Alcohol: Children’s Health

Lord O'Shaughnessy Excerpts

Monday 3rd April 2017 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what assessment they have made of whether the way in which supermarkets and convenience stores display and promote alcohol can endanger the well-being and health of children.

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

My Lords, Public Health England’s evidence review identified the negative impact that the advertising and marketing of alcohol can have on children and young adults. The Government are committed to working with industry to address concerns over any irresponsible alcohol promotions, advertising or marketing to make sure that children and young people are protected.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I take it from that reply that no research has been undertaken on this. In those circumstances, I wonder whether the Minister is prepared to commit himself to the Government undertaking such research. If they are not willing to do so on their own, will they enter into discussions with the drinks industry—probably the Portman Group, which represents the drinks industry—to see whether such research can be undertaken jointly?

[Lord O’Shaughnessy]

The noble Lord is not quite right on that. Public Health England’s evidence review identified a negative impact, and that constitutes research. It looked at the evidence, which is that advertising and marketing to young people has a negative impact on their drinking behaviours. There are stringent rules, particularly around advertising, which is policed by the Advertising Standards Authority, to make sure that that does not happen.

[Lord Robathan (Con)]

My Lords, while we all wish to see responsible supermarket advertising, is it not the case that law already exists to prevent the sale of alcohol to children? Surely this law should be enforced and parents held responsible if their children are drinking illegally.

[Lord O’Shaughnessy]

As my noble friend points out, there are very strict rules around the sale of alcohol to children under the age of 18, and tough punishments exist for anyone who is doing so.

[Lord Rennard (LD)]

My Lords, does the Minister accept that we really need better labelling on alcohol products, particularly to assist those seeking to follow a healthier lifestyle and who might be seeking to purchase low-alcohol or no-alcohol products? We need to improve labels to show more clearly the level of alcohol, the number of calories in the product and the amount of sugar in the product to assist those consumers.

[Lord O’Shaughnessy]

The noble Lord makes a good point. I believe that something like 80% of alcohol for sale is now labelled in some way, whether that is in units or calories and so on. The issue is currently being looked at at a European level—

[Noble Lords]

Oh!

[Lord O’Shaughnessy]

Given what is going to happen in the next couple of years, we might want to look at it ourselves, too.

[Baroness McIntosh of Pickering (Con)]

My Lords, is my noble friend aware that it is currently not an offence to sell alcohol to those under 18 at airports, airside, for the simple reason that the Licensing Act 2003 does not apply? Will my noble friend undertake to review this with a view to making it an offence in future and to bring the whole regime under the Licensing Act 2003 without delay?

[Lord O’Shaughnessy]

I thank my noble friend for that question; I was not aware of that issue. I understand that there is a voluntary code in place, but I shall write to her to outline in much greater detail what the situation is regarding the sale of alcohol to underage young people at airports.

[Lord Hunt of Kings Heath (Lab)]

Now that we can see the end of the light-touch European regulations on alcohol labelling, can I take it that the Minister’s department is looking to 2019 to produce a much tougher labelling regime, for which we have called for many years?

[Lord O’Shaughnessy]

We are obviously looking at all aspects of alcohol control, and this has nothing to do with Brexit per se. It is worth pointing out that successive Governments’ alcohol policies have had a very positive impact on the activities of young people. Fewer young people than ever are drinking—it is fair to say that they set an example to older cohorts. However, there is more to do. Around 400 11 to 15 year-olds drink weekly. That is clearly not acceptable and we need to do more.

[Baroness Royall of Blaisdon (Lab)]

Will the Minister remind the House of what the Government’s attitude now is towards a minimum price for alcohol?

[Lord O’Shaughnessy]

The noble Baroness will know that on minimum unit pricing a court case is ongoing in Scotland, where the proposed introduction of minimum unit pricing has been challenged by the Scotch Whisky Association. We are awaiting the outcome of that court case before we move ahead.

[Baroness Farrington of Ribbleton (Lab)]

Will the Minister give an undertaking that, in looking at this issue in the broad, the Government will have regard to the number of children who grow up in households where there is a severe alcohol problem among the parents or adults? Will he undertake to monitor carefully how much the public health authorities are providing and enhancing alcohol treatment centres, which appear to be diminishing in some parts of the country? Many children grow up suffering because of this sort of family problem.

[Lord O’Shaughnessy]

The noble Baroness highlights a difficult and, indeed, tragic area. The other day, my honourable friend the Public Health Minister met the APPG on Children of Alcoholics. In preparing for a debate last week organised by the noble Lord, Lord Brooke, I discovered that Alcohol Concern estimates that there are 95,000 children under the age of one who live in a family where the parent has an alcohol problem. That is a rather horrifying statistic. One way we are dealing with that is through the family nurse partnerships; indeed, more than 16,000 places are now available and one of the capacities they have is to provide help for families struggling with addiction, whether it is to alcohol, drugs or other things.

[Lord Brooke of Alverthorpe]

My Lords, I want to come back to the Public Health England report that the Minister mentioned, of which I am aware. Would he concede that many issues are raised in that report? For example, it recommends that minimum unit pricing should be introduced, but it is not being introduced. When I am in my local Co-op, I am surrounded by alcohol as I queue for the checkout. I am also surrounded by children. Why are the Government not taking action to stop that?

