Children: Oral Health

Lord O'Shaughnessy Excerpts

Monday 4th December 2017 Lords Chamber

[Baroness Benjamin]

To ask Her Majesty’s Government what action they are taking to address the problem of child tooth decay, in the light of the finding by Public Health England in its most recent oral health survey that 25 per cent of five year olds had experienced dental decay.

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

Public Health England, NHS England and the Department of Health are working together to improve children’s oral health. For example, the “Starting Well” initiative will support outreach to children not currently seeing a dentist in the areas of highest need, while dental contract reform supports our longer-term aim for all care to have a preventive focus. Furthermore, we are taking steps to reduce the amount of sugar consumed by children.

[Baroness Benjamin (LD)]

My Lords, I thank the noble Lord for that Answer. We all need to ensure that everyone fully understands the importance of oral health practice, which, ideally, should start when babies are six months old. It is therefore great to hear that NHS England has introduced the “Starting Well” programme. However, this is being delivered in only 13 local authorities, despite the fact that many children across the country suffer from tooth decay; indeed, it is the No. 1 reason for hospital admissions. Will the Government therefore consider taking further action by introducing supervised tooth-brushing sessions in all nurseries, as they do in Scotland, to improve oral health education for all our children?

[Lord O'Shaughnessy]

The noble Baroness is right to highlight this important issue. Twice as many five to nine year-olds are admitted to hospital with tooth decay as are admitted with broken arms—that is how bad the problem is. It has improved in recent years: 75% of all five year-olds have no sign of physical decay, up from 69% in 2008. Supervised tooth-brushing is part of the “Starting Well” programme, but Public Health England and local authorities are responsible for commissioning and will look at the results to see whether it can be rolled out into general dentistry practice.

[Baroness Gardner of Parkes (Con)]

My Lords, does the Minister appreciate that in Australia and the United States there is widespread community fluoridation? Fluoride has been established as one way of preventing dental decay. I went on to Google today and found an article that states:

“With 60 Years of Data and 3000 Studies, Australia Declares Fluoride ‘Completely Safe’”.


That is supported by community water fluoridation, which means that your water authority cannot only see that the right amount is put in but will take out any oversupply above the optimum rate. The noble Baroness said that she thinks that oral health is important for children from an early age; I took my treatment antenatally for my children, who have very good teeth.

[Lord O'Shaughnessy]

My noble friend is quite right that fluoridation is effective. The 2012 Act allows local areas to choose to introduce it—with local legitimacy, which is important because this issue still stirs passions. We encourage any local area considering this—I believe that Greater Manchester is one—to look at the study my noble friend mentioned in order to see its effectiveness.

[Lord Colwyn (Con)]

My Lords, I am delighted that my noble friend mentioned the dental contract because the current target-driven contract was introduced in 2006. The Government committed to reforming it in their 2010 manifesto, but progress has been very slow. The latest reports speak of a national rollout no earlier than 2021. We urgently need a new contract that rewards prevention. Does my noble friend not agree that patients and dentists should not have to wait so long?

[Lord O'Shaughnessy]

Yes, I agree with my noble friend. Preventive care is important. Pilot schemes have been going on in 75 practices to look at incentivising preventive care and population care. I understand that an evaluation report of that first full year of prototyping is due to be published in the new year.

[Lord Turnberg (Lab)]

My Lords, regarding fluoride and dental decay in children, can the Minister provide figures for the incidence of dental decay in areas that fluoridate their water compared with those that do not?

[Lord O'Shaughnessy]

I do not have that exact comparison in front of me. I understand that areas that fluoridate have much better oral health than others, which is why, as I said to my noble friend, we encourage all local areas to look at the evidence and make decisions accordingly.

[The Countess of Mar (CB)]

My Lords, does the Minister realise that, in order to get children to be seen by a dentist, their parents have to take them, and many parents are not happy themselves about going to the dentist? How can that be overcome?

[Lord O'Shaughnessy]

Probably not by giving out lollies to say well done for coming. The noble Countess makes an important point, but some 7 million under-18s were seen by a dentist in the last year for which data is available, which is an increase on previous years, so I think that things are improving.

[Lord Bradshaw (LD)]

Will the Minister consider asking manufacturers of sugary cereals to include in the packet a free toothbrush, which would cost them very little?

[Lord O'Shaughnessy]

That is one idea that I will certainly take away. Some of the impact that we are having is on reformulation, which is perhaps even more preventive than putting toothbrushes in cereals. There is a plan to reduce sugar in key foods by 20% by 2020, specifically for the benefit of children.

[Lord Lexden (Con)]

Does not part of the answer to this problem lie in that attractive four-letter word “milk”? Does not research evidence show that milk helps to protect the teeth of young children, as well as combating obesity?

[Lord O'Shaughnessy]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord O'Shaughnessy]

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

[Lord Colwyn]

My Lords, I forgot to declare my interest, so I apologise.

Nurses and Midwives: Numbers

Lord O'Shaughnessy Excerpts

Monday 4th December 2017 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government, in the light of the report of the Nursing and Midwifery Council published on 2 November which found that the number of nurses and midwives joining its register from the European Union had dropped by 89 per cent over the last year, how they plan to make good the anticipated shortfall.

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

My Lords, the Government value immensely the contribution of EU staff working across the NHS and social care systems. We are committed to ensuring a clear pathway to permanent residency for these EU citizens. The figures in the NMC report represent a 0.2% decrease in those currently registered. Meanwhile, there are more nurses on our wards since last year. Numbers will increase because of a 25% increase in training places.

[Baroness Thornton (Lab)]

I thank the noble Lord for that response, although I think it borders on the complacent. I asked this Question because the statistics are very stark and concerning. Although we know that registration of UK-based nurses is falling—by 9% last year—the decrease from the European Union varies between 70% and 95%. That means that instead of there being 1,966 nurses from Spain, for example, the number has dropped to 104 in the last year. The numbers from Poland have dropped from 305 to 34. Even from Ireland the numbers have dropped, from 381 to 204. That looks, with winter looming, like a crisis might be looming. Given that it takes at least three years or so to train nurses and midwives, I return to my Question: how will the Government make up the immediate shortfall and replace those nurses and midwives that come to us from the European Union?

[Lord O'Shaughnessy]

I agree with the noble Baroness that there is a need for more nurses. That is why we are introducing more training places and new routes into nursing, such as the nursing apprenticeship. I know that she is particularly concerned about EU national nurses and health visitors. I think noble Lords will be reassured that between June 2016 and June 2017, there was an overall 5% increase in the total number of staff from the EU within the NHS, which is welcome. The one area, as I said, that has fallen marginally—by about 162 in practice—is in nursing and health visitors. That was significantly due to the new language test that was introduced. That is something that the NMC is looking at to make sure we are getting nurses capable of practising in this country to come here.

[Lord Clark of Windermere (Lab)]

My Lords, as the Minister knows, citizens of the EU who have spent five years working in the UK can avail themselves of the opportunity to apply for a right to remain permanently in the UK. That is now unclear. Will he announce that those who have been granted the permanent right to remain in Britain as EU citizens will be entitled to stay and work here? That would be a good way to start building confidence.

[Lord O'Shaughnessy]

My Lords, the rules as they are apply, so those who are eligible to apply for a right to remain can do so. We are talking about providing a path for those who are not yet at that point, now or in the future, to achieve settled status to provide the kind of certainty that we know. I understand that this causes some people to pause for thought about whether they should stay.

[Lord Naseby (Con)]

Will my noble friend ensure that the answer he has just given is publicised in every NHS hospital in the United Kingdom? There is not that depth of understanding in the average medical practitioner, nurse or administrator in our hospitals that he has so clearly communicated. Will he also reconfirm that the number of training nurses is going up, as I think he said, and is considerably higher than it has been during the previous decade? If that is the situation, it is surely to be greatly welcomed.

--- Later in debate ---

[Lord O'Shaughnessy]

I agree with my noble friend’s point on communication. I shall certainly look at whether we can do that better as an NHS. It is why I do not miss an opportunity from the Dispatch Box to say how much those nurses are valued and how much we want them to stay. That is what the Government are committed to doing. I mentioned the increase in the number of training places which my noble friend has pointed out. New UCAS data out today show that the picture is slightly better even than when we talked about it last week. Although the total is slightly down on last year, it is the second-highest number of nurses recruited in the history of nursing being a degree profession.

[Lord Rennard (LD)]

My Lords, is this not a problem particularly given that 35,000 nurses and midwives left the profession last year? Does the Minister agree with the Royal College of Nursing that the problem is made worse by the loss of student bursaries, deterring more mature students from applying to train as nurses and denying the profession the benefit of their valuable life experience?

[Lord O'Shaughnessy]

Retention is critical. A number of nurses have gone through return-to-practice programmes to make sure they can come back into the profession. I recognise that today’s UCAS data show that while the number of applications has risen among the under-21s, it has fallen among the over-21s. It is important to point out that financial support is available for those people, in terms of both help with childcare and extra financial support. Now, for the first time, we are providing funding for second degrees if they are in nursing.

[Lord Tomlinson (Lab)]

The Minister said clearly that he never misses an opportunity to say how much we value our nurses. Does he accept that “value” is best recognised in a tangible form rather than in words that have no meaning?

