has put forward an excellent idea and I shall certainly take it to my new colleague.

[Baroness Jolly (LD)]

My Lords, £100 million of the money announced by the Chancellor went into primary care streaming, which is designed to keep all but the most ill out of A&E. Some £55 million of that was handed out in April and £21 million in June. Can the Minister give an indication of the impact thus far of primary care streaming and tell the House where the other £24 million went?

[Lord O’Shaughnessy]

Nine out of 10 type 1 A&E departments now have streaming in place, so the money has gone into that. However, obviously we want to get to 100% so that is where the extra funding will go, but it is already having an impact. A full quantitative evaluation will take place at the end of the winter.

[Lord Porter of Spalding (Con)]

My Lords, will my noble friend confirm that this Government have spent more on the National Health Service than any of their predecessors—considerably more as a proportion of our income, particularly in a world where money is in short supply? Does he agree that the only way to get a truly sustainable health service is to make sure that adult social care is funded to an adequate level? He has already acknowledged that the delays in transfers to social care that result in bed blocking have been reduced, indeed at twice the rate of the delays caused by health service internal delays. From what we have seen over the past few months, it is clear that money invested in social care is the best way of helping the health service.

[Lord O'Shaughnessy]

I thank my noble friend for pointing out the fact that no Government have funded the NHS like this one. Indeed, the proportion of public spending taken up by NHS spending has been increasing in the last seven years, contrary to the views held by those opposite. On the impact of adult social care, my noble friend speaks with great wisdom. We know that money invested in the social care sector has a big impact. It already has, as he pointed out. That is why it is meaningful that the department has taken on full control over social care policies so we can push ahead with integration, which, as we know, is the right way to solve these problems.

[Lord Clark of Windermere]

My Lords, it is a question not only of money, but of planning and training staff. Did the Minister see yesterday that the head of chemotherapy at Churchill Hospital, Oxford, said that cancer treatment and chemotherapy were being delayed and curtailed because of the lack of trained nurses? Yet the Prime Minister denies this. Who are we to believe?

[Lord O'Shaughnessy]

I think that the trust has been clear that there are not going to be delays. If the noble Lord is talking about the story on the front page of the Times yesterday, the trust has subsequently been clear that it will not delay or curtail its treatments. We know that more nurses are required. That is why, as I am sure he will be pleased to know, there have been around 11,700 more nurses on wards in the last seven years.

[Baroness Hollins (CB)]

My Lords, I have heard from clinicians, including an on-call psychiatrist working over Christmas at St George’s Hospital in south London, about the difficulties experienced and the teamwork displayed to manage the exceptional strain and capacity problems hospitals face. Particular concern was expressed about the pressure to discharge patients quickly and the possible impact on people with learning disabilities or serious mental illness, especially given similar pressures in social care. What steps are being taken to prevent this, for example, by targeting flu vaccination to these vulnerable groups, but also to monitor the impact on them?

[Lord O'Shaughnessy]

The noble Baroness is right to pay tribute, as we should all do, to the incredible work that NHS and social care staff are doing during winter. Of course there is a need to discharge patients, but that should be only when it is clinically appropriate. If she has seen or heard of instances in which she believes that that is not the case I urge her to write to me with them. On how we deal with vulnerable groups, one example is clearly flu vaccination. I point out, and this is important, that not only were flu vaccinations offered for all NHS staff for free this year, with 60% uptake, but for the first time they were also offered to care home staff. That is a really important point about making sure we go to the community to prevent infection.

Agency Nurses

Lord O'Shaughnessy Excerpts

Wednesday 10th January 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government, further to the Written Answer by Lord O’Shaughnessy on 27 November 2017 (HL3070), what assessment they have made of the operation of the “break glass clause” in the supply of agency nurses to hospital trusts from off-framework agencies.

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

My Lords, significant progress has been made in reducing agency staffing in the NHS. In 2016-17, the NHS spent £700 million less on agency staff than in the previous financial year. The “break glass” clause is one of a number of measures introduced to support patient safety while we seek to reduce the use of agency staff. Since a peak in April 2016, the number of nursing shifts procured from off-framework agencies has more than halved.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer on this very complicated issue. However, does he recall his Answer to my Written Question of Monday in which he confirmed that the incoming Conservative-led Government in 2010 cut the number of nurses virtually every year, sometimes in excess of 10,000, with the result that we have fewer nurses working in the health service today than in 2010? That is the cause of our reliance on agency nurses, which costs the NHS billions of pounds. This cannot continue, so will the Minister use his influence to try to ensure a proper workforce plan for the NHS so that we have sufficient staff to meet the needs and demands of the British people?

[Lord O'Shaughnessy]

The noble Lord is quite right that we need sufficient staff. He will know that when the Government came to office in 2010 difficult decisions needed to be made about the funding of all public services, because of the economic situation at the time. It is worth pointing out that, since that time, there are over 10,000 more nurses on wards, which is obviously particularly important at this time of year. In terms of the future figures, I hope he will be aware that there will be an increase in the number of training places for nursing—£5,000 a year. Indeed, Health Education England, which is responsible for workforce planning, will deliver a long-term plan to make sure that we can tackle this issue, which has been a long-standing problem for the NHS.

[Baroness Jolly (LD)]

My Lords, the Royal College of Nursing surveyed its members on this issue and two key things came out. One was that they wanted flexible working hours and the other was that they wanted the ability to choose a ward or specialty. It is clearly better for nurses to be employed by their trust rather than through an agency, so what are NHS trusts doing to accommodate nurses’ desire for flexible working patterns and a choice of where they work?

[Lord O'Shaughnessy]

On the issue of flexible working there is an important distinction between agency working and bank working. Bank working provides a degree of security and familiarity, in that the nurses employed by nursing banks often work in the same hospitals. That is one of the most important ways that we can provide the flexible working which, as the noble Baroness quite rightly said, nurses want.

[The Earl of Listowel (CB)]

Can the Minister reassure the House on the supply and retention of psychiatric nurses, and that they are getting the excellent support that they especially need? He might wish to write to me on that.

[Lord O'Shaughnessy]

I will certainly write to the noble Earl specifically on psychiatric nurses. He will, I hope, be aware of the plan to recruit many more mental health staff as we seek to radically improve outcomes and delivery in that area.

[Baroness Gardner of Parkes (Con)]

My Lords, as a former hospital chairman, I am aware that agency staff are called in only when they absolutely have to be, when there is no other alternative. I wonder whether the National Health Service has looked at offering existing nurses in hospitals the opportunity of doing some more work out of hours, as some of them would find that convenient. There is a tendency for doctors as well as nurses to look for locum and agency jobs because they are better paid.

[Lord O'Shaughnessy]

It is that last issue that we are trying to address. One factor is that there is now an hourly rate price cap on agency spend, precisely to drill down into that issue. The reason that the number of agency staff went up was in response to the Francis review and what it said about safe staffing levels in the service. The immediate response was to deal with that through agency staff. That was expensive, of course, which is why we have had to push down those costs. Nurses have to come from somewhere, and my noble friend is quite right that using existing nurses and support from nursing banks is one way of meeting demand with better value for money.

[Baroness Pitkeathley (Lab)]

My Lords, I noted carefully the Minister’s words about 10,000 extra nurses on the wards. Can he update the House on the position for community and district nurses?

[Lord O'Shaughnessy]

The number of those nurses has fallen—as have the numbers in mental health, which is worth pointing out—and we are trying to address this. I think I made a slip of the tongue a moment ago when I said that £5,000 more will be spent each year on training nurses; I meant that there will be 5,000 more student nursing places.

[Baroness Thornton (Lab)]

My Lords, the Question further teases out the sometimes expensive inadequacies in workforce planning in our NHS. Under the circumstances of the winter crisis and the 40,000-nurse shortfall, clearly trusts have no choice sometimes but to take on agency staff in specialist and other services—and this is expensive. Does the Minister expect that the late funding made available for the winter crisis will be spent largely in this way? Will his department penalise trusts for using agency staff in this way?

[Lord O'Shaughnessy]

The noble Baroness is quite right that agency staff are sometimes used to fill vacancies—about nine out of 10 vacancies are filled in that way. The key is to make sure that they are used in a proper, planned way that is not expensive. The point about the “break glass” clause is that the rules that exist to cap agency spend can be broken where there is a need and where that need is approved by the trust for patient safety purposes. That is an important feature of the system.

[Baroness Masham of Ilton (CB)]

My Lords, in this present crisis, are more nurses taking advantage of the “break glass” clause?

[Lord O'Shaughnessy]

The number of uses of the “break glass” clause has actually fallen since April 2016, which was the peak. This shows that there has been a much more planned use of bringing in extra staff as they are needed, rather than an ad hoc response, which was what it was designed to address.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, further to the question from my noble friend Lady Pitkeathley, now that the noble Lord’s department has had “Social Care” appended to its title, does he agree that community and district nurses must be a vital part of the interface between healthcare and social care? As he has indicated that he accepts that there are fewer of them, what is being done to ensure that there are more in the future?

[Lord O'Shaughnessy]

That is an incredibly important point. We know the role that district and community nurses have, particularly in the interface between hospitals and social care. I have pointed out that more nurses will be trained. That will provide an opportunity to recruit to those areas which have not seen the increases that other areas of nursing have done, including district and community.