--- Later in debate ---

[Lord O’Shaughnessy]

Action is being taken. There are clear rules and mandatory guidelines around the promotion of alcohol. It is important to point out that alcohol is different from smoking, where there are extremely strict rules on promotion. Most people enjoy alcohol in moderation as part of their healthy, pleasurable, normal social life, so there is a difference. However, there are clear and strict rules around promoting, advertising or selling to children.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that whereas the commonest cause of cirrhosis of the liver used to be alcohol, it is now the obesity epidemic, which could be cured by eating less?

[Lord O’Shaughnessy]

My noble friend is right. Of all the things we should do in our lives, we should eat less and drink less—as I am sure every Member of this House does.

Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) (Amendment) Regulations 2017

Lord O'Shaughnessy Excerpts

Thursday 30th March 2017 Lords Chamber

Moved by

[Lord O'Shaughnessy]

That the draft Regulations laid before the House on 1 March be approved.

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

My Lords, I am delighted to speak about these important regulations, which will continue to ensure the provision of five mandatory health and development assessments and reviews as set out in the Healthy Child Programme. It was a policy I first worked on over 10 years ago. Having had three children in that time, whose births and early months were not always straightforward, my wife and I know from personal experience the benefits of the programme.

The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) and Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) (Amendment) Regulations 2015 transferred responsibility for commissioning public health services for children aged zero to five from NHS England to local authorities, allowing local public health services to be shaped to meet local needs. This includes responsibility for delivering the healthy child programme. This programme is the main universal health service for improving the health and well-being of children, providing families with health and development assessments and reviews, health promotion, screening and immunisation. This is supplemented by advice around health, well-being and parenting. The five reviews are offered by health visitors to pregnant women, new mothers and children from birth to age five and include the antenatal visit, the newborn review, the six to eight week check, the one year review and the two to two and a half year review. They are required to be provided by all local authorities in England.

I know that your Lordships will agree that health visitors play a crucial role in ensuring that children have the best possible start in life, and lead the delivery of the elements of the healthy child programme which relate to these children. Health visitors provide valuable advice and support to families and are trained to identify health and well-being concerns. Through the health visitor programme, the Government have supported the profession more than ever before to transform the service and I pay warm tribute to its excellent work. In April 2015, at the end of the health visitor programme, there was an increase of around 4,000 in the number of full-time equivalent health visitors in the workplace since May 2010. Health Education England is now ensuring sustainable development of the health visitor workforce and there are presently more than 800 health visitor student training places commissioned. This, along with service transformation, means that more families now have access to the support they need in those precious early years.

The Government are also committed to supporting school-aged children and young people by promoting their health and well-being through school nursing services. There are currently around 1,100 school nurses in England, supported by other professionals, such as community staff nurses, healthcare support workers and nursery nurses. In January 2016, Public Health England published commissioning guidance for school nursing which makes it clear that school nurses should be accessible and responsive to children’s needs. The current 2015 regulations, which place a duty on local authorities to provide the five universal health visitor reviews, contain a sunset clause and so will lapse on 31 March 2017—tomorrow. The legal obligation on local authorities to provide health visitor services is also set to lapse tomorrow. The draft regulations before the House will prevent this. The current regulations also include provision for a review to be undertaken of the operation of the regulations.

The Department of Health commissioned Public Health England to carry out a review of the operation of the five mandated universal health visitor reviews following the transfer of responsibility to local authorities, as set out in the 2015 regulations. A review was carried out in summer 2016 and Public Health England’s report of the review was published on 1 March 2017. The review found widespread support from local authorities and commissioners for the universal health visitor programme remaining in place, in order to secure the delivery of long-term benefits from the healthy child programme, including improved health and well-being outcomes for children and their families. There was also a strong view held by professional representatives of local government and the nursing profession that the services are essential for prevention and early intervention and a general agreement that they deliver a positive return on investment and contribute to other government priorities such as reducing childhood obesity, controlling tobacco and improving maternal mental health. I thank Public Health England for its important work on the review and for helping to inform these regulations.

Local authorities will continue to be funded to deliver the mandated health visitor reviews. They will receive more than £16 billion between 2015-16 and 2020-21 to spend on public health, which includes children’s services including health visitors. This is in addition to what the NHS will continue to spend on vaccinations, screening and other preventive interventions. The Government announced earlier this month that the ring-fence on the public health grant will be retained for a further year, until 2019, as we move towards implementing 100% local business rate retention. This is a step on the way to a more locally-owned system and will help smooth the transition by providing some certainty for the next two financial years.

It is right that local authorities should have appropriate flexibility to deliver against their local priorities, but it is also appropriate that there are some key requirements set nationally, such as the five universal health visitor reviews. By continuing these mandated elements of the healthy child programme, this Government intend to maintain consistency across all local authorities when ensuring the delivery of these services. The draft regulations before your Lordships today will remove the sunset clause from the current regulations, ensuring that local authorities continue to provide these important visits to families. Removing the sunset clause will ensure that the current duty on local authorities to provide these services does not lapse on 1 April. I am confident that this sends a clear signal to health visitors, family nurses, local authorities and the public of the Government’s ongoing commitment to universal public health support for pregnant women, children, and their families.