[Lord O'Shaughnessy]

I think that words do have meaning, and it is important not to miss the opportunity to say how much we value those nurses who have come from the European Union as well as all staff in the NHS. One example of the value with which we hold them is the announcement in the Budget that the Chancellor will fund an Agenda for Change pay settlement for nurses.

[Baroness McIntosh of Pickering (Con)]

My Lords, I congratulate my noble friend on the increase in the number of training places, but can he give the House an assurance today on the figures for recruitment and retention of nurses in rural areas and, in particular, that their travel is fully paid for when they drive round remote parts of the country such as North Yorkshire and other isolated areas that they have to cover?

[Lord O'Shaughnessy]

Yes, absolutely—travel costs should be accounted for, as long as they are incurred in the course of an ordinary working day. I should also point out that extra travel costs are now supported as part of the student finance package for those who need to travel for study.

[Lord Watts (Lab)]

My Lords, given the shortage of medical staff right across the board, should not the Government exempt them from quotas so that we can guarantee that we will have the medical staff and support staff that we need in our hospitals?

[Lord O'Shaughnessy]

In the long run, we want to be in a position to provide more of our staff domestically. There are concerns about the fact that we recruit from other countries, not least developing countries—I do not think that that is a long-term, sustainable position. In addition to the additional nurse training places that I mentioned, more medical training places for doctors are coming through, so we will be achieving that position in future.

[Lord Pearson of Rannoch (UKIP)]

My Lords, do the Government accept that the £10 billion per annum in net cash that we shall no longer pay to Brussels after Brexit is equivalent to the annual salaries of some 1,000 nurses every day?

[Lord O'Shaughnessy]

The noble Lord’s mental maths are far better than mine. I agree that it will provide for the possibility of yet more funding for the NHS, which is something that this Government have delivered in the past seven years.

[Lord Turnberg (Lab)]

My Lords, I wonder whether the Minister can help clear up my confusion. He is telling us that the number of training places is increasing while my noble friend Lady Thornton suggested that the number of people coming into those places is decreasing. What is the correct interpretation? Have we got more, fewer, or what?

[Lord O'Shaughnessy]

I will do my best to provide clarity. If you look at nurse training places in universities, in 2016 the number was 3% higher than this year. One reason for that has obviously been the change in the financing arrangements. However, this year still represents the second-highest number since it became a degree profession. If we look to the future, from 2018 onwards there will be 5,000 more funded clinical placements which will enable the number of nurse training places to increase by some 20% to 25%.

HIV Prevention Services: Public Health Funding

Lord O'Shaughnessy Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord Cashman (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer to my entry in the register of interests, particularly as patron of the Terrence Higgins Trust.

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

My Lords, the UK is one of the first countries to witness a substantive decline in new HIV diagnoses in gay and bisexual men. Between 2015 and 2016, new HIV diagnosis fell by 21% across the UK and by 29% in London due to reduced transmission of HIV. New diagnosis in heterosexual black, Asian and minority-ethnic groups fell by 16%, mostly due to changing migration patterns.

[Lord Cashman]

My Lords, I thank the Minister for that response. Great progress has been made and I pay tribute to all those concerned, but there is concern at the cuts seen in HIV support services and sexual health services across the United Kingdom, not least in the two areas with the highest prevalence of HIV, Lambeth and Southwark, through to Oxfordshire, Portsmouth and Bexley. How are the Government working with local authorities in England to ensure that such services are fully funded and meet the needs of local communities at risk of HIV? Furthermore, what steps are they taking to ensure that people living with HIV have access to support services that fully meet their needs?

[Lord O'Shaughnessy]

First, I pay tribute to the work of the Terrence Higgins Trust and its leadership in this area in making progress in the UK in dealing with the HIV/AIDS epidemic. The delivery of open access to sexual health services is mandated for all local authorities, which are funded to do so by the public health grant. It is incredibly important to point out that over the last four years there has been a 500,000 increase in the number of attendances at sexual health clinics, and more testing and treatment is taking place. That is starting to show in the reduced number of diagnoses, as well as in other factors. It should also be pointed out that as regards looking after those suffering from the consequences of HIV/AIDS, the Care Act 2014 is extremely clear that the legal framework for social care applies to adults, including those who live with HIV.

[Baroness Jolly (LD)]

My Lords, very large populations of gay men live in metropolitan areas such as London and Manchester, but my question is about the far-flung corners of the country: the north-east, the north-west and the south-west. Can the Government be confident that young men are able to access services and have PrEP available in those sorts of areas?

[Lord O'Shaughnessy]

The noble Baroness is quite right to point out the difference. If you look at the performance in London against the UNAIDS 90-90-90 targets, you will see that they have been met. However, England as a whole is at least slightly behind on at least one of those factors—people with HIV not being diagnosed—which points to the fact that out of metropolitan areas there is more work to do, as she says. One of the ways in which local authorities meet that challenge is through offering home testing kits, which are being sent out and which are now seeing the kind of return and diagnoses levels that you would see in sexual health clinics.

[Baroness Masham of Ilton (CB)]

My Lords, is it correct that six clinics have closed in London recently? Is he aware that other infections, such as gonorrhoea, have become drug-resistant? Many people from ethnic minorities need to know where to go, and communication is so important.

[Lord O'Shaughnessy]

I did not know about the closures that the noble Baroness mentioned. I reiterate that more tests are taking place. Indeed there has been a substantial decrease in the amount of new diagnoses, which is good news because it means that transmission is falling. We want to focus on the outcomes here, which are positive, particularly in London. She is of course quite right about other STIs being important. There is good news there as well, because diagnosis is falling, so some of the public health plans being put into place are starting to pay dividends.

[Baroness Thornton (Lab)]

My Lords, following on from the question from the noble Baroness, who is quite right, the facts are that there was a 28% decrease in HIV support services between 2015 and 2017, and in London that is 35%. Combine that with the local government public health cuts of £200 million this year and the wider impact that will have on all sexual health services. Does the Minister agree that the long-term implications of this reduction in services could have serious implications for both individuals—some of whom, perhaps, have not been diagnosed with HIV—and specific vulnerable communities? Can he commit to bring to the House an assessment of the impact of these reductions in services and expenditure?

[Lord O'Shaughnessy]

The data that the noble Baroness refers to on spending also shows that STI testing and treatment in general has risen year on year. There is clearly still an improvement of the picture in the amount of testing and treatment. As I pointed out, the benefit of that is that fewer people are being diagnosed, which means transmission levels are falling due not just to testing but to other factors, including good treatment and preventive work. Indeed, the number of undiagnosed people is falling as well. This is all good news.

[Baroness Hussein-Ece (LD)]

My Lords, despite HIV testing being free and universally available across the United Kingdom, there are very good estimates that around 13,500 people are not aware that they are carriers and have HIV. I note what the Minister just said, but surely that figure is still unacceptable and there needs to be more testing, particularly of people living on the fringes of society or those who are not registered with a GP and do not come into contact with health services. There need to be some targeted efforts to reach those people to ensure that once they are tested they receive treatment.

[Lord O'Shaughnessy]

I quite agree with the noble Baroness. As I said, across England about 12% or 13% of gay and bisexual men and other men who have sex with men are undiagnosed. That is clearly unacceptable and means we are still not yet meeting the UNAIDS target. I will point out a couple of the interventions happening to try to address that in addition to the ones that I have already mentioned. A new contract has been awarded by Public Health England to the national HIV prevention programme for the most at-risk populations precisely to try to reach them. Another £600,000 is being given to 12 schemes under the HIV innovation fund. By definition, the people we need to reach next are the most difficult to reach because they have not come into the system.

[Lord Patel (CB)]

My Lords, as PrEP is clearly scientifically assessed through meta-analysis to be the most effective treatment for reducing incidence of HIV for the at-risk population, will the Minister say how widely this treatment is available for the at-risk population through the NHS?

--- Later in debate ---

[Lord O'Shaughnessy]

Yes, I am happy to do so. PrEP will be provided by the NHS through an initial three-year trial to an estimated 10,000 people, which makes it the largest single study of its type in the world. That is happening in a handful of cities throughout England. Once we know the results of that study we will be able to understand how best to roll it out beyond that.

Health and Social Care: Falls Prevention

Lord O'Shaughnessy Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord Jordan]

To ask Her Majesty’s Government what assessment they have made of the value of every local authority adopting a strategic approach to falls prevention in the context of easing the burden on the health and social care systems.

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

My Lords, in July 2016 Public Health England established the national falls prevention co-ordination group. It has recommended that local authorities and clinical commissioning groups agree a falls and fracture prevention strategy and identify a commissioning lead with a remit for falls, bone health, multi-morbidity and frailty.

[Lord Jordan (Lab)]

My Lords, I thank the Minister for his reply and declare an interest as vice-president of RoSPA. Will he acknowledge that injuries and deaths resulting from falls have reached alarming levels, especially among the elderly? There are more than a quarter of a million emergency hospital admissions in England every year as a result of falls by people aged over 65. More than 70,000 of these are hip fractures, which are the leading cause of accident-related deaths of older people in the UK each year. The annual cost of hip fractures alone, including medical and social care, is estimated to be more than £2 billion. Will the Government commit to easing this huge burden on health and social care services by supporting and funding local authorities for falls prevention work?