NHS Winter Crisis

Lord O'Shaughnessy Excerpts

Monday 8th January 2018 Lords Chamber

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

My Lords, with the permission 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:

“Thank you, Mr Speaker. I thank the right honourable gentleman for tabling this Question, as I agree with him that it is helpful for colleagues in this House to be updated on the current performance of the NHS during this challenging time.

We all know that winter is the most difficult time of year for the NHS, so I would like to start by saying a heartfelt thank you to all staff across the health and care system who work tirelessly through winter, routinely going above and beyond the call of duty to keep our patients safe. They give up their family celebrations over the holiday period to put the needs of patients first. It is these dedicated people that make the NHS truly great.

Winter does place additional pressure on the NHS, and this year is no exception. The NHS saw 59,000 A&E patients every day within four hours in November; that is 2,800 more each day compared with the year before. The figures for December will be published this coming Thursday. We have done more preparing and planning this year than ever before, with planning beginning earlier, meaning that the NHS is better able to respond to pressure when it does arise. In the words of Professor Sir Bruce Keogh, the national medical director:

‘I think it’s the one [winter] that we’re best prepared for. Historically, we begin preparing in July/August. This year we started preparing last winter. We have, I think, a good plan’.


Let me tell the House about some of the things that have been done differently this year. We have strengthened further the NHS’s ability to respond to risk, including the NHS setting up the clinically led national emergency pressures panel to advise on measures to reduce the level of clinical system risk. We are supporting hospital flow and discharge. We allocated £1 billion for social care this year, meaning local authorities have funded more care packages. Delayed transfers of care have been reduced, freeing up 1,100 hospital beds by the onset of winter. Additional capacity has been made possible through the extra £337 million invested at the Budget, helping 2,705 more acute beds to open since the end of November. We have also ensured that more people have better access to GPs.

We allocated £100 million to roll out GP streaming in A&Es, and I am pleased that 91% of hospitals with A&E departments had this in place by the end of November. For the first time people were able to access GPs nationally for urgent appointments from 8 am to 8 pm seven days a week over the holiday period. In the week of New Year’s Eve the number of 111 calls dealt with by a clinician more than doubled, compared to the equivalent week last year, to 39.5%, reducing additional pressures on A&E. We also further extended our flu vaccination programme, already the most comprehensive in Europe. Vaccination remains the best line of defence against flu, and this year an estimated 1,175,000 more people have been vaccinated, including the highest-ever uptake among healthcare workers, which by the end of November had reached 59.3%.

We all accept that winter is challenging for health services, not just in this country but worldwide. The preparations made by the NHS are among the most comprehensive, and we are lucky to be able to depend on the extraordinary dedication of front-line staff at this highly challenging time”.

[Baroness Thornton (Lab)]

I thank the Minister for that Answer, and I am pleased to see that he is still with us and in his place at this time. I wish him a very happy and prosperous new year. I question the idea that the Government and the NHS were prepared for this winter crisis. It seems to me that, if extra funding was made available in November and December, that does not smack of preparedness at all. I was very struck and somewhat chilled yesterday by what Andrew Marr said to the Prime Minister on his show. He said that had he experienced, when he had his stroke, the kind of five-hour delay experienced by Leah Butler-Smith and her mother, he would not have survived. I invite the Minister to have a stab at making a better job of answering that question today. What would he say to those whose lives have been put at risk by this winter crisis?

Will the Government be making available to us an analysis of the impact on patients, and the lives cost, of a combination of: 55,000 cancelled operations; 75,000 people held in ambulances; overstretched accident and emergency departments, with people on trolleys and even on the floor; up to 90% bed occupancy, which is very dangerous; a shortage of GPs; and inadequate social care due to the starving of funding to local authorities over a long period? When will we know what the impact of this has been on people? When will the Government properly fund and manage the winter stresses in our NHS?

[Lord O’Shaughnessy]

I thank the noble Baroness for her good wishes, and I wish her and all noble Lords a happy new year. She asked several questions, and I will try to deal with them all. Her first question was about being well prepared. Those were the words of Sir Bruce Keogh from NHS England, not mine. I should also point out that Keith Willett, the director for acute care for NHS England, said that the service is better prepared than ever. Of course, that does not mean that there are not challenges. We know that this happens every year.

One of the ways that we see challenges happen is that there are cancelled elective procedures. I have been looking back over the data for the past 20 years. In quarter 4 of each year—January to March—those cancellations do happen. In fact, I was looking back at 2000-01 and there were 24,000 cancelled or postponed operations that year, which is actually one of the highest over that period. These things do happen during winter, and that is one of the ways of coping. The Prime Minister has apologised for that, and I endorse that. Of course, it is not a state of affairs that we want to happen, but it is necessary to make sure that the most urgent cases are treated. It should be pointed out that the direction about elective procedures made it clear that time-critical procedures around cancer operations and others can go ahead. We will see over time what the impact of that was.

I will mention one other thing about preparedness. The noble Baroness talked about bed occupancy. Of course, we know that high levels of bed occupancy are a concern. Bed occupancy was below the target of 85% going into this period—on Christmas Eve it was 84.2%, I believe—so that was put in place. We know it is going to be challenging. We know that flu is going to continue to have an impact over the next few weeks, and we will see what we can do, but we know that the NHS has put in unprecedented levels of preparation to make sure that we can get through what is always a difficult period.

[Lord Naseby (Con)]

My Lords, is it not encouraging that at least this year there was preparation for winter? The fact that it was not an enormous success everywhere is a lesson that I hope Her Majesty’s Government will take on board. Against that background, will my noble friend be preparing a report on the experience this winter? Will he confirm that next year there will be a plan which takes on board the experience of this year? I can quote only from local experience but is it not a fact that Luton and Dunstable University Hospital, which has had a special A&E unit for some years, did not have difficulty, whereas other hospitals that were not prepared to that extent appear to have had difficulty? If that is the case, is it not time we brought the other hospitals up to a better standard—the sort of standard that Luton and Dunstable University Hospital gives to its community?

[Lord O’Shaughnessy]

I thank my noble friend. He is right to point out that there is variation across the country. He mentions Luton and Dunstable University Hospital. It has been a pioneer of how to make sure that people coming into A&E are properly dealt with. Indeed, the £100 million that was invested in A&E services to support better triaging was based on the Luton and Dunstable model. Obviously, we need to make sure that those high standards are replicated across the country.

I will give one further example of an area where that planning has taken place. We know that there has been pressure on ambulance services and that there has been a variability of performance there. There is now a national ambulance control centre which is keeping real-time data and looking at how to manage that performance so that we can get a proper national grip on this picture.

[Lord Crisp (CB)]

My Lords, does the Minister acknowledge that 59,000 people a day going into A&E is an indicator that there simply is not enough support in the community? Can he give us any indication of how many people he thinks could have been prevented from going into A&E and causing these sorts of problems in hospitals if there were more support in the community, which would mean, for example, that people with infections were caught early and would not need to be admitted? Does he also note that a recent survey showed that one-fifth of the people in adult mental health hospitals were there simply because there was no provision for them in the community? That does not mean just social services; it means housing.

[Lord O’Shaughnessy]

I thank the noble Lord for that point. He will have experienced a few of these difficult winters when he was running the NHS. It is difficult to say what number or proportion of those 58,000 or 59,000 people could have been treated in the community. We do know that the 111 service has been successful this year, with nearly 40% of calls involving a clinical opinion keeping people out of A&E, as has primary care. It is difficult to estimate, but we know that a number of people have been kept away. Of course, there is a growing and ageing population, and that is the underlying driver of demand. On mental health, the noble Lord is quite right. We have not done enough in mental health over many years, and that is one of the reasons that it has been a priority for the Prime Minister, with a big increase in the number of mental health staff in the years ahead.

[Lord Campbell-Savours (Lab)]

My Lords, I understand there is a new strain of flu in circulation this year, for which the flu jab was not designed. Does that mean that elderly people, who are particularly vulnerable to this new strain of flu, should have a second inoculation?

[Lord O’Shaughnessy]

There are of course at any one time a number of flu strains going around. There is particular concern about one of those strains affecting elderly people. Its circulation has come about quite late, as it were, and I would absolutely point out that the best way for elderly people and all at-risk groups to protect themselves is still to get that inoculation. For those who have not—

[Lord Campbell-Savours]

A second one?

[Lord O’Shaughnessy]

I am not in a position to say whether they should have a second inoculation, but there are still a number of people who have not had that inoculation. Those vaccines are available in GPs, surgeries, and we absolutely encourage all groups to have at least a first one.

[Baroness Jolly (LD)]

My Lords, it seems as if a winter crisis, year on year, is totally predictable. I cannot remember a year when there was not one, but I echo the Minister in paying tribute to those NHS staff, right across the system, who have worked flat out 24/7. Part of the problem is that the social care system and health system are not properly integrated—although I note from Twitter just now that Secretary of State Hunt has responsibility for social care, with immediate effect. Can the Minister tell me whether there are hospital beds occupied by people who no longer need them but are unable to return home? Can he give me an indication of the shortfall in accommodation or beds in the public, private and not-for-profit sectors in nursing and care homes? What gives the Government confidence that the £335 million in the autumn Budget will help, and can he give us some clarification on how that money is to be distributed?