[Lord O'Shaughnessy]

The noble Lord is quite right to highlight this important issue. The statistics are quite alarming, as he has pointed out. Every year, about one in three over 65 year-olds will experience a fall, and that rises to one in two for those aged over 80. This is a very significant problem with a very obvious human cost, as well as the economic cost that he described. The main area we need to work on is obviously prevention. I point him to the increased funding going into the disabled facilities grant, which has doubled over the last few years and is continuing to grow. That is about preventing falls in the home, which is where most falls take place. The consequences of doing that are huge. It means fewer hospital admissions, people can stay in their homes for longer, and reduced harm to patients.

[Lord Howarth of Newport (Lab)]

My Lords, is the noble Lord aware, as I am sure are many noble Lords who are of more advanced years than the Minister, of the benefits of dance for the health of older people? Is he aware that 85% of people who participate in Dancing in Time, a falls-prevention programme in Leeds, completed the course, compared to some 40% who complete standard NHS falls-prevention courses, and that evidence shows that dancing, even for just an hour a week for six months, brings measurable benefits to the cognitive and motor functions of healthy older people? Will the Government encourage health and well-being boards to consider the merits of prescribing dance and, indeed, other artistic activities?

[Lord O’Shaughnessy]

I will happily do so. Dance is very popular in my household, with “Strictly Come Dancing” on the television at the moment. Debbie McGee might not be quite over 65 but she is a great advert for older people dancing. I absolutely support what the noble Lord says. I have seen the evidence on the impact that was published as part of the APPG’s work on this; it is very convincing and we will certainly let health and well-being boards know that this is exactly the kind of thing—social prescribing, if you like—that they should be looking at to prevent falls.

[Baroness Brinton (LD)]

My Lords, the Royal College of Physicians estimates that between one-quarter and one-third of falls could be prevented through assessment and intervention. NHS Improvement ran 19 projects with volunteer trusts. There is not much evidence of those pilots working closely with local authorities, which is the nature of the Question of the noble Lord, Lord Jordan. What were the results of the pilots that started in January? One of the key findings of NHS Improvement was that two-thirds of trusts were still using outdated predictor equipment which NICE has recommended against. Can the noble Lord let me know, either now or later, whether he can confirm that those predictor instruments that NICE is now saying should not be used have been withdrawn, particularly from hospitals and general practice?

[Lord O’Shaughnessy]

I do not have the specific details that the noble Baroness has asked for; I will write to her. The figures are not good; there are still around a quarter of a million falls in hospitals and mental health trusts each year, which is equivalent to the emergency admissions, so it is still a significant problem. NHS Improvement is working with the poorest-performing trusts and is reporting that those interventions have seen improvements, but we clearly need to phase out some of the poor practice that exists in order to reach higher standards.

[Baroness Altmann (Con)]

My Lords, does my noble friend accept that the social care system is in crisis? As council budgets are squeezed and the number of elderly people keeps rising, councils have had to withdraw preventive spending on such things as handrails, home adaptations and meals on wheels. This may save money in the short term—the focus on those with extreme need is understandable—but will my noble friend please relay concerns from these Benches back to the department that there has been insufficient urgency in adopting a long-term, strategic approach and introducing meaningful reforms rather than a sticking plaster on this ever-growing problem, which will result in more frail, elderly people costing more money to the NHS?

--- Later in debate ---

[Lord O’Shaughnessy]

I accept that there is a challenge that we have to meet in social care: it is the reason that the Government are committed to a social care Green Paper next summer to provide long-lasting reform. In the meantime, I hope that my noble friend will recognise that another £2 billion was announced in the previous Budget to go into social care over the next three years in order to move people out of inappropriate hospital stays and into their homes. That is backed up, as I pointed out, by a doubling of the disabled facilities grant year on year, precisely to provide the kind of interventions that have a huge pay-off for the public sector. Something like £1 spent on the disabled facilities grant saves £4 in the wider public sector, so this is very important work.

[Lord Turnberg (Lab)]

My Lords, one of the main causes of fracture of the hip in someone who falls is osteoporosis, which is both preventable and treatable. Will the Minister consider starting a screening programme for at-risk groups?

[Lord O'Shaughnessy]

That is a very interesting idea. I will write to the noble Lord. Of course, since this summer general practices are now obliged to carry out screening of over-65s specifically to look at frailty, looking at those with mild, moderate and severe frailty, and that may already include osteoporosis. But I will write to him with the specific details.

NHS: Staff

Lord O'Shaughnessy Excerpts

Thursday 30th November 2017 Lords Chamber

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

My Lords, I thank the noble Lord, Lord Clark, for calling this debate and all noble Lords for their contributions. It is the first time I have had the opportunity to debate with the noble Baroness, Lady Emerton, which I hope will not be the last and that she does indeed continue contributing.

We all agree that the NHS is one of our great institutions. It spans political divides and brings people together, although apparently it does not bring together enough Ministers to satisfy the noble Baroness, Lady Walmsley. We are all rightly proud of our NHS and the staff who work incredibly hard for the good of patients. The quality and dedication of our NHS staff is why we have the best health service in the world. It is, as the noble Lord, Lord Clark, said, second to none. It is also a great privilege to have so many former NHS staff in this House speaking today, including the noble Lord, Lord MacKenzie, and the noble Baronesses, Lady Donaghy and Lady Emerton.

We as a Government do not pretend that everything is perfect, but we should be proud of the NHS’s many achievements: universal access; the progress we are making on improving cancer survival rates; transforming care for dementia and mental health; our strong primary care; research and development; and the quality of medical education and training, among many others. It is because of those achievements that the independent Commonwealth Fund recently rated the NHS as the best health system in the world for the second year in a row. Contrary to the accusation from the noble Lord, Lord Clark, I believe that this shows the very opposite: success. Of course, the NHS faces challenges, but it is doing well.

The first part of the title for today’s debate refers to the Government’s fiscal policy, so I want to begin by laying out the reasons for that policy and the actions taken within it. I will resist the urge to lecture, I hope, but I will point out the facts. In 2010, the coalition Government inherited one of the most challenging fiscal positions in the world. The Conservative and Liberal Democrat parties came together with a plan to reduce the deficit because we understood that a failure to do so would burden the next generation with debts which they had no hand in creating. It was fairness, particularly intergenerational fairness, which drove that policy.

We also understood that you cannot have strong public services without a strong tax base; and a strong tax base requires a strong economy, in which investors have confidence that the Government will be fiscally responsible and where it becomes easier to create and sustain jobs. That is what we, as a coalition and then as a Conservative Government, set out to do. Inevitably, this approach necessitated many difficult decisions, but we have now reduced the deficit by three-quarters, from 9.9% of GDP in 2010 to 2.3% in 2016-17. We forecast it to fall gradually to 1.1% in 2022-23, the lowest for 20 years. Employment is at a record high and the economy continues to grow.

As the noble Baroness, Lady Walmsley, pointed out, the greatest health policy is to reduce poverty, and having more people in work is a core part of that. It is because of those firm fiscal and economic foundations that we were able to protect and grow NHS budgets at the spending reviews in both 2010 and 2015. Furthermore, because we recognise that the NHS is under pressure right now, in the Budget last week we heeded calls for more funding, with £2.8 billion extra over the next three years to help the NHS meet its performance targets, and over the next five years a £3.5 billion programme of additional capital investment.

Several noble Lords, including the noble Baronesses, Lady Jolly and Lady Pitkeathley, and the noble Lord, Lord Warner, asked about the lack of mention of social care in the Budget. It is worth pointing out that we had two Budgets this year. In the previous Budget, in March, there was an announcement of £2 billion extra for social care. Indeed, we confirmed recently that there will be a Green Paper in the summer to take social care reform forward. It will deal with the issue of carers, as referred to by the noble Baroness, Lady Pitkeathley. I should point out that it has the continuity to build on suggestions made by Andrew Dilnot’s expert advisory group in the past.

As the noble Baroness, Lady Jolly, said, we need to look at the money. That means that funding in real terms on the health service will be £12.5 billion higher this year, £14.2 billion next year and £15.8 billion higher by 2020-21 compared with 2010-11.

Both the noble Lords, Lord Hunt and Lord Clark, cited Malcom Grant, Sir Bruce Keogh and others. I cite Jim Mackey, the head of NHS Improvement, who said, in the light of the Budget,

“news that the pay award will be funded in full is very welcome, as is additional revenue, starting this winter and over the next couple of years”.

As a consequence of the funding that we have put into the NHS, despite the necessary fiscal readjustment we had to undertake to reduce the historic deficit left in 2010, the proportion of public spending consumed by the NHS has grown. That is not an overblown statement; it is a fact, and it is a mark of this Government’s and this party’s commitment to our cherished NHS.

I understand that there are huge concerns about the long-term sustainability of the health and social care services in the future. I understand the appeal of a royal commission, convention or some such although, like the noble Baroness, Lady Pitkeathley, I am sceptical about the need for it at this time. Several noble Lords have served Governments who have had commissions of this kind—and we know what those reports are doing, as she pointed out. Therefore, I think it is important for us just to move ahead. I recognise that my department’s response to the Lords Long-term Sustainability of the NHS Committee has been too slow. I have had a useful note from my officials during this debate which will enable me to commit to publish it very shortly.