[Lord O’Shaughnessy]

First, I join the noble Baroness by reiterating on a personal basis a tribute to the staff who have worked so hard over this period. I think we all know many of those people, and they do an extraordinary job. Social care is clearly a really important part of the picture because it is not just the flows into hospitals but the flows out. A lot of that is to do with delayed transfers of care. That is one reason why additional funding has been going in—I think it is £1 billion this year. It is important to point out that all local authorities have now signed up to plans to reduce what are called DToCs, in the jargon. DToCs have been falling, which means that there is the opportunity to get people out of hospital. That could be into a care home or residential care or it could be to their own home.

[Lord Framlingham (Con)]

My Lords, the disastrous white elephant which is HS2 will cost a minimum of £60 billion. The NHS needs £5 billion to balance the books, and a fraction of HS2’s cost would provide finance for the NHS for years to come. I urge the Minister to please urge the Government to scrap HS2 and spend the money saved on sensible projects, with the NHS at the top of the list.

--- Later in debate ---

[Lord O’Shaughnessy]

My Lords, I am happy to endorse calls for more funding for the National Health Service. That is precisely what the Chancellor provided in the Budget.

[Baroness Finlay of Llandaff (CB)]

My Lords—

Smoking: Vaping

Lord O'Shaughnessy Excerpts

Tuesday 19th December 2017 Lords Chamber

[Viscount Ridley]

To ask Her Majesty’s Government whether, in the light of Public Health England’s decision to include vaping within its stop smoking campaign for 2017, they will review vaping regulations in line with the commitment in the Tobacco Control Plan for England; and if so, when.

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

My Lords, the Government are committed to a review of the Tobacco and Related Products Regulations 2016 by May 2021. There is limited scope for amending the regulations in advance of the UK exiting the EU, so the Government envisage a review taking place after 29 March 2019. Protecting the public’s health will be the priority in any review.

[Viscount Ridley (Con)]

My Lords, I thank my noble friend for that Answer but I am a little disappointed. Given the strong evidence that vaping is much safer than smoking, that it is very effective at getting people off smoking and that the strength of the vaping industry in this country is one of the main reasons why we are now the second-lowest smoking country in Europe, and given that the Government promised some sensible deregulation in the tobacco control plan, does the Minister share my regret that the EU’s tobacco products directive restricts advertising in particular, making it very hard for vaping companies in this country to bring to smokers the news of the health benefits that can come from it? Will he consider a public information campaign to bring the country’s attention to what vaping can do? Will he perhaps also consider giving clear advice to businesses and councils that they should not be treating vapers as smokers?

[Lord O'Shaughnessy]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord O'Shaughnessy]

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

[Lord Palmer (CB)]

My Lords, the noble Viscount made a good point, because the same European legislation also brought in a ban on all small tobacco packs, which had a devastating impact, particularly on small local shops. Will the Minister therefore commit to reversing the ban on small packs once we have left the European Union? I declare my interest as set out in the register.

[Lord O'Shaughnessy]

I am afraid I shall have to disappoint the noble Lord there. Our broad approach on restricting the advertising and sale of tobacco has been incredibly successful: we have very low smoking rates in this country, and they are falling all the time. We have ambitious goals to reduce smoking prevalence, including a long-term goal of reducing it to less than 5% of adults, and I am not convinced that what he describes would help.

[Lord Brabazon of Tara (Con)]

Can my noble friend explain the advertising point to me, as one who has given up smoking through vaping? I have not had a cigarette for three and a half years. I tried patches, I tried chewing gum, and I even went to a hypnotist. None of those worked. Can my noble friend tell me why those three things are allowed to be advertised, although they do not work, whereas vaping, which does work, is not?

--- Later in debate ---

[Lord O'Shaughnessy]

The noble Lord is right; we are looking at the guidelines at the moment, with Ofcom and the Advertising Standards Authority. There are limits on what we can do on vaping under the current regulations, but we will have the opportunity to look again at this issue as we leave the European Union, and reconsider our domestic legislation.

[Lord Rennard (LD)]

My Lords, vaping has proved an effective way for many people to give up smoking tobacco—but there are, of course, no inherent health benefits in taking up vaping if one is not already addicted to nicotine. Does the Minister agree that we should seek regulations that allow the promotion of vaping solely as an alternative to smoking tobacco, and not something that people not already addicted to nicotine should be encouraged to take up? Can he tell us when Public Health England will publish its report on e-cigarettes, which was due in 2017?

[Lord O'Shaughnessy]

I think that the noble Lord is making the point that we need a balanced approach. We want to emphasise the relative health benefits, but we must also recognise that harmful effects can come from nicotine in itself. Obviously, we want to get to a position in which people are not smoking and not taking nicotine at all, and the relative benefits of the different ways people can go about that are taken into account. I think that the UK has a sensible approach. I am afraid that I do not have the date when the Public Health England report will be published, but I will write to the noble Lord with that information.

[Earl Cathcart (Con)]

My Lords, as my noble friend Lord Ridley said, vaping has been hugely successful in getting 2.8 million Brits—myself included—off smoking tobacco. Snus, however, has been even more successful in reducing tobacco use in Sweden: 5% of Swedes still smoke tobacco, compared with 16% of Britons and 24% across the EU states. Given the success and safety of snus, why can we not use it in this country?

[Lord O'Shaughnessy]

My noble friend is quite right to point out that vaping is a British success story as an anti-smoking aid, and it has made a huge contribution not just to noble Lords but to around 2.5 million e-cigarette users, half of whom used to smoke. There is, of course, as he will no doubt be aware, a court challenge going on at the moment. It is under consideration by the CJEU, and we expect a judgment in the summer of 2018, so I am unfortunately not in a position to comment until we have that judgment.

[Lord Wallace of Saltaire (LD)]

Could the Minister possibly encourage his colleagues to consider publishing a list of EU regulations which are there primarily because British lobbies with the support of British Ministers have pushed them on to the EU? I am thinking in particular of animal welfare, as well as a lot of health and smoking regulations. It would help to educate opinion in this country as to what sort of regulations might be likely to diverge after we leave, and which will not.

--- Later in debate ---

[Lord O'Shaughnessy]

Anyone who really wants to find out how many regulations there are provided by the EU can find that online, and I am sure that it would be a wonderful way to spend a weekend. I am just going to bother myself with the ones that have been dedicated to the health area. We are, of course, looking at everything within that realm to make sure that, when we leave the European Union, we end up with the best possible health regime.

Health: Atrial Fibrillation and Stroke

Lord O'Shaughnessy Excerpts

Tuesday 12th December 2017 Lords Chamber

[Lord Black of Brentwood]

To ask Her Majesty’s Government how many people with a diagnosis of atrial fibrillation who were admitted to hospital with a stroke in 2016-17 were not on an appropriate anti-coagulation therapy prior to admission.

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

My Lords, audit data shows that around half of patients with known atrial fibrillation who have a stroke have not received anti-coagulation treatment before their stroke. Figures for last year show that this varies from 25% in some clinical commissioning group areas to almost 100% in others. More than 300,000 people in England have undiagnosed atrial fibrillation.

[Lord Black of Brentwood (Con)]

I thank my noble friend for that Answer. As he knows, atrial fibrillation is a significant cause of stroke but it is also avoidable, because it is easily diagnosable and easily treatable with anti-coagulant medication. Yet as the figures he just gave us show, more than 7,000 people in England who were admitted to hospital with a stroke last year were known to have AF but were not receiving proper therapy. Is my noble friend aware that the National Clinical Directors for cardiovascular disease prevention and stroke recently stated:

“Failure to prescribe an important treatment”,


such as this,

“needs to be seen as an error that is equally as serious as prescribing the wrong treatment”?

What action can the Government take to ensure that all eligible patients with AF are prescribed anti-coagulation to help protect them from stroke and the devastating consequences that flow from that for them and their families?

[Lord O’Shaughnessy]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord O’Shaughnessy]

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

[Lord Patel (CB)]

My Lords, during the House of Lords Select Committee inquiry on the long-term sustainability of the NHS we heard a great deal of evidence demonstrating the great variations in care, in the treatment not only of atrial fibrillation but of other conditions. Is it not time that we made the NICE guidelines, which are very clear about the management of patients with atrial fibrillation, mandatory to reduce the variation in care and improve outcomes?

[Lord O’Shaughnessy]

As the noble Lord will know better than anyone, making them mandatory is a challenge because of the importance of clinical autonomy. What we can make mandatory is an understanding of those guidelines and that they inform every treatment pathway. That is part of what the NHS RightCare programme, which is now rolled out across the country, is doing. It is introducing new things such as stroke pathways so that there is clarity about the options available. Patient choice is at the centre of that decision.

[Lord Cormack (Con)]

My Lords, I have this condition but I had never heard of it until I was diagnosed about seven years ago. I urge my noble friend to try to ensure that greater publicity is given to it. Could we start by making sure that every Member of your Lordships’ House has the opportunity to be tested for it?