As regards the workforce of the NHS, we all know, and have recognised today, that our growing and ageing population continues to create increased demand and activity, and this means that there has been a need to recruit more staff. We have been working hard to do this. That is why, as several noble Lords have pointed out, there are some 10,000 more nurses on wards and more midwives and health visitors. Over 50,000 nurses are in training and there is an increase in medical training places. Those are the facts. A particular example of our approach is the determination to transform the NHS workforce through apprenticeships. It was good to hear the noble Lord, Lord MacKenzie, welcome the fact that we recently announced an expansion in the numbers of nursing associates. Plans will see 5,000 nursing associates trained through the apprentice route in 2018 and 7,500 in 2019. I will certainly look at the issue of naming. It is quite wrong that they should be wrongly named because the name that they have been given is specific to the functions that they perform. I shall write to him on that issue. We expect that once this new route into nursing is established, up to 1,000 apprentice nurses could join the NHS every year, benefiting staff and patients.

We had the opportunity yesterday to discuss the issue of nurse bursaries and they evoke passionate responses across the House, not least from the noble Lord, Lord Clark, whose paramount concern I know is making sure that the NHS has the staff it needs to deliver the quality of care we all demand of it. I have outlined why we made changes in the system and do not suggest that anyone particularly wants to hear me reprise that, but it was done to put nursing on a more equitable basis with other university degrees. We moved away from centrally imposed number controls and financial limitations. Furthermore, through additional clinical placement funding announced this summer and further funding in October this year, around 5,000 more nursing students will be able to enter training through funded clinical placements each year to 2020-21. I certainly take on board the point that the noble Baroness, Lady Emerton, made about looking at their training and making sure that it is as multidisciplinary as possible. As a result, in the future NHS employers, as well as those in the independent, care and voluntary sectors, will have a larger pool of highly qualified homegrown staff available.

Noble Lords asked whether the NHS has enough staff. The most recent workforce figures show something like 30,000 more clinically qualified staff working in the NHS over the last seven years. We can argue about whether that is enough but it is more than a 60% increase at a time when, as we all know, there have been difficult fiscal decisions to make. We know that increased supply is only one part of the equation, which is why NHS Improvement has launched a new programme to improve staff retention and reduce leaver rates. This includes, among other things, targeted support for all mental health providers to improve the retention rates of all staff groups within these trusts, and an intensive package of clinically led support targeted at providers with above average leaver rates for nurses. However, as the noble Baroness, Lady Jolly, said, probably the greatest way to retain staff is to ensure that they are properly paid. That is why we have introduced the new national living wage to make sure that lower-paid staff groups in the NHS and social care, whose work the noble Baroness, Lady Donaghy, rightly lauded, see increases in their pay packets, and why I warmly welcome—as did my noble friend Lady Redfern—the commitment in the Budget to end the pay gap and to fund the Agenda for Change pay negotiation package that is agreed, subject to reasonable conditions about improved productivity, which, for example, might be to do with the better use of technology and demonstrable beneficial impacts on recruitment and retention. My noble friend Lady Redfern also pointed to the recent announcement we made on using NHS disposable surplus land to provide homes for staff. Again, that is a very welcome gesture.

We also need to attract back staff who have left the profession. The noble Baroness, Lady Jolly, asked particularly about this issue. I reassure her that, since September 2014, Health Education England has supported over 3,500 nurses to successfully complete the nursing return-to-practice programme and they are now ready for employment. It has also worked with the Government Equalities Office in creating a national allied health professional return-to-practice campaign to make 300 professionals available for the workforce in a couple of years’ time.

I come to the Brexit section—we have to do it. Several noble Lords asked about the impact of Brexit. I think it would be churlish of me to point out that 80% of the vote in the most recent general election was for parties whose manifestos committed us to leaving the European Union. But, more importantly, if noble Lords look at the data on EU staff in post in the National Health Service and compare it from the month of the referendum to a year later, they will see that there was actually a small increase in the number of EU staff working in the NHS. I take this opportunity to send a message to those staff that we value them, want them to stay and want to deal with the issue of citizens’ rights with the EU as soon as possible in the next phase of negotiation.

If we want to deliver world-class staff, we need enough of them. We need them to stay in the service and have working conditions that will allow them to thrive, professionally and personally. This is why our manifesto committed us to encourage flexible working, improve health and well-being and take action against those who attack or abuse NHS staff. The NHS has to keep pace with increasing demand but it cannot do this if it is out of step with the demands of modern family life. We know that caring responsibilities are most likely to fall to women, who make up around two-thirds of the NHS workforce. As the noble Baroness, Lady Donaghy, pointed out, inflexibility leads staff to work for agencies, diverting resources away from the NHS which could be invested in the permanent workforce. I reassure the noble Lord, Lord Clark, that we are reducing spend on agencies. He was right to point to the jargon in my Written Answer to him. I was obviously having an off day and did not spot it—either that or I have gone native, but I am usually quite good at striking it out. I think the point that it was trying to make was that you can recruit agency staff, but the agencies must first be approved. However, we could certainly have expressed that better. Our aim is to discourage the use of agencies by improving the staff banks that trusts use, making it easier for staff to work flexibly, pick up extra shifts at short notice and be paid quickly. Next year, we will pilot a new network of modern staff banks across the NHS. I give noble Lords an example of how that is working. Milton Keynes had very low take-up of bank shifts, leading to a disproportionate reliance on agencies. It developed a new system, including an app, and, as a result, shifts filled within 30 minutes of being advertised on the app and agency shifts reduced from historic high levels of 600 per week down to 300. That is impressive but I think we can do more.

It is also crucial that employers pay close attention to and invest in the health and well-being of their staff. Reducing sickness absence improves productivity, the quality and continuity of patient care and saves money. That is why NHS England’s commissioning for quality and innovation initiative will allow for quicker access to a range of health services such as musculoskeletal and mental health services for NHS staff.

Bullying can be one the greatest causes of ill health and staff unhappiness and, unfortunately, we know that bullying rates in the NHS are too high. It is completely unacceptable, which is why in July 2016 senior NHS leaders and the Social Partnership Forum developed a collective call for action. We are committed to working with the health system and, critically, trade union leaders through the Social Partnership Forum to tackle violence and abuse against staff. That is a key priority.

The Government have also been supporting Chris Bryant MP’s Bill in its passage through Parliament. The Bill, drafted with the assistance of the Home Office and the Ministry of Justice, will provide police and courts with effective powers to deal with those who use violence against emergency workers. Everybody in the House will agree that it is completely unacceptable that staff should be at risk of harm, simply for doing their job. Employers have a duty of care to all their staff and must take all the necessary steps, including disciplinary action where required, to put a stop to it.

The noble Lord, Lord Hunt, made a point about subsidiary companies. I am not aware of that issue but I will certainly investigate it and write to him; I will place a copy of the letter in the Library.

In conclusion, despite the difficult but necessary decisions that this Government and the coalition Government before them had to take, NHS funding is at record levels, with more doctors, more nurses on wards and more operations being performed than ever before. Survival rates are at a record high. Last year, the NHS treated more people than ever, which was possible only through the commitment and dedication of NHS staff.

However, we understand that we cannot rest on our laurels, and that the NHS must continue to attract and keep the staff it needs to be the best it can be. Staff choose a career in the NHS not just because of pay, but because they want to help to improve the lives of the patients who rely on them, whether in hospital or in the community. We want to create an NHS in which staff want to work and feel valued for that work, where they are motivated and feel safe, and where bullying and harassment are not tolerated. With record funding and innovative policy solutions, this Government are committed to delivering that as the NHS reaches its 70th year.

Nurses: Tuition Fees

Lord O'Shaughnessy Excerpts

Wednesday 29th November 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government whether they will write off the tuition fees of nurses who spend a number of years working in the NHS or related public care services.

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

My Lords, there are currently no plans in place to write off tuition fee loans for nurses who take up work in the NHS. Substantial financial support is available for nurses in training. With the increase in the student loan repayment threshold introduced by the Department for Education, from April 2018 a newly qualified nurse will not pay back their loan on earnings up to £25,000 a year.

[Lord Clark of Windermere (Lab)]

My Lords, when we have a shortage of 40,000 nurses, when the Government’s introduction of tuition fees has resulted in fewer nurses entering training, and on the very day it is announced that we are having to import 5,500 nurses from India, is it not crucial that we incentivise everything we can to get British students into nursing? Would my proposal about working in the NHS not help that?

[Lord O'Shaughnessy]

My Lords, nurse training places have been discussed a number of times in this House. I am sure noble Lords will be keen to know that, while there has been a small percentage drop-off in places year on year, the numbers recruited this year are comparable to 2014-15. That is common with the introduction of tuition fees for other courses and we would expect it to rebound. In the long run, the intention is to grow more of our own nurses and to recruit from the United Kingdom, which is why there will be an increase of 25% in the number of clinically funded training places for nurses—5,000 extra—from 2018-19 onwards.

[Lord Forsyth of Drumlean (Con)]

Can my noble friend indicate what percentage of the borrowing by student nurses under the student loans scheme will be paid back at the point when it is written off after 30 years? If so, would it not be better to do this earlier in their careers, rather than at the end of them?

[Lord O'Shaughnessy]

My noble friend is quite right to point out that student debt is forgiven after 30 years. The point of that is to ensure there is an equitable system, where those who earn more pay back more over the course of their working lives. It is important to point out that, with the new threshold moving up to £25,000, a nurse earning £26,000 in band 5 of the Agenda for Change pay scale would pay back £7.50 of that loan per calendar month.

[Baroness Brinton (LD)]

My Lords, with the NHS reporting that 96% of hospitals are currently failing to meet their planned number of registered nurses, and UCAS reporting a decline in student nurse applications, as the noble Lord mentioned, as well as the further news that one in four post-qualifying nurses leave in their first year, what are the Government proposing to do to change the problem of recruiting new nurses, including returning to bursaries and abolishing tuition fees altogether? Specifically, what are the Government doing right now to attract nurses into our hospitals?

[Lord O'Shaughnessy]

It is important to point out that there are 10,000 more nurses on wards than there were seven years ago. One of the things that we are trying to do is encourage nurses to return to practice—3,000 of those nurses have been on the return to practice programme. In regard to attracting them to hospitals, the main thing is that we need to train more nurses to fill those places so that we fill the demand that we know that we have from a growing and ageing population. That is why there are going to be 5,000 more funded nursing training places from 2018 onwards.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, is it not necessary to offer the most attractive terms to get more nurses into training? Will the Minister reflect on the very helpful suggestion made by the noble Lord, Lord Forsyth, that there is a possibility that a fair number of these people will never repay the full amount? Will he tell the House what the estimated write-off is of the repayments that will apply to nurses? If it is a high figure, will he reflect on the answer that he gave to the noble Lord?

[Lord O'Shaughnessy]

I shall certainly write to my noble friend, and indeed all noble Lords, about the proportion of the write-off. Let us remember, however, why the student loans system exists. It exists because those people who earn enough over the course of their working lives end up paying more than those who do not. Therefore, if somebody has gone into nursing but has then gone on to work in another profession, earning more money and being able to pay it off, it is equitable that they pay it off. That was the policy of the Labour Government, and it has been adopted by the Conservative Government precisely on the point of equity. It is only right that the loan is written off for those who have not earned enough but, for those who have earned enough, that they pay it off.

[Baroness Butler-Sloss (CB)]

My Lords, will the Government reconsider the issue of bursaries?

[Lord O'Shaughnessy]

I obviously have not been clear enough; I thought that I had. The answer to that is that we are not considering that at the moment.

[Lord Tugendhat (Con)]

My noble friend is explaining the policy very eloquently, but surely he ought to take into account the point raised by my noble friend Lord Forsyth. The problem is that the way the scheme works disincentivises people from entering occupations that are extremely socially desirable and much needed by the country precisely because they are going to be loaded with debt. Although they do not in the end pay it off, it bears very heavily on them during their working lives.

[Lord O'Shaughnessy]

The system that we have means that the people who benefit most from higher education are those who pay for their higher education and, in doing so, they subsidise those who go into the professions that my noble friend has mentioned, which are extremely worth while but might not be that well paid.

[Baroness Wheeler (Lab)]

My Lords, the Health Foundation research has shown that the change in nurse training funding arrangements in England has led to a fall in student numbers, rather than the Government’s promised increase. One of the most alarming statistics shows a 31% shortfall in the number of applicants aged 30 and over, just the group with the background and experience the NHS needs, many of whom are care workers with hands-on experience wishing to develop their skills by becoming qualified nurses. Does the Minister agree that these are the very people whom nursing needs, but for whom taking on a huge debt, often at a time of heavy financial commitment, seems an impossible hurdle? Does this not all underline the need for urgent reinstatement of nurse bursaries?

[Lord O'Shaughnessy]

I think that the figure on shortfalls that the noble Baroness has given is not right. If one looks at the UCAS data, it shows, as I said, a small drop of around 6%, but the numbers going into training are comparable to 2014-15. She is quite right about the need for additional financial support, and there is £1,000 available for childcare support for those who need it, as well as exceptional support funds of up to £3,000.

[Baroness Gardner of Parkes (Con)]

My Lords, is the Minister aware that there was a great disincentive for people to enter nursing when it was decided that it was necessary to have university-level academic education to do it? The SENs—the state enrolled nurses—were abolished. Does he think that the apprenticeship scheme, which I understand is put forward all the time as being the replacement for that, is really working well, or is there a need to bring back that middle layer of nurses who cannot get five A-levels but can nevertheless be excellent nurses?

[Lord O'Shaughnessy]

My noble friend makes an important point. It is precisely to, if you like, recreate that route into nursing that the nursing apprenticeship and nursing associate positions have been created, and the numbers are increasing.

Mental Health Care: Vulnerable Children

Lord O'Shaughnessy Excerpts

Tuesday 28th November 2017 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they are taking to address the concerns raised by the Care Quality Commission in its review published in October about the particular difficulties faced by children and young people in vulnerable circumstances, such as looked-after children and those with learning disabilities, in accessing mental health care.

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

My Lords, improving children’s and young people’s mental health is a priority for the Government, especially for the most vulnerable. The Government welcome the CQC’s recent report in this area, which was commissioned by the Prime Minister in January. Government initiatives to improve the mental health of vulnerable children include piloting new approaches to the mental health assessments that looked-after children receive as part of their initial health assessment, and testing models for personal budget use for looked after children.

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his response. With the Green Paper promised before Christmas, I hope we will not have to wait until the next CQC review for the urgent action that is needed, given the scale of unmet need for mental health care among vulnerable children. Barnardo’s recent survey showed that one in four looked-after children faced a mental health crisis on leaving care, and yet nearly 65% of them did not receive any statutory support; and whilst in care, local factors such as a lack of permanent or settled placement can lead to support action being denied. On children with learning difficulties, in all my research for this Question I was truly alarmed at the lack of information that is available on the scale and problems of this vulnerable group of children. What action is the Minister taking to ensure that the CQC, Ofsted and, sadly, the police and probation inspectors combine their efforts to investigate this issue as closely as it deserves?

[Lord O'Shaughnessy]

The noble Baroness is right to highlight these disturbing facts about the mental health of looked-after children. Nearly 50% of looked-after children have a diagnosed mental health disorder, so that is what we are up against. In terms of how we are dealing with it, the increases in funding to raise the number of treatments that are taking place by 70,000 will obviously help vulnerable children, and there is the additional assessment that I have talked about. She asked particularly about children with learning difficulties. I am sure that she is aware of it, but I would point her and other noble Lords to the Lenehan review, which set out several recommendations, all of which the Government have adopted. One of the actions that stems from that includes new guidance from the Local Government Association and NHS England on commissioning mental health services for children with learning difficulties.

[Lord Leigh of Hurley (Con)]

Does my noble friend the Minister agree that we can take some comfort from, particularly, chapter 4 of the first phase of the CQC report, which was commissioned by the Prime Minister only in January this year? With 80% of specialist mental health care for children and young people being rated as good or outstanding, there is much, to quote the report,

“we should celebrate and learn from”

[Lord O'Shaughnessy]

My noble friend is right to highlight that overall the provision is good. There is still work to do, particularly in specialist community mental health services. Part of the strategy we are undertaking is to make sure that those services have the staff they need. There will be 21,000 more posts in mental health services to ensure that the average rating improves over time.

[The Lord Bishop of Worcester]

Does the Minister agree that there remains, despite lots of good work, a terrible stigma attached to mental health problems? Will he assure us that the Government are committed to tackling it, as we seek to do in the Church, while also improving provision for identification and treatment?

[Lord O'Shaughnessy]

The right reverend Prelate is quite right: there is stigma attached. There have been a number of important initiatives, not least from His Royal Highness Prince Harry—who I am sure we all want to congratulate on his recent engagement—to reduce stigma and to demonstrate that mental health problems can, unfortunately, strike anyone of any positional station in society at any time in their life. Making that admission is the first step to seeking help.

[Lord Watts (Lab)]

My Lords, what are the Government doing to make sure that health trusts spend the resources available on this area of work? The facilities that these children are being seen in is appalling in some cases. What are the Government going to do about both of those issues?

[Lord O'Shaughnessy]

I can reassure the noble Lord that spending on children and young people’s mental health by CCGs, which are responsible for commissioning those services, increased by 20% between 2014-15 and 2015-16, so spending is increasing. Clearly, one of the areas in which that money is being spent is on better facilities. One of the additional changes is that about 150 new beds will be commissioned in underserved areas so that we can reduce the number of out-of-area placements, which can be quite disturbing for some of the children and young people who have to use them.

[Baroness Jolly (LD)]

My Lords, in England there are around 60,000 looked-after children, and there is evidence that some health providers are denying treatment to looked-after children if they have not yet established a permanent living situation. This is completely unacceptable. What action are the Government taking to ensure that all children’s care is addressed? Will the Minister confirm that the long-awaited Green Paper will be published this year?