[Lord O'Shaughnessy]

I like my noble friend’s idea of putting on a special clinic. I hope he is getting excellent care with his own AF. The idea of publicity is an important one, and I draw attention again to the role that the Stroke Association is playing within the development of the new plan, because clearly it has fantastic reach to patients and is a trusted voice. It has a key role in making sure that there is that understanding among both patients and the clinical community.

[Baroness Jolly (LD)]

My Lords, regular checks of the pulse rate can help indicate whether someone has atrial fibrillation. These should be carried out at the five-yearly general health check that GPs offer to those aged between 40 and 74. Could the Minister tell the House how many GP practices routinely call patients for this health check, whether they are paid to do so and how many patients take up the opportunity? I declare an interest as I am in this age range and have never been offered a health check.

[Lord O'Shaughnessy]

I too am in that age range. I am afraid I cannot tell the noble Baroness what the global figures are, but I shall write to her to do so.

[Lord Mackenzie of Framwellgate (Non-Afl)]

My Lords, a couple of years ago I attended a clinic in this House where there was a device, on which you placed your hand, which diagnosed whether you had atrial fibrillation. The idea was that these would be rolled out into doctors’ surgeries, where people could test themselves while in the waiting rooms. How is that progressing?

[Lord O'Shaughnessy]

The noble Lord is quite right that this is a very easily diagnosable condition through checking pulses. The device that he described and other ones are doing that. They are in every GP surgery and form part of the health checks that the noble Baroness talked about. As I said, I do not have the figures for just how many of those are taking place, but we know that 300,000 people are undiagnosed with this condition. Many of them will be in regular contact with the health service, and this is about making sure that GPs use the opportunity to carry out those tests, which will inform the treatment that follows.

[Baroness Finlay of Llandaff (CB)]

My Lords, could the Government undertake to ascertain from NHS England why the commissioning of day-case ablation for the treatment of atrial fibrillation is way below the European average, given that it is shown to be safe and effective, and to improve symptoms and the rate of return to work? It also almost certainly, although this is not yet completely proven, decreases the incidence of strokes, so it can be a preventive measure.

[Lord O'Shaughnessy]

Yes, I shall certainly write to NHS England to find that out, and I will write to the noble Baroness with that information.

[Lord Colwyn (Con)]

My Lords, it is quite clear that many people do not receive the anti-coagulants that they need, and my noble friend has reminded us of the figures relating to those suffering from this problem. Since 2012, four novel oral anti-coagulants—NOACs—have been recommended by NICE as both clinically and cost effective for the prevention of stroke in patients with AF. Their use is increasing but is lower than expected. Can my noble friend explain why access to the full range of anti-coagulation therapies is not acceptable to many GPs, who appear to lack confidence in their use of NOACs, and why some patients are still being given aspirin to prevent AF-related stroke? I should declare my interest as an officer of both the Arrhythmia Alliance and the Atrial Fibrillation Association.

[Lord O'Shaughnessy]

My noble friend is quite right to highlight the benefits that come from new treatments. We clearly have a long way to go, as half the people presenting with strokes have not had those anti-coagulants, but there has been an increase in the number of pre-stroke patients receiving anti-coagulants, up from 38% to 53%, so it is an improving picture. The NICE guideline recommends the use of anti-coagulants and, critically, encourages patient choice for the new breed of NOACs and DOACs. There is very clear guidance within the system. It is getting better, but there is some way to go.

NHS: EEA Doctors

Lord O'Shaughnessy Excerpts

Tuesday 12th December 2017 Lords Chamber

[Baroness Walmsley]

To ask Her Majesty’s Government what assessment they have made of the number of doctors from European Economic Area states working in the United Kingdom who may be planning to leave the NHS after the United Kingdom’s withdrawal from the European Union.

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

My Lords, the Government value the contribution of all European Union staff working across the NHS and social care systems immensely. We have set out a clear pathway to permanent residency for these EU citizens. According to the latest NHS digital data, there are now more non-UK EU doctors working in the NHS than ever before, with almost 500 more since 30 June 2016.

[Baroness Walmsley (LD)]

My Lords, according to the BMA, almost half of EEA doctors are considering leaving the UK and one in five has already made plans to do so. Given that it takes 13 years to train a consultant, what is the Minister doing to fill these gaps in the short term? Is he aware that there are numerous doctors from around the world already resident in the UK but whose qualifications fall short of what is required by the NHS? They would dearly love to be able to upgrade their qualifications and help us to fill the gap that is going to be left by the Tory Brexit, but there is no organisation that will advise and support them to improve their qualifications. What will the Minister do about that?

[Lord O'Shaughnessy]

I recognise that, as the noble Baroness pointed out, there has been uncertainty. That is why I am sure that the entire House will welcome the agreement reached last Friday to provide that certainty, and I encourage all noble Lords to look at and circulate the letter written by the Prime Minister to EU citizens explaining how much we value them, how much we want them to stay and how we have now agreed with the EU a process for doing that. The noble Baroness will be interested to know, as I am sure will other noble Lords, that there were 470 more EU doctors working in the NHS in June 2017 compared to June the year before—so, happily, we have not seen the exodus that so many people have warned about. We need to grow more of our own in the future, of course, and there are 1,500 training places for doctors coming on stream in September 2019, but I shall certainly look at the issue that she raises about providing opportunities for doctors—not least refugees; that issue has been raised with me—to upgrade their qualifications so that they can serve in the NHS.

[Baroness Thornton (Lab)]

My Lords, can the Minister guarantee, if the Government sort out the immigration status of EU medical staff in a timely fashion, that this will be with the retention of existing workers’ legal rights such as the working time regulations and related employment directives in UK law for the current and future workforce?

[Lord O'Shaughnessy]

I think I may have detected a qualified welcome from the noble Baroness for the achievements of last year in providing that reassurance. Clearly, we want to make sure that there is the best possible working environment for our medical staff, wherever they come from, and that involves, as the Prime Minister has set out, having world-leading employment rights.

[Lord Naseby (Con)]

My Lords, is the Minister as concerned as I am that this Question refers to the EEA as well as the EU? I am mystified about why any Norwegian or Icelandic doctor should be concerned about Brexit. In addition to that, is my noble friend not absolutely correct? I went to Bedford Hospital a week ago on a Sunday with an EU doctor. That doctor made it quite clear to me that the reassurance that had been given by Her Majesty’s Government was sufficient for her—and, I believe, her husband—to continue to work in the NHS.

[Lord O'Shaughnessy]

I thank my noble friend for pointing that out. It is extremely reassuring to know that the message is getting through. We as a department and as a Government have a job to do in making sure that everybody hears that message of reassurance, because we want those EU workers to stay and contribute to our NHS.

[Lord Falconer of Thoroton (Lab)]

My Lords, what work has been done by the Department of Health to identify what impact leaving the European Union is going to have on the health service, and what is it doing about it?

[Lord O'Shaughnessy]

The noble and learned Lord will know that a variety of reports have been published. I am sure that he has taken the opportunity to sign in and read them, which is very welcome, and I encourage all noble Lords to do that. One of the greatest things that we have to do is look at workforce issues. I come back to the point about being able to provide reassurance to people who are thinking of leaving but have not yet done so. I stress that we have more EU and EEA people working in the NHS, which is a very welcome thing and I hope they take comfort from that.

[Lord Wallace of Saltaire (LD)]

My Lords, over the weekend a number of Ministers, including the Secretary of State for DExEU, said that these agreements are fine but that nothing is settled until everything is settled. That seems to be not quite the reassurance that everyone would want. Is it possible for the Government to go further and say that they will offer a guarantee to all EU citizens working in the National Health Service that, whatever else happens, they will continue to be welcome? I am conscious that the figures on nurses and midwives are not as good as those for doctors at present and that we are in severe danger of having a short-term gap in the number of nurses and midwives, which would be very serious.

[Lord O'Shaughnessy]

I point the noble Lord to the Prime Minister’s letter, in which she talks about the fact that the rights will be written into law as we leave the EU. He is right to point out the position of nurses and midwives; that is the only category where fewer EU staff are working in the National Health Service year on year. However, as we have talked about many times in the House, new language tests may have had a critical role in that and that is something we are reviewing it to make sure that we can continue to welcome nurses from abroad.

[Baroness Finlay of Llandaff (CB)]

Given the current vacancy factor, and the fact that we have some refugees who are doctors and some who are nurses with an enormous amount of clinical experience but whose English language skills need to be improved, what are the Government doing to provide targeted English language training and apprenticeship attachments so that these refugees can enter the workforce and become economic contributors?

[Lord O'Shaughnessy]

This is an excellent idea that the noble Baroness has shared it with me before. We are looking at it and we have a workforce strategy coming out, so I will do my best to ensure that it includes something on this.

Social Care: Sleep-in Payments

Lord O'Shaughnessy Excerpts

Thursday 7th December 2017 Lords Chamber

[Baroness Hollins (CB)]

I beg leave to ask the Question standing in my name on the Order Paper, and I remind the House of my interests.

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

My Lords, we recognise that the historic liabilities associated with the national minimum wage for sleep-in shifts present a challenge to the financial position of many care providers. The Government have been working with representatives of the social care sector to understand how liabilities for back pay for sleep-in shifts impact on the provision of care for vulnerable people. We are exploring options to minimise any impact on individuals and the sector.