[Lord O'Shaughnessy]

I ask the noble Baroness to write to me on that specific case. Of course, health services should never be withheld on such a basis; they should be provided on the basis of need, as we all know. I can confirm that the Green Paper will be published before the end of the year.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain why some looked-after children who have been on waiting lists for mental health care and are then transferred out of the area for foster care have to start their wait for access to mental health services again, if we have a National Health Service?

[Lord O'Shaughnessy]

I think this picture of a fragmented service is one that the CQC report highlights. One of the ways in which the Government are trying to address that is through incentive payments in the tariff system to make sure that trusts are incentivised to join up care, particularly when children are moving from place to place.

[Lord Cotter (LD)]

The Minister mentioned concerns about mental health, but crisis teams are reported not to be available in all parts of the country for under-18s, who are very vulnerable. Will the Minister look into crisis teams not being available for under-18s in many parts of the country?

[Lord O'Shaughnessy]

The noble Lord is highlighting that there is a good deal of variation, which is again highlighted in the CQC review. I think that is what he is describing in terms of crisis teams. I will certainly look into that and write to him with more details.

Maternal Safety Strategy

Lord O'Shaughnessy Excerpts

Tuesday 28th November 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 repeat a Statement made by my right honourable friend the Secretary of State for Health in the other place on the maternity strategy. The Statement is as follows:

“Giving birth in England is the most common reason for admission to hospital. Thanks to the dedication and skill of NHS maternity teams, the vast majority of the roughly 700,000 babies born each year are delivered safely with high levels of satisfaction by parents. However, there is still too much avoidable harm and death. Every child lost is a heart-rending tragedy for families that will stay with them for the rest of their lives. It is also deeply traumatic for NHS staff involved. Stillbirth rates are falling, but still lag behind many developed countries in Europe, and when it comes to injury, brain damage sustained at birth can often last a lifetime, with about two multi-million pound claims settled against the NHS every single week.

The Royal College of Obstetricians and Gynaecologists said this year that 76% of the 1,000 cases of birth-related deaths or severe brain injuries that occurred in 2015 might have had a different outcome with different care. So in 2015 I announced a plan to halve the rate of maternal deaths, neonatal deaths, brain injuries and stillbirths. Last October, I set out a detailed strategy to support this ambition. Since then local maternity systems have formed across England to work with users of NHS services to make maternity services safer and more personal. More than 80% of trusts now have a named board-level maternity champion, and 136 NHS trusts have now received a share of an £8.1 million training fund. We are six months into a year-long training programme and, as of June, more than 12,000 additional staff have been trained. The maternal and neonatal health safety collaborative was launched on 28 February; 44 wave 1 trusts have attended intensive training on quality improvement science and are working on implementing local quality improvement projects with regular visits from a dedicated quality improvement manager; and 25 trusts were successful with their bids for a share of the £250,000 maternity safety innovation fund and have been progressing with their projects to drive improvements in safety.

However, the Government’s ambition is for the health service to be the safest, highest-quality care available anywhere in the world, so there is much more work that needs to be done. Today I am therefore announcing a series of additional measures. First, we are still not good enough at sharing best practice. When you fly to New York, your friends do not tell you to make sure you get a good pilot. But if you get cancer, that is exactly what they ask about your doctor. We need to standardise best practice so that every NHS patient can be confident they are getting the highest standards of care. So when it comes to maternity safety, we are going to try a completely different approach.

From next year, every case of a stillbirth, neonatal death, suspected brain injury or maternal death that is notified to the Royal College of Obstetricians and Gynaecologists Each Baby Counts programme—about 1,000 incidents annually—will be investigated not by the trust at which the incident happened, but independently, with a thorough, learning-focused investigation conducted by the Healthcare Safety Investigation Branch, or HSIB. The new body started this year, drawing on the approach to investigations in the airline industry, and has successfully reduced fatalities with thorough, independent investigations whose lessons are rapidly disseminated around the whole system. The new independent maternity safety investigations will involve families from the outset, and will have an explicit remit not just to get to the bottom of what happened in an individual instance but to spread knowledge around the system so that mistakes are not repeated. The first investigations will happen in April next year, and will be rolled out nationally throughout the year, meaning we will have complied with recommendation 23 of the Kirkup report into Morecambe Bay.

Secondly, following concerns that some neonatal deaths are being wrongly classified as stillbirths, which means a coroner’s inquest cannot take place, I will be working with the Ministry of Justice to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law, giving due consideration to the impact on the devolved Administration in Wales. I would like to thank the honourable Member for East Worthing and Shoreham for his campaigning on this issue.

Next, we will do more to improve the training of maternity staff in best practice. Today we are launching the Atain e-learning programme for healthcare professionals involved in the care of newborns to improve care for babies, mothers and families. The Atain programme works to reduce avoidable causes of harm that can lead to infants born at term being admitted to a neonatal unit. We will also increase training for consultants on the care of pregnant women with significant health conditions such as cardiovascular disease.

We also know that smoking during pregnancy is closely correlated with neonatal harm. Our tobacco control plan commits the Government to reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less by 2022, so today we will provide new funding to train health practitioners, such as maternity support workers, to deliver evidence-based smoking cessation according to appropriate national standards.

The 1,000 new investigations into Each Baby Counts cases will help us transform what can be a blame culture into what needs to be a learning culture. But one of the current barriers to learning is litigation. So earlier this year I consulted on the rapid resolution and redress scheme, which would offer families with brain-damaged children better access to support and compensation as an alternative to the court system. My intention is that in incidents of possibly avoidable serious brain injury at birth, successfully establishing the new independent HSIB investigations will be an important step on the road to introducing a full rapid resolution and redress scheme in order to reduce delays in delivering support and compensation for families. Today, I am publishing a summary of responses to our consultation, which reflect strong support for the key aims of the scheme: to improve safety, patient experience and cost effectiveness. Going forward, I will look to launch the scheme, ideally from 2019.

Finally, a word about the costs involved. NHS Resolution spent almost £500 million settling obstetric claims in 2016-17. For every pound the NHS spends on delivering a baby, another 60p is spent by another part of the NHS on settling claims related to previous births. Trusts that improve their maternity safety are also saving the NHS money, allowing more funding to be made available for front-line care. In order to create a strong financial incentive to improve maternity safety, we will increase by 10% the CNST maternity premium paid by every trust, but refund that increase, possibly with an even greater discount, if they can demonstrate compliance with 10 criteria identified as best practice on maternity safety.

Taken together, these measures give me confidence that we can bring forward the date by which we achieve a halving of neonatal deaths, maternal deaths, injuries and stillbirths from 2030 to 2025, which I am today setting as the new target date for our ‘halve-it’ ambition. Our commitment to reduce the rate by 20% by 2020 remains and, following powerful representations made by voluntary sector organisations, I will also include a reduction in the national rate of preterm births from 8% to 6% within this ambition. In particular, we need to build on the good evidence that women who have continuity of carer throughout their pregnancy are less likely to experience a preterm delivery, with safer outcomes for themselves and their babies.

Mr Speaker, I would not be standing here today making this Statement were it not for the campaigning of numerous parents who have been through the agony of losing a treasured child. Instead of moving on and trying to draw a line under their tragedy, they have chosen to relive it over and over again. I have often mentioned members of the public such as James Titcombe and Carl Hendrickson, to whom again I pay tribute. I also want to mention Members of this House who have bravely spoken out about their own experiences, including the honourable Members for Colchester, for Eddisbury, for Lewisham, Deptford, for Washington and Sunderland West, for Banbury and for North Ayrshire and Arran. The passionate hope of bereaved families outside this House as they stand shoulder to shoulder with those Members inside this House is that by drawing attention to what may have gone wrong in their own case, mistakes are not repeated and others are spared the terrible heartache that they and their families endured. We owe it to each and every one of them to make this new strategy work, and I commend this Statement to the House”.

--- Later in debate ---

[Baroness Jolly (LD)]

My Lords, I pay credit to our midwives, who do a wonderful job all across the country, and to those who campaigned to get the report and have spoken about it—I woke up this morning to a very moving Radio 4 piece on the “Today” programme.

I also welcome the Statement from the Secretary of State. Bereaved parents certainly want an answer, and this is an ideal way of helping them to reach some sort of closure. One of the critical points that the Each Baby Counts report makes about maternity care is the importance of continuity of care both for the expectant mother and for the team in the delivery suite. Staffing is an issue, with the workforce being short by 3,500 and a third of our midwives approaching retirement. Some midwives are adopting different patterns of work or choosing to leave the profession, but temporary midwives, be they bank or agency, are not the solution. They undermine the continuity that is so critical. A perfect storm is approaching about recruitment and retention.

Will the Government reconsider some form of financial support for midwives in training? Are any other incentives being considered? Will they guarantee an NHS midwife who is an EU national a job should we leave the EU? What measures are being considered to bolster the morale of NHS midwives, because at the moment, it is really quite low?

[Lord O'Shaughnessy]

My Lords, I thank both noble Baronesses for their overall support for the important announcements made today, and join them in paying tribute to both the staff, who provide amazing care every day, which of course is the norm for most parents, and those campaigners who have campaigned so bravely to raise the profile of these issues with great success.

I shall deal with the issues raised in order. First, on legislation, it is important to point out that the Healthcare Safety Investigation Branch is up and running. Obviously, the intention is that the Bill will put it on a statutory basis, which will give it a degree of security and continuity. Draft legislation will be considered by a committee before turning it into a fully fledged Bill. Although I am not entirely sure of the timetable, I reassure the noble Baroness that we intend to have proper primary legislation following consideration of the draft Bill.

It is important to recognise that the number of staff has increased in the past few years, whether maternity nurses working in maternity services and neonatal nursing, midwives or doctors working in obstetrics and gynaecology. It is also important to recognise, first, that the number of births has risen, so there is a greater workload; and secondly, that on average births are becoming more complicated, as mothers become older, on average, and have more concomitant health problems—smoking and obesity are two of the greatest. I recognise the challenge.

I should point out that more than 6,800 midwives are in training, so there is an intention to continue growing the workforce. However, I recognise that more needs to be done to support them so that they can deliver the care. That is why the training packages announced today are so important.

In terms of learning lessons, the whole point of the rapid-resolution redress process by involving the HSIB is to provide resolution to parents so that they are satisfied while avoiding the sometimes adversarial situation that can emerge, when all that happens is that the problem is delayed for 10 years and creates great heartache for the families involved. We are trying to come up with a process that deals with it more quickly, without disadvantaging the families concerned, and means that it is easier to spread the lessons. That is why the independent HSIB investigations are so important.

Finally, I emphasise the point about the importance of continuity of care, which is referred to on page 16 of the maternity strategy. Here is a stark fact: women who receive continuity of midwife-led care are 16% less likely to lose their babies. That is about one in six, an extraordinary statistic. I understand that it does not necessarily require more staff to deliver that but it does require staff to be organised differently. That is one of the challenges that we have ahead.

[Lord Patel (CB)]

My Lords, credit where credit is due: I commend the Government for this initiative. It was first suggested some years ago but that does not matter; it is here now. My question relates to the root cause analysis, which is rightly the way to analyse stillbirths that occur. It should take account of all the circumstances, including staffing levels, as mentioned. It is not just about the care itself. Can the Minister clarify how the system of doing root cause analysis of every stillbirth will work if, at the same time, a coroner is doing an investigation?

[Lord O’Shaughnessy]

I thank the noble Lord for his support for today’s announcements. Obviously, independent investigations are just that. They will be operated by HSIB, which will be able to delve into the causes of the tragedy, however it might have happened, and provide an opinion on that. On the interaction with the coroner’s report, obviously we have focused mainly today on these new independent investigations and we are looking at extending coronial law to take in stillbirths that were previously not included. That is one of the issues that needs to be worked out in the coming months through interaction with the Ministry of Justice.

[Baroness Cumberlege (Con)]

My Lords, I start by declaring my interests. I am a fellow of the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Nursing, and president of the National Childbirth Trust. Those positions are unremunerated but I am remunerated by NHS England for implementing the report of the review of maternity services.

There is absolutely no doubt that the Secretary of State has concentrated the minds of all of those working in and for the NHS on safety. It is the golden thread that has run throughout his time in office, especially now when he is concentrating on maternity services. We have never seen safer services, but we are being urged to go further with some new initiatives that have been declared today.

I welcome the Statement, particularly the part on investigations. Those of us tasked with implementing the report Better Births—the review of maternity services for England—have been concerned by the way many investigations have been conducted, causing further misery and trauma to the families concerned. We have full confidence that the Healthcare Safety Investigation Branch will ensure independence, and above all, will involve the families. After all, the families were there; they knew what took place. They have a legitimate role in investigations, but often their views and experiences are ignored. Even worse, the learning that has been gathered has not been passed down to the teams within the trust, nor indeed has it spread to other organisations in the wider world. It is absolutely essential that that happens so that we see fewer stillbirths, early neonatal deaths and brain-injured children.

It was those anxieties that made us in the maternity review consider a new scheme, for which we coined the title “rapid resolution and redress”. I pay tribute to Professor Sir Cyril Chantler, who was my vice-chairman. He has worked tirelessly with colleagues across the world and in this country to frame the scheme, so we are delighted that Ministers see the merit of this proposal. However, I should like to question my noble friend about the timing. I understand that more policy work is to be done, but is it possible to bring forward the second part of the implementation of rapid resolution and redress so that the families in question do not have to wait until 2019?

I am interested in the coroner’s investigations. I understand the desire to ensure that no stone is left unturned, but I want to express my concerns at this moment because it is another inquisitorial initiative, when RRR is designed to avoid using the courts in order to spare parents from trials and tribulations. Therefore, I ask my noble friend to consider whether there could be a pause so as to wait for the evaluation of RRR; otherwise, we will have a range of initiatives which not only might cause confusion but will be in conflict with one another. I thank my noble friends for introducing continuity of care—something that is very close to my heart.

[Lord O’Shaughnessy]

I am delighted to be able to respond to my noble friend, who, probably more than anyone else, has really led the charge in this area. I pay tribute to her for her work on better births, as I do to Sir Cyril Chantler, her deputy. She is right that patient safety is the golden thread that runs through all the work that the Secretary of State has led, and she is right to highlight that we have safer services. The changes that we are making, together with bringing forward the “halve it” ambition, will save 4,000 babies’ lives, which is a great prize.

With regard to my noble friend’s questions, the endorsement of the HSIB is very welcome. Some months ago I organised a briefing for noble Lords with Keith Conradi, who runs it, and I shall be very happy to organise another one. It is a very interesting organisation with an interesting methodology that has proved incredibly effective in the airline industry, where Mr Conradi comes from.

On RRR, I appreciate my noble friend’s concerns about the timing and I will certainly look into whether it is possible to bring forward its implementation. As she knows, there are some issues around governance and how it will operate that mean that we need to tread carefully, but I shall certainly take that into consideration because we want to get the scheme up and running as soon as possible.

[Baroness Tonge (Non-Afl)]

My Lords, I too declare an interest. Like the noble Baroness opposite, I am an honorary fellow of the Royal College of Obstetricians and Gynaecologists. Of course I welcome this investigation that the Government have announced, but I am a little worried that at the end of the investigation we shall hear the usual phrase “lessons will be learned”. From past experience, lessons are never learned, especially in the health service, because the main cause of the difficulty and of these babies dying is a shortage of midwives and a lack of staff. When will the Government seriously address funding in all sectors of the health service but, on this occasion, especially midwifery?

--- Later in debate ---

[Lord O’Shaughnessy]

The whole point of these reforms is that lessons should be learned, and they can be. The Francis inquiry, and other investigations that have taken place into poor practice, have led to dramatic improvements. The fact that there are over 10,000 more nurses on wards was a direct response to the Mid Staffordshire crisis and the finding that there were not enough staff on wards to look after patients and make sure that they were not vulnerable. It is possible to be optimistic about this. We are already seeing improvements through the learning from deaths programme and from the reduction in the number of stillbirths. The noble Baroness is shaking her head but that is rather a gloomy view, which does not reflect the support for these proposals in this House.

In answer to the point about staffing, there are more midwives in the service and more coming through training. We need to make sure that that continues so that the level of support that is needed is there.

[Baroness Hayman (CB)]

My Lords, like others, I welcome the Statement and the determination to deal with this issue. The Minister will recall that a few weeks ago I asked him about coroners’ inquests on stillbirths and I will address myself to that. Does he agree that, for many parents, the depth of their bereavement at a stillbirth means that they feel the weight and authority of a coronial investigation is absolutely warranted? I therefore welcome the discussions that are to take place. Can the Minister tell me a little about the timing of that and about the legislative vehicle? I understand that primary legislation will be necessary and a Private Member’s Bill that refers to this is currently in the Commons.

[Lord O’Shaughnessy]

I am glad to be able to return to the topic, which the noble Baroness has raised before. There was a powerful story on “Today” this morning, about parents who wanted precisely that for the level of authority it would bring. The hospital was not necessarily treating them as well as it could. These independent investigations will provide a degree of authority and independence that is perhaps sometimes lacking. We want to see how this pans out, but the Secretary of State is committed to looking at coroners investigating stillbirths. This is obviously a complex issue, so I hope the noble Baroness will forgive me if I am not in a position to provide more detail at this point. However, there is a desire and willingness to look into this in the months ahead. When we have some more details, I will certainly write to her.

Brexit: Mental Health Research Funding

Lord O'Shaughnessy Excerpts

Thursday 23rd November 2017 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government whether they intend to match the current European Union contribution towards United Kingdom mental health research funding after the United Kingdom leaves the European Union.

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

My Lords, the Government have made clear that UK businesses and universities should continue to bid for competitive EU funds while we remain a member of the European Union and that we will work with the Commission to ensure payment when funds are awarded. The Government will underwrite the payment of such awards, even when specific projects continue beyond the UK’s departure from the European Union. This will include mental health research funded by the Horizon 2020 programme.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister recall the Government’s promise in the May manifesto:

“We will make the UK the leading research and technology economy in the world for mental health”?


I am reassured by some of the Answer he gave, but he has not given a firm commitment that this will continue after Brexit. Will he give such a commitment; and given the promise that was made in the manifesto, will he outline how the Government intend to increase the amount of research that will be undertaken in mental health in the future?