[Baroness Hollins]

The Minister will be aware of the considerable stress and anxiety faced by people with learning disabilities and their families about the likely loss of service providers. People with personal budgets who directly employ support staff fear being made bankrupt if they are found to owe arrears to them. We have been aware of this issue for some time now. Will the Government commit to funding these historical liabilities for sleep-in shifts and end the stress and anxiety which is now prevalent within this sector?

[Lord O’Shaughnessy]

We absolutely recognise the pressures that this has caused for providers of all kinds, whether they are large providers of social care or those with personal budgets in receipt of direct payments. I should point out that HMRC is working with local authorities where they are providing funding for direct care, so it is not just a discussion between individuals and HMRC. Local authorities are involved as well because they clearly need to look at the budgets they are providing to make sure they are adequate to pay for existing costs. We are looking at all the issues around historic liabilities, but I am afraid that I cannot give the noble Baroness the commitment she is asking for today.

[Lord Wigley (PC)]

My Lords, I declare my links with Mencap as shown in the register of interests. Will the Minister tell us what contingencies the Government have put in place to fund the services received by people with a learning disability to cover their financial difficulties arising from the Government’s decision not to fund historic liabilities on account of sleep-in shifts?

[Lord O’Shaughnessy]

It is not our position that they will not be funded. That is one of the options being explored at the moment. A huge amount of work is going on with providers and all parts of government. In the end, however, the Care Act 2014 means that local authorities have a responsibility to take on the commissioning of and, ultimately, provision for providers, if they are looking at exiting the market, to make sure there is proper and comprehensive provision in the local area.

[Baroness Wheeler (Lab)]

My Lords, it is absolutely right that sleep-ins are defined as working time and therefore subject to payment of the national minimum wage. However, the Government’s November compliance scheme proposal not only failed to offer support for hard-pressed providers but also means that thousands of care workers, who are among the lowest paid in society, could be waiting until March 2019 to get paid what is owed to them. Does the Minister agree that these low-paid workers should not have to pay the price for the Government’s £6 billion cuts in social care or their failure to take action on addressing the social care funding crisis?

[Lord O'Shaughnessy]

I am grateful that the noble Baroness has raised the compliance scheme. For those providers that enter it, the scheme offers the opportunity to take 12 months for self-review and then report to HMRC, which will then allow a further three months for the providers to pay. That gives a 15-month leeway compared with the usual default enforcement period of 28 days. There is clearly a balance to be struck between the financial challenges posed to providers and the money that staff, rightly, need to take. I think that the compliance scheme provides that balance so that we can do it in a way that is sustainable.

[Lord Tebbit (Con)]

My Lords, I declare an interest in that my wife requires 24-hour care. I am sure that my noble friend is aware of the impact of the backdating of this decision on so many people, not least charities such as Mencap, which will become seriously financially embarrassed unless some help is forthcoming. The amounts are enormous to such charities, but they are really pretty small beer compared with overseas aid, for example, and I hope the Government will look to their priorities in that respect.

--- Later in debate ---

[Lord O'Shaughnessy]

I absolutely recognise the picture that my noble friend paints. We know the impact of the decision on backdated pay on those providers of social care of all kinds—charities, families and others. We are looking carefully at this, and there is a market analysis going on at the moment to find out the number of affected providers, the number of affected staff and the overall cost implications. Discussions are taking place with the European Commission to make sure that whatever route we take, we know it will be legally possible.

[Baroness Barker (LD)]

My Lords, these providers have been hit this year with a bill of £400 million. HMRC has given a one-month deferment of its decision, which is not enough time for them either to raise the money or to make alternative arrangements. Does the Minister agree that this can only be solved satisfactorily, without detriment to people with learning disabilities and people who are cared for, if there is a rescheduling of the liabilities? Are the Government looking, with HMRC, at drawing up a longer deferment schedule to allow them to raise the money?

[Lord O'Shaughnessy]

Again, I would point the noble Baroness in the direction of the social care compliance scheme that has been set up, which allows precisely that deferral of payments. It allows for a period of up to 15 months for assessments to take place while providers work with HMRC to provide the payment. I should also point out that although HMRC would usually levy fines in the case of underpayment of taxes after 28 days, those fines have been waived in these cases, as one would expect.

Social Care

Lord O'Shaughnessy Excerpts

Thursday 7th December 2017 Lords Chamber

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

My Lords, with the permission of the House, I shall now repeat a Statement on social care made in another place by my honourable friend the Parliamentary Under-Secretary of State with responsibility for care and mental health. The Statement is as follows:

“This Oral Statement is the Government’s response to the recent Opposition Day debate on social care on Wednesday 25 October. Since that debate, the Government have announced further plans for the Green Paper on care and support for older people on 16 November. This Oral Statement reiterates the substance of that announcement while providing further detail to the House in some specific areas.

An ageing society means that we need to reach a longer-term sustainable settlement for social care. This is why the Government have committed to publishing a Green Paper by summer 2018, setting out our proposals for reform. An inter-ministerial group is overseeing this work. It builds on the additional £2 billion over the next three years that we have already provided to meet social care needs. In developing the Green Paper, it is right that we take the time needed to debate the many complex issues and listen to the perspectives of experts and care users, building consensus around reforms that can succeed. This is why we are starting a process of initial engagement over the coming months through which the Government will work with experts, stakeholders and users to shape the long-term reforms that will be proposed in the Green Paper.

The Government have asked a range of independent experts in this area to provide their views, including the leads of the two most recent reviews on social care, Andrew Dilnot and Kate Barker. We are also engaging closely with key stakeholders, along with people who use services and their carers. The Government will be hosting a number of round tables to hear a range of perspectives from those representing different constituencies, including carers, service recipients and providers, health services, financial services providers, local government and working age adults. Once the Green Paper is published, it will be subject to a full public consultation.

The Government also recognise that there is broad agreement across Parliament that reform of social care is a priority and look forward to working with parliamentarians to hear a range of views. We have already written to the chairs of the relevant all-party parliamentary groups to invite them to meet with us to discuss their priorities and perspectives for reform.

The Prime Minister has been clear that the consultation will include proposals to place a limit on the care costs that individuals face. To allow for a fuller engagement and development of the approach, with reforms to the care system and the way it is paid for considered in the round, we will not be taking forward the previous Government’s plans to implement a cap on care costs in 2020. Further details on the Government’s plans will be set out after we have consulted on the options.

The Green Paper will focus primarily on the reform of care for older people, but will consider elements of the adult care system that are common to all recipients of social care. We are committed to ensuring that people with disabilities and complex conditions are able to live healthy, independent lives and to participate fully in society.

Many of the issues and questions about the sustainability of the care system will be relevant to adults of all ages. To ensure that issues specific to working age adults with care needs alone are considered in their own right, the Government have committed to taking forward a parallel programme of work on working age social care which is being led jointly by the Department of Health and the Department for Communities and Local Government. This work will also be overseen by the inter-ministerial group to ensure close alignment with the Green Paper.

Carers are vital partners in the health and social care system. It would not make sense to pursue strategic issues related to carers in isolation from the wider work on the future of social care. They will therefore be a key part of this Green Paper. A sustainable settlement for social care will not be possible without focusing on how our society supports carers. I am committed to making sure that the issues raised with us through the call for evidence on carers in 2016 are central to any proposals for the wider social care system. Alongside this, we must continue to work to improve the experience of carers today. The Government remain fully committed to supporting carers to provide care as they would wish and to do so in a way that supports their own health and well-being, employment and life chances.

Ahead of the Green Paper’s publication, the Department of Health will also publish an action plan for carers in the new year, setting out priorities for a cross-government programme of work to support carers over the next two years. In the short and medium term, we are taking important steps to ensure that we have a stable adult social care sector. We are promoting quality care across the system and supporting the wider networks and services that keep people living independently for longer.

It is important to recognise that quality across the adult social care sector remains good overall. The October 2017 State of Care report found that 80% of adult social care settings had been rated as good or outstanding. However, the Care Quality Commission also underlined that there are substantial variations in the quality of care, depending on where people live. The Department of Health is working with the adult social care sector to implement “Quality Matters”—a shared commitment to take action to achieve high-quality, person-centred adult social care. Through our programme of sector-led improvement, we are supporting councils to make savings and improve services by promoting good practices, including new approaches.

Looking beyond social care provision, it is important to highlight the broader support and services that help people to live independently. This means that well-adapted, specialised housing is becoming increasingly important. The disabled facilities grant is a means-tested grant to help meet the cost of adapting a property for the needs of a person with a disability or support need. The autumn 2017 Budget provided an additional £42 million for the rest of the 2017-18 financial year, taking funding for this year to £473 million.

Getting social care right means a better system that everyone can have confidence in, where people understand their responsibilities, can prepare for the future, and know that the care they receive will be of a high standard and help them maintain their independence and well-being. The Government want to take the time to consult and build consensus on a long-term, sustainable settlement for the future, which includes looking at the quality of care being delivered, the funding of the system and how it will be paid for in the round”.

[Baroness Wheeler (Lab)]

I thank the Minister for reading out the Statement in response to the October Labour Opposition debate on the social care funding crisis.

We are told that the Statement builds on the extra £2 billion over the next three years provided by the Government to “meet social care needs”. However, for the record, the Minister will know that independent think tanks such as the Nuffield Trust and the King’s Fund, care providers across the social care sector, voluntary organisations such as Age UK, and organisations representing the staff who deliver the services have all shown clearly the inadequacy of this sum to meet existing and rising demand and to address the funding crisis. Government cuts to local authority budgets have meant cuts to adult social care funding since 2010, which are set to reach £6.3 billion by March 2018. That is the scale of the funding gap that needs to be addressed, and we know that social care did not get even a mention in the Budget. Can the Minister explain to the House why such a key issue was left out?

On the Green Paper and the Government’s preparations for yet another round of consultation, the Minister will accept that this stop/start Green Paper has been a very long time coming, particularly when viewed in the light of the agreed Care Act provisions that were first promised for full implementation in 2016. On 16 November, the Minister told the House that a group of independent experts, including Andrew Dilnot and Kate Barker, would support government engagement with stakeholders. Today’s Statement says that these two are among a range of experts who will “provide their views”. An inter-ministerial group has also been set up. What role will these key experts—who have widespread respect and authority among key stakeholders —play in overseeing the review and consultation? Will they be involved at the heart of the review or will they just feed their views to Ministers?

The Minister will know that it is particularly upsetting for those of us who were involved in the painstaking work on the Care Act to be lectured again about how complex the issues are and on the need to “build consensus around reforms”. That consensus was part of the Care Act and the Government chose not to go ahead with it. We know, too, that they consulted on their proposed care “floor” during the general election; it was roundly rejected by the electorate, causing huge despair and consternation among the millions of disabled people and their carers struggling to cope. Meanwhile, many people are still faced with the catastrophic and rising costs of paying for care.

I mention carers specifically. The Minister is right to acknowledge that they are vital partners in the health and social care system, but the reality is that they have now been waiting nearly two years for the national carers strategy to be updated, refreshed or called to action, with promised deadlines being set back time after time. Last summer, carers were finally told that the strategy would be morphed into the end-of-the-year Green Paper. It was not a satisfactory situation, but carers organisations put huge effort and time into consulting with carers across the country to meet the deadline—only to then receive the announcement of the delay of the Green Paper to summer 2018.

Katy Styles, a carer and campaigner for the Motor Neurone Disease Association, contributed to that consultation and hoped that her voice would be heard. She said:

“Not publishing the National Carers Strategy has made me extremely angry. It sends a message that carers’ lives are unimportant. It sends a message that Government thinks we can carry on as we are. It sends a message that my own time is of little worth”.


We now have the promise of an action plan in the new year. Does the Minister acknowledge that he now has to be straight and play fair with carers and provide them with a date for the action plan? Can he be more specific about the scope and funding that will be allocated to the action plan?

Finally, Age UK estimates that there are 1.2 million people currently living with unmet care needs and that almost a quarter of all adult social care services receive the poorest safety rating from the Care Quality Commission. Can the Minister tell the House how the Statement will help people going without essential daily care, such as help with washing, dressing and toileting, to receive a better quality of care?

[Lord O'Shaughnessy]

I thank the noble Baroness for her response and her questions; I will deal with them in order.

First, she asked about funding. She is quite right to point out the £2 billion of extra funding that was announced in the March Budget; of course, we have had two Budgets this year, so extra funding was included in a Budget this year. I should also point out that that was the latest tranche of additional funding, which totals over £9 billion over three years, taking into account the additional funding announced in recent financial Statements. The precise purpose of the funding is to address the fact that we have a growing and ageing population. The number of people requiring care packages is rising, and often the complexity of those packages is becoming more acute—hence the need for more funding, as we all recognise.

Experts will be fully engaged in the Green Paper, providing advice to Ministers and supporting engagement. There is no point in having such an august group and not drawing on their expertise. I do not think that there is any contradiction in the way that I have described their role. We would not want to involve those people—and they would not want to be involved—if they were not going to be listened to.

On carers, I acknowledge the delay in the carers strategy and I understand that that must be frustrating for those who have invested so much time in it. I have two things to say in response. First, it is right that the position of carers is considered in the round, with care costs. Secondly, that is why the action plan is important: it provides a staging post between now and the intention to introduce fully fledged policy proposals in due course. I am afraid that I do not have a specific date or a funding package for that, but I will write to the noble Baroness with as much detail as I can find and place a copy in the Library.

[Baroness Jolly (LD)]

My Lords, I too thank the Minister for repeating the Statement. I declare my interest as chairman of a learning disability charity, providing services to around 2,000 adults in England.

On the long-awaited Green Paper, I welcome the Government involving independent respected experts in the field, including Andrew Dilnot, Kate Barker and Caroline Abrahams. However, we are sorry that the Green Paper will not have any element of care for working-age adults when published.

I want to raise a few issues that were mentioned by the Minister in the other place in her answers to MPs. She called for all party groups to be involved and said that there could be no change without consensus. That is exactly what I wanted to hear and it makes sense. The Minister knows our views on this.

On carers, in a debate earlier this week the noble Baroness, Lady Pitkeathley, talked about the worth of carers being equivalent to the NHS budget. I also praise carers and I am delighted that they will be involved in this review, but I am somewhat disappointed, along with the noble Baroness, Lady Wheeler. They went through quite a lot of consultation for the carers strategy and there is a certain amount of irritation that they might have to revisit all this work. If they have caring responsibilities, it is not always easy for them to get to a central place. I hope some mechanism can be found to ensure that that is captured, but also to see whether anything should be changed.

The Minister also agreed that health and social care cannot be considered independent of each other—another area of agreement. Will the Government consider introducing a statutory, independent budget monitoring agency for health and care similar to the Office for Budget Responsibility? This would report every three years on how much money the system needs to deliver safe and sustainable treatment of care. It could even be the first stage in the integration of health and care.

With the delay of the Green Paper, it is unthinkable that the Government are now leaving the social care sector in this state of uncertainty. They have completely failed to address the critical crisis in social care and now there are more than a million vulnerable older people without the support they need. With a funding gap, as we heard just now, of at least £2 billion by 2020, I wonder how much worse things will have to get before the Government will act. To put that in a more balanced way, does the Minister have any sense, whatever the outcomes may be from the Green Paper, of when we might want to see some of those becoming reality? Local authorities will also tell you that they are desperate for a solution. I echo what I said before: how long does the Minister reckon we will have to wait to see something change?

[Lord O'Shaughnessy]

Again, I thank the noble Baroness for those questions. I will try to deal with them in order. As I set out in the repeat of the Statement, there will be a parallel programme for working age adults. It is important to note that that feeds into the same inter-ministerial group. I emphasise that in terms of its profile in the overall work programme. It is of course separate from social care for older people, but it is a parallel programme.

The noble Baroness is quite right about the need to build consensus. We all know how much we need sustainable reform in this sector. Governments of all hues have tried it. We really do need to get there now. I cannot give her timings at this point of course, but it is becoming urgent as our population changes.

I completely agree with the noble Baroness on carers. I pay tribute to those carers of all ages, including young ones, who take on extraordinary responsibilities and dedicate their lives to caring for others. It is an amazing thing to do. I recognise her frustrations at the delay. I hope contributing to the Green Paper should not involve much additional work, although inevitably there will need to be some updating. As I said, I will write to noble Lords to give more details about the carers action plan, which is intended to be a bridge between now and the consequences of the Green Paper and the options it lays out.

Finally, we do not agree, as the noble Baroness knows, that there is a need for such a body on health and social care. She is of course right about integration. That is why metro mayors, such as the one in Manchester, are taking on these combined responsibilities. It is why integration is built into the better care fund. This is a direction we need to push down to provide proper, holistic, wraparound care for older people.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests as vice-president of Hospice UK and my role with the Royal College of Emergency Medicine. I will ask the Minister three short questions. Will the voluntary sector be closely involved, given that there is a £1 billion contribution to care from hospices and the voluntary sector, which looked after 212,000 patients last year, providing health and social care that otherwise would have fallen to statutory funders? Secondly, given that falls are the major cause of deterioration in the health of older people, and the lack of social care in preventing falls and in being able to take people out of hospital afterwards, will the Minister assure me that this will look at the flow through hospitals and the requirements of social care provision in an integrated way? Thirdly, while the Minister has mentioned young carers, will he specifically provide assurance that this will also look at child carers, some of whom might be at primary school age? They are often forgotten when people look at the burden on carers because they are, in a way, invisible apart from in the school sector.

[Lord O'Shaughnessy]

I can absolutely provide that reassurance on the voluntary sector. The noble Baroness is quite right to highlight the vital role it plays—it is essential and critical to this sector. On falls, she will know just how important reducing falls is. The disabled facilities grant is increasing. It is not a well-known bit of government spending and not talked about much, but it amounts to about half a billion pounds a year. It can have a really big impact by keeping people in their homes for up to four years longer, reducing falls by 40%. It is something we have had the opportunity to discuss in this House recently. It is critical. She is quite right to focus on the frontier between health and social care and making sure that it flows and works well.

On child carers, I will write with more details about what the action plan covers, but clearly we will make sure that it looks at all carers, because a carer could be of almost any age. As she pointed out, it includes very young children as well as people in their 80s and 90s. A true carers approach would encompass all of them.