[Lord O'Shaughnessy]

In our future partnership paper we have set out that we want an ambitious agreement on science and innovation and that we will continue, albeit in a new form, to collaborate with the European Union on health research, including mental health research. On honouring the bids that were underwritten, I should point out that that applies not just to bids or projects that are taking place but to bids that have been submitted up until exit day, so there is a long lead time. It is also important to point out what the Government have been doing domestically. For example, the National Institute for Health Research has increased by over 50% the amount of funding that it puts into mental health research, so the Government have been going a long way in increasing the amount of funding in this area.

[Baroness Hollins (CB)]

My Lords, cancer research gets 25% of the UK’s annual research budget. The Minister mentioned that there has been an increase in the research money available for mental health but, as I understand it, mental illness gets only about 6% of the research budget. Why is that, and is there hope that that will be improved?

[Lord O'Shaughnessy]

In relation to the NIHR funding that I talked about and the specialist disease areas that receive funding, mental health is second only to cancer, so it is getting a great deal of funding. I could talk about the increase in the Medical Research Council’s budget and so on, but more funding is going in specifically to mental health research.

[Baroness Jolly (LD)]

My Lords, the UK is currently the second-largest receiver of research funding from the EU—second only to Germany—and is among the most productive places in the world in mental health research output. Does the Minister share my concern that the best will follow the money to the USA or elsewhere?

[Lord O'Shaughnessy]

As I set out in my Answer to the noble Lord, Lord Brooke, the intention is to continue our relationship with and involvement in cross-EU health projects. Other third-party countries do that, and there is no reason why that would not be the case. In terms of the workforce, which I think is what the noble Baroness was referring to, the Prime Minister has been very clear that we want to continue to attract the brightest and best to this country. Once we have left the European Union, our immigration system will be set up to do just that.

[Lord Pearson of Rannoch (UKIP)]

My Lords, is not this yet another area where there is really no such thing as EU funding? Do the Government agree that the contribution to which this Question refers comes out of the £10 billion per annum which we pay to Brussels and which it sends back? That is not to mention the additional £10 billion per annum which we pay to Brussels in net cash. So surely the Government can agree without qualification to fully fund this very important service and, if necessary, increase it after Brexit.

[Lord O'Shaughnessy]

The noble Lord is right that the European Union does not in itself have a tax base and that we are a net contributor to European Union budgets. As I said, our intention is to continue to have a productive relationship with the European Union as a third party, contributing to research budgets and benefiting from them, as we do, in terms of both funding and the people who work together on these important areas.

[Baroness Thornton (Lab)]

My Lords, the European Commission made it very clear in October 2017 that British researchers funded under Horizon 2020 programmes will lose access to their grants in the future. Given that the EU is the largest single funder of mental health research in Europe and that the UK is a net gainer, will the Minister inform the House when we will see the plans to ensure that the UK remains a leading contributor and beneficiary of European-wide mental health research?

[Lord O'Shaughnessy]

As I said, we continue to bid for funds that we can draw down, and the Government are committed to underwriting any successful bids as part of the Horizon 2020 programme. Our intention is to continue in that programme. Obviously, if that is not the case, we will have funding available to support health research in this area, but our intention is to continue with the partnership that has proved so fruitful.

[Lord Bird (CB)]

Will the Minister accept that, in spite of all the wonderful research, Britain is falling way behind at the point of need and that on the streets and among the poorest in this country, mental health support has completely disappeared?

[Lord O'Shaughnessy]

I totally do not accept that proposition. Mental health is certainly a problem in this country. One in six adults and one in 10 children has a common mental health disorder, and those figures are pretty devastating. However, the Government have been increasing funding for mental health. It has gone up by 8.4% over the last two years, so there is funding. There are more staff in mental health trusts and we have pledged to treat 70,000 more children. Therefore, we are putting the money in and getting better results.

NHS: Deficit

Lord O'Shaughnessy Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord Harris of Haringey]

To ask Her Majesty’s Government, in the light of the quarterly performance report published by NHS Improvement on 16 November, what is their current projection for the aggregate deficit of NHS provider organisations at the end of this financial year.

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

Prior to today’s Budget settlement, recent figures from the NHS suggested that trusts will end the year with a combined deficit of £600 million. The vast majority of trusts are on plan to balance their budgets or better, and for those trusts in financial special measures, significant support is available to return them to good financial health.

[Lord Harris of Haringey (Lab)]

My Lords, I am grateful to the Minister for that Answer. He glided over the fact that the level of deficit in trusts seems to be rising rather more rapidly than the Government can cope with. Two weeks ago, the Nuffield Trust, the Health Foundation and the King’s Fund produced a joint report that said that the levels of funding then planned for the NHS were,

“far below what is needed to maintain standards of care”.

They said that £25 billion would be needed by the end of the Parliament and £4 billion was needed urgently next year. The Government have given £1.6 billion in today’s Budget for next year. This is at a time of rising numbers of mixed-sex wards, and of trusts delaying payments to small business suppliers and having to take out bank loans to pay their staff. Is this a case of the Government not caring about the NHS and wanting to see it wither on the vine?

[Lord O’Shaughnessy]

That is a completely unfair accusation and unjustified, both by the funding settlement that the NHS had and by the improved settlement today. First, deficits have been falling year on year for the past couple of years in terms of both outturn and forecast, and that is before today’s announcement on additional funding. The Chancellor today announced over £2.5 billion-worth of extra revenue funding over the next two years. That means that the actual value of the spending review settlement will end up being £11.5 billion compared with £8 billion, so I reject the idea that this Government are not funding the NHS properly.

[Baroness Jolly (LD)]

My Lords, the NHS is very nearly 70. There was some continued investment in today’s Budget, which we welcome, but we consider that it is only a sticking plaster unless we look at social care and the NHS together. If we want the NHS to continue for another 70 years, we really need to see a change. A cross-party group of MPs visited the Prime Minister and put that to her, suggesting that there needs to be an all-party conversation about this—an all-party commission. Will the Minister tell the House whether the Government are minded to pursue that and, if not, why not?

[Lord O’Shaughnessy]

As the noble Baroness pointed out, additional spending is going in. I should point out that the proportion of public spending on health has increased under this Government, so even while fiscal retrenchment has taken place, more money has been spent on health. On the idea of a cross-party convention, we talk about building a cross-party consensus on social care with the Green Paper that will come out in due course. We need to focus on action. The danger with conventions and commissions is that they just prolong the process of making decisions, whereas moving ahead with decisions on both integration in the NHS and getting consensus behind reforming social care is the way forward.

[Baroness Manzoor (Con)]

My Lords, does my noble friend agree that there is nothing to prevent NHS organisations, acute services and social care working together? There are no barriers and that can be done currently. Therefore, having a commission that will prolong things is not necessary. We must exclude any barriers that exist now.

[Lord O’Shaughnessy]

My noble friend is absolutely right: there are no barriers. Indeed, the five-year forward view, in which the NHS sets out its own future, talks about integration and moving towards accountable care systems. Some capital programmes have been announced today under what will amount to a £10 billion capital programme over five years. These are precisely to deliver the transformation which is needed by making the kind of investment to provide that level of integration.

[Lord Patel (CB)]

My Lords, the Minister has said previously that he read the cross-party House of Lords report on the long-term sustainability of the NHS and adult social care with enthusiasm. No doubt he will have noticed several recommendations in it that would go a long way towards making the NHS financially stable and sustainable over the long term. Does he agree that what is now enthusiastically required from him and from the Government is to accept those recommendations? A short answer made up of a three-letter word will suffice.

[Lord O’Shaughnessy]

The noble Lord waits patiently. I pay tribute to the quality of the report and we have already accepted some of the ideas set out in it. Now that the Budget is over and the Treasury can turn its mind to additional things, we will be responding to the report very soon.

[Lord Clark of Windermere (Lab)]

My Lords, in his Budget Statement today, the Chancellor referred to the fact that he was establishing a working party of the department and the unions to look at salaries in the NHS, but he was a bit vague when it came to the funding of the outcome. Can the Minister give an assurance that the Government will fund whatever is agreed by the department?

[Lord O’Shaughnessy]

The Chancellor has confirmed that he will fund an Agenda for Change, as it is known, pay deal on the condition that the pay award enables improved NHS productivity and is justified on recruitment and retention grounds.

[Baroness Wheeler (Lab)]

My Lords, is the Minister aware that the number of GPs has fallen sharply over the past year, despite the government pledge to increase the supply of family doctors by 5,000 by 2020? How many more targets are likely to be missed by the Government? When did the NHS last achieve the A&E 95% target or the 92% 18-week treatment target? What will the actual impact of today’s funding announcements be on the Government’s performance on these key targets and their ability to ensure that planned improvements in priority areas of care such as cancer and mental health will not be stopped, as Simon Stevens has warned?

[Lord O’Shaughnessy]

The noble Baroness has pointed out the disappointing numbers as regards GPs. I should point out that there has been an increase in training places for future years. It is critical that we deliver those places and bring more staff into the service. I am glad that she drew attention to where the additional funding will go. There will be £340 million to help the NHS through this winter, £1.6 billion of additional revenue in 2018-19 and £900 million in 2019-20. That is precisely, as the Budget pointed out, to improve A&E waits, turn waiting list growth around and improve performance against the RTT targets.