[Baroness Verma (Con)]

My Lords, I thank my noble friend for the Statement. I refer to my registered interests. I will ask my noble friend about two issues. The first is respite care, which seems too often to be missed, particularly when there are reduced services. Services have been cut back for many service users. When family members have to manage the burden we need to have some discussions on extra respite support. Secondly—I am a broken record on this—we need seriously to look at the value we put on paying care workers a proper return on the work they do, given the extra responsibilities being put on them all the time.

[Lord O'Shaughnessy]

I am grateful to my noble friend for raising both those points. She is quite right about respite care. Local authorities have a duty to provide it, but I also note that there is pressure on the system. Indeed, the issue of one particular respite home, Nascot Lawn, has been raised. It is something I am interested in and I am looking at it. I will take that point away. We are trying to look at the care service in the round, so respite care must be part of that.

My noble friend is right about paying care workers properly. We have increased the national minimum wage, now moving on to the national living wage, precisely to provide a proper recompense for people who work in that sector and, critically, to start to provide a proper career structure so that people can move on, add to their skills and progress while staying in the caring profession.

[Lord Bradley (Lab)]

My Lords, I was pleased to be a member of the Select Committee on the Long-Term Sustainability of the NHS, the title of which was extended to include social care. The consultation seems to be constructed to continue the siloing of social care away from the broader care system between the NHS and social care. Will the Minister confirm that the whole relationship and integration of the NHS and social care will be included in the consultation? Will he confirm when the Government will respond to our Select Committee report, which was published last April?

[Lord O'Shaughnessy]

I thank the noble Lord for raising that point. I apologise again for the lateness of our response to the Lords committee. What I hope is now the final version is with me for approval, and I hope it will be provided very soon.

On the Green Paper, we all want more integration between health and social care. We know that is important for the people who are increasingly using those services who are in older age, have comorbidities and are moving in and out of different settings of the time. Social care is paid for on a different basis from the NHS. That is critical. We have to get a sustainable financial basis on which we distribute social care while thinking about how it interacts with the health service. The Green Paper is trying to crack a nut that, frankly, has eluded Governments for the last 20 years.

[Baroness Brinton (LD)]

My Lords, I am grateful to the Minister for referring to Nascot Lawn. I was not going to raise it today because that is about care for severely disabled children under 18, but I want to pick up on my noble friend’s point about adult care for people with disabilities and long-term conditions. As we know, their care needs are very different from end-of-life needs. Both the current social care system and the Dilnot proposals were focused on end-of-life care, so I welcome the parallel work stream, but will it operate to exactly the same timescale and report back?

I have a further question on housing. Your Lordships’ House will remember that the recommendations of the Lords Select Committee on the Equality Act 2010 and Disability included a whole chapter on housing. It is not just about the disabled facilities grant, which is important; it is also about Building Regulations ensuring that enough of our homes are built so that, as people age and their needs change, houses can be adapted easily if need be. Will that recommendation be forwarded to the group to look at?

[Lord O'Shaughnessy]

Once again, I thank the noble Baroness for raising this issue and I am pleased that she supports the parallel work stream. I will come back to her with details on the timing—I am afraid that I do not have those with me today—but I stress the importance given to it and the fact that it is reporting to the inter-ministerial group is significant.

The noble Baroness’s question on housing goes slightly beyond my remit. I know that building regs have changed over time to encourage more homes to be built, but I will have to come back to her with more details on that point.

[Lord Ramsbotham (CB)]

My Lords, sadly, the fastest-growing part of the prison population is the elderly. The lack of provision for them is one of the disgraces in the current prison system. Has the Minister considered, as part of the carers strategy, whether prisoners might be employed and trained as carers for the elderly, because that might transform the situation?

--- Later in debate ---

[Lord O'Shaughnessy]

That is a novel suggestion. We usually talk about young people going off the rails, but I did not realise that that was true of the prison population. I have not heard such a proposal. I shall certainly take it back to my colleague, the Parliamentary Under-Secretary of State for Community Health, who is leading the carers strategy, so that we can look at whether it might be possible.

[Baroness Altmann (Con)]

My Lords, in the context of our demographics, with the current baby-boomer generation foreseeably entering the age at which they will need care in the next 10 to 15 years, no money has been set aside, either at public sector or at the private sector level, to cope with the rising costs of care. Councils have increasingly rationed care so that they exclude preventive expenditure to help people avoid extreme need. Whatever happens with this review, does my noble friend agree that families will need money set aside if they are going to pay for care? There is no automatic provision. There is a state pension; there are huge incentives for private pension provision, but there is nothing to build up money that would pay for care. Will my noble friend comment on the urgency of helping families understand the importance of, for example, using some of their ISAs as an allocated fund for future care? People in their 60s and 70s have ISAs and pensions. Perhaps we might allow tax-free pension withdrawals for care, so that, at some point soon, we help families put money into a fund that can last into their 80s and 90s and be there for care—in case it is needed—or perhaps be passed on to the next generation, thus starting an ethic of saving for care as well as pensions.

[Lord O'Shaughnessy]

As ever, my noble friend makes excellent and wise suggestions, which I am grateful for. She highlights an important point, which is that social care is a co-funded service for most people. Most people make a contribution to their social care and the state will often make a contribution, too. Therefore, vehicles that allow people to save up in advance, whether through pensions, ISAs or the other means that my noble friend has suggested, are an excellent idea. I am sure that they will be part of considering the financial sustainability and build on products that are already in the market, whether equity release or deferred payments, so that people can go into their old age with confidence that, whatever their care needs, they will be able to afford them.

[Lord Howarth of Newport (Lab)]

My Lords, I think I heard the Minister mention in the Statement that his ministerial colleague had written to chairs of relevant all-party parliamentary groups to invite their participation in preparatory work in the department leading up to the publication of the Green Paper. Does he think there may have been an oversight here, because, as co-chair of the All-Party Parliamentary Group on Arts, Health and Wellbeing, I have received no such letter? I know that the Minister has seen the report of the APPG entitled, Creative Health: The Arts for Health and Wellbeing, and was kind enough to speak warmly of it in the House last week. Will he and his colleagues in the department study the substantial evidence presented in that report that engagement with the arts can confer considerable benefits in the field of social care in terms both of quality of life for people receiving care and their carers, whether family members or professional carers, and of value for money? Will he investigate the possibility of the APPG on Arts, Health and Wellbeing being involved in the process that he has mentioned?

[Lord O'Shaughnessy]

I will certainly be happy to do that. I absolutely endorse the ultimate finding of that report about the valuable contribution that the arts have to make. I shall investigate whether a letter has perhaps gone astray.

[Lord Elystan-Morgan (CB)]

Have Her Majesty’s Government given any thought to a far-off, divine event, by which I mean the total merger of the services aspect of social services with the NHS, thus cancelling out a great deal of imperial rivalry between the two bodies? At a personal level, such rivalry often means a whole platoon of people beating a path to a patient’s door, unco-ordinated with each other and duplicating each other’s services.

[Lord O'Shaughnessy]

I think that everyone in this House endorses the idea that health and social care should be better integrated. That statement is easy to make but difficult to achieve, as I think we would all agree, not least because the funding bases are very different. The NHS is taxpayer funded and free at the point of use; social care is funded on a different basis. That is one of the factors, as well as the bodies responsible for commissioning and so on. A practical way forward is to seek integration at a local level. That is happening now, for example, in Greater Manchester, which has powers over both services and is looking to integrate, and it lies at the heart of NHS England’s five-year forward view, which is about bringing services together in 44 areas, known as STP areas, to provide that level of integration. Patients do not want to have to flit through different bodies all the time. They want a sense that there is one service looking after them throughout their needs.

[Lord Trefgarne (Con)]

My Lords, perhaps I may underline the words of the noble Lord, Lord Ramsbotham, a few moments ago about the care for very elderly prisoners in our system. I have heard some shocking stories of failures in that regard. I hope that my noble friend can make some inquiries.

[Lord O'Shaughnessy]

Yes, I will certainly do so.

[Baroness Donaghy (Lab)]

My Lords, in the absence of my noble friend Lady Pitkeathley and the noble Lord, Lord Warner, I feel a sense of responsibility for seeking an assurance that all the evidence and issues that have been submitted to the various reports, not least Dilnot and the carers reports, will be put together as part of the consideration and that we will not reinvent the wheel. This is a well-trodden path; some of us are quite disappointed that we have got only to Green Paper stage. As my noble friend Lady Pitkeathley said only on Monday, we know what the problem is and what the answers are, so why cannot we just get on with it? Can we have an assurance that all that work will not be wasted?

--- Later in debate ---

[Lord O'Shaughnessy]

I am happy to provide that assurance. Inevitably, there is economic modelling that will need to be updated from previous reviews. It is the reason that, in particular, Dame Kate Barker and Sir Andrew Dilnot have been invited to play a role as well as others, as I am sure the noble Baroness knows. We do not want to have to reinvent the wheel and we know what we want to achieve. The difficulty is that, as Governments have found throughout the years, it is easier to say that than to do it. We all want to get through that process and hopefully achieve it this time.

[Baroness Uddin (Non-Afl)]

My Lords, in the light of all the previous comments I want to raise a couple of issues. I welcome having another look at social care in general and the fact that the Minister says that the Government are looking at integrated care. That is not the experience of men, women and children on the ground; I declare an interest in that I have a son with autism but I receive no service, so I do not really need to declare that. I think an awful lot of parents are like me and my husband: their families manage it themselves. The level of support for social care for adults with autism or a learning disability has been decimated over the last 10 years in various ways. How will this new approach to social care ensure that there is some reverse, so that there is dignity and honour for those individuals who go through the social care process and system?

Does the Minister agree that it is really important to ensure that there will be some reparation, almost, for the loss of services in the past so that adults, particularly those with a learning disability and autism, have access to services such as simply going to the library? My noble friend Lord Howarth mentioned the arts earlier but there is also music, as was pointed out earlier in the Chamber. There is a variety of ways in which social care is now more innovative, and that access should be available to service receivers in all parts.

My final point is about the communities that do not automatically understand the new approach or the latest fads and reports. They do not follow the system. How will we ensure that all kinds of communities understand that there is an approach to integrated social care, and that they will not be left behind simply because they do not understand the system or are not au fait with it, or if they are not politically correct and shouting the loudest?

[Lord O'Shaughnessy]

The noble Baroness put it beautifully in saying that the people we are talking about, who are on the receiving end of care, need to be treated with dignity and honour. I wholeheartedly agree with her.

I will separate integrated care into older people and working-age adults, as the noble Baroness did. On older people—and on health and care in general—I encourage her again to look at the five-year forward view and the plan for integration. In the recent Budget, we funded more than £200 million of capital programmes to help move a handful of local areas to what are called accountable care systems. That is where you look at the health of a population, which is quite an important step forward towards integrated care. I agree with her that that is not necessarily the everyday experience.

On disabled working-age adults, we may talk about the ageing and growing population but I believe that they are the fastest-growing group of care users. There is of course excellent work going on at the local authority level; I had the privilege many years ago to chair a special school in Wandsworth and saw the fantastic work it did with a peripatetic autism service there. But I know that there is huge variation, which is why the parallel programme of work that I talked about is so important.

Finally, the noble Baroness talked about hard-to-reach communities, and I could not agree more on that. One of the ways of reaching them is to engage with those who give voice to those communities. I would be delighted to discuss that with her, to make sure that we are listening to every voice we can as we move ahead.

[Baroness Tonge (Non-Afl)]

My Lords, way back in the early 1980s when I was working as a community doctor, I was also chair of social services in my borough. The main topic of conversation and angst then was how to combine health and social care budgets so that patients could receive proper care. How many more decades do we have to wait for this country to get its act together and do something about it? Other countries in Europe have good social care; why cannot we?

[Lord O'Shaughnessy]

First, I think we do have good social care in this country. That was the CQC’s finding, and it is important for us to recognise that we are building from a position of strength. Secondly, I agree with the noble Baroness on her point about integration. It has taken too long and that is what we are all focused on doing. I hope that she will join in this process so that we can build a true consensus as we move ahead.

Brexit: Health Policy

Lord O'Shaughnessy Excerpts

Wednesday 6th December 2017 Lords Chamber

[Baroness Quin]

To ask Her Majesty’s Government what are their priorities concerning health policy in the Brexit negotiations.

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

As the UK leaves the European Union, the Government are committed to safeguarding the success of the health and care sectors as well as the UK as a whole. Our priority is to make sure that, whatever the outcome of the negotiations, British citizens will continue to receive world-class healthcare. We are undertaking detailed planning for all scenarios.

[Baroness Quin (Lab)]

Given the concerns expressed by the British Medical Association and others about such issues as recruitment and retention in the NHS, research, mutual recognition of qualifications, the market in pharmaceuticals and medicines and so on, do the Government agree that a full impact assessment of the effect of Brexit on this sector would be a very good idea? Since I understand some progress has been made on mutual rights between British and European Union citizens, will the Minister say whether that means that all British citizens will be able to enjoy entitlement to the European health insurance card in future?

[Lord O’Shaughnessy]

I can reassure the noble Baroness that we are meeting a range of stakeholders. Indeed, I met the BMA, which she specifically mentioned, yesterday to talk about the impact of Brexit on the workforce and other issues. I assure her that we have had extensive discussions with the NHS, doctors’ groups, nurses, industry and so on, so that we understand the consequences of a range of options and so that we make sure that ultimately patients’ health and interests are protected. The noble Baroness asked about mutual benefits. I think she was talking about reciprocal healthcare with the EHIC. We have made good progress so far in the withdrawal discussions. For example, we will continue to cover the healthcare costs of pensioners who are permanently resident abroad, and anyone abroad at the point of exit will be able to use their EHIC. That was all that the first-wave mandate allowed us to do, but as we get to the second phase, we will be able to talk about what the future looks like.

[Lord Spicer (Con)]

Is not the real reason behind these negotiations the protection of democracy, which is best conducted at the nation state level where the Government are directly accountable to the people and the people are accountable for the Government, which is a million miles away from the type of government we have from a bunch of bureaucrats in Brussels?

[Lord O’Shaughnessy]

My noble friend gives a wonderful exposition of the values of democracy, which I wholeheartedly endorse. I should point out that the UK Government are implementing the wishes of the British people, as expressed through the referendum, and that this position was supported by the manifestos of parties that gained 80% of the vote at the most recent general election.

[Baroness Jolly (LD)]

My Lords, EU workers comprise some 5.6% of the healthcare workforce overall, including 10% of our doctors and 7% of our nurses. Most of these workers, who are not trained in the UK, are able to come and work here through the EU mutual recognition of professional qualifications directive. Can the Minister reassure the House that these reciprocal arrangements are afforded to EU and UK health professionals in perpetuity?

[Lord O’Shaughnessy]

The noble Baroness is right about the important role that EU workers play in the NHS, and I pay tribute again to the work that they do. We value them and want them to stay. We are in a position with the stock of EU workers here—and, equally, UK workers in other health systems—to recognise those qualifications. Clearly we will have to agree to continue doing that as part of the future negotiations. It has to be said that some concerns have been expressed by bodies such as the GMC about how that operates. We are working with them to make sure we get that right.

[Lord Foulkes of Cumnock (Lab)]

My Lords, could the Minister remind us what the effect of Brexit has been on the location of the European Medicines Agency?

[Lord O’Shaughnessy]

The European Medicines Agency will be moving to Amsterdam.

[Lord Lansley (Con)]

My Lords, the life sciences sector deal has been published today. From the point of view of the pharmaceutical and medical devices industries, one of the important and immediate objectives of the negotiations is to secure agreement to mutual recognition for things such as batch product testing and release, so that at the very least, through the transitional deal, they will not be required to move elsewhere in Europe for batch product testing and release in March 2019. Could my noble friend reassure the industries that the transition deal will give them that degree of protection for an additional period?

[Lord O’Shaughnessy]

I thank my noble friend for mentioning the sector deal. There are some big announcements in it on investments and creating growth and jobs in the UK, which is a huge endorsement of our leading role as a life sciences hub throughout the world. We have said that we want a continued relationship with EMA. The MHRA, our sovereign regulator, makes a huge contribution, by both approving licences for medicines and issuing safety notices. It is our intention as we move to the next phase of talks that we will have that kind of relationship going forward with the EMA.

[Baroness Thornton (Lab)]

My Lords, to follow on from the point made by the noble Lord, Lord Lansley, there is great anxiety in the medical research and clinical worlds about research, medical trials, the regulatory framework and access to drugs, including new drugs. Can the Minister give the House a categorical guarantee today that UK patient access to crucial drugs will be maintained and that this access will not be restricted in any way when the UK leaves the European Union?

[Lord O’Shaughnessy]

The Secretary of State has set out very clearly that patients should not be disadvantaged as a result of the new arrangements, whatever they may be. Clearly, those new arrangements will be a matter for negotiation, but we will make sure that patients are not disadvantaged and that the industry can continue to get its drugs and devices to the UK market as quickly as it does now.

[Baroness Masham of Ilton (CB)]

My Lords, how many people from Europe who are in the medical field have already left because of insecurity and not knowing what is happening?

[Lord O’Shaughnessy]

I recognise that there is uncertainty. That is why we have set out our intention of offering a route to settled status for those people working here, and why we want the issues of citizens’ rights to be dealt with as soon as possible in the next phase of talks. The noble Baroness and other noble Lords will be interested to know that, if you compare June 2016 to June 2017, there are more EU workers working in the NHS from one year to the next.

[Lord Cunningham of Felling (Lab)]

My Lords—

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[Lord Tebbit]

Does my noble friend understand—I am sure he does—that on both sides of the channel we are all concerned about the rights of British people in the EU and EU citizens here to health service treatment free of charge? Of course, the numbers are different. Would it not make it much more equal if we could agree with our friends in Europe that after Brexit we would issue a similar number of cards entitling people to treatment—Brits and EU citizens? If there was a disparity, whichever side needed more cards could buy them from the appropriate Government.

[Lord O’Shaughnessy]

My noble friend is, as ever, a huge source of ideas and advice, for which I am grateful. This point about reciprocal health care is really important, because our reciprocal healthcare arrangements predate membership of the European Union. They worked in the interests of people in both the UK and the European Union and I have every expectation that they will continue in the future.