This Government are committed to improving the health outcomes of our children and young people, so that they become among the best in the world. What happens in pregnancy and during the early years of life has a huge impact throughout the life course. Therefore, a healthy start for all children is vital for individuals, families, communities and ultimately the nation. I commend these regulations to the House.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, I am delighted to support these regulations because I am an enormous fan of a universal health visitor service, and in particular the healthy child programme. Our economy is never going to keep up with the demand for health services unless we pay more attention to the issue of prevention. That really is the public health agenda. Any doctor will tell you that you really must lay the foundations for a healthy body, lifestyle and habits in the early years or you will get illnesses later on. The review of the programme so far has been very positive. As the noble Lord, Lord Hunt, said, there have been significant improvements in the populations reached. However, we will not see the true benefit of this programme until we are years down the track and find that those young children who have been given a healthy foundation grow up to have fewer of the terrible but preventable chronic diseases that are costing the country so much.

I am very proud of the coalition Government’s vision of improving the health outcomes of children, young people and their families. Transferring the responsibility to local authorities was part of that: it gives them the chance to combine services, right up to the age of 19. However, as the noble Lord, Lord Hunt, said, there are serious questions to be asked. The first, of course, is about resources. Although these services are mandated, and although the Minister may say that the money has been ring-fenced, budgets have been cut and are going to be further cut. Local authority councillor friends of mine tell me that it is getting more and more difficult for local authorities to provide even those services which they are mandated to provide because things are getting so tight financially. I hope the Minister can give us some encouragement on that, although I somehow doubt it.

The other question on resources is about people. We have heard from the Minister about the number of health visitors in training. Are they going to be enough to serve rising demand? We have a rising population and a lot of additional young people and families who require services. A universal service is terribly important because you do not just get health problems among the most deprived. However, there is a great deal of poverty in this country and the need for these services is growing. How confident is the Minister that we will have enough sufficiently trained nurses, given the stresses on all health service staff and given that so many people are leaving and retention is getting more difficult? Are we going to have enough people?

Are there any plans to extend these services a little further up the age range? I am particularly concerned about the large number of children who are starting school between the ages of four and five already overweight, obese or with poor eating habits. So, although the healthy child programme and the reviews that are mandated here in these regulations go up to the final check at two to two and a half years, it is really important that we do it again just before the child goes to school, because at that point they are already at a disadvantage. Many of these children are from a disadvantaged background and sadly these problems occur more frequently in those backgrounds. They get to school and they are already developmentally a good deal behind children from more advantaged backgrounds. I think the proof that we have had over the few years that this programme has been in place is sufficiently convincing to tell us that perhaps we ought to extend it a little bit further.

[Lord O'Shaughnessy]

My Lords, I am grateful to both the noble Lord, Lord Hunt, and the noble Baroness, Lady Walmsley, for their endorsement of the universal health visiting service. The noble Baroness is quite right to emphasise the long-term benefits that derive from a universal health visiting service of high quality and it is true that it is a great coalition achievement that we should be proud of. I am also grateful to the noble Lord, Lord Hunt, for his endorsement of not only the programme but also the mandated reviews and indeed of local authorities taking ownership of the programme.

To deal with the funding issue first, as I set out there is both the £16 billion that is going into local authorities for public health and the extension of the ring fence for another year. I will not gloss over the fact that it is a challenging fiscal environment. We know why that is; it is because the country continues to borrow more than it is bringing in in tax. I do not want to go into the reasons for that for fear of being accused of being too political, but we do operate in a challenging environment. That is why the business rate retention and reform is so important, to give local authorities more sustainability for their own funding base. I should also point out that, whether the issue is smoking or other risky behaviours, we are still making good progress, so it is possible to continue to reduce these kinds of risky behaviours, notwithstanding the pressures that are inevitably placed on budgets. In the round, total health budgets are increasing, not just in the NHS but across all health budgets. So while I do not gloss over the fact that it is a challenging fiscal environment, we are still making very strong progress, not just on health visitors but on a number of important public health issues.

In terms of the point that the noble Lord, Lord Hunt, made about the review by Public Health England of mandated services, obviously there are no plans to review the health visiting service, as I think we are all agreed that this is something we want to happen. Health visitors are popular and desired. I am not in a position to say at this point whether any other services are under review but I shall certainly write to him about that.

Both the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, asked about the numbers of health visitors. They increased by 50% in the last Parliament, which I think is a huge achievement. It has become slightly more difficult to track their numbers because they have a number of employers now that the budget has been devolved, but there are still very high numbers of them as a result of the changes made in the last Parliament. There are over 800 training places for health visitors and there are more nurses in the system as well. So there is investment going into the workforce, and I absolutely recognise that there has got to be a high-quality workforce. It is also the case that other healthcare professionals are able to deliver some of these services. If a family, which of course will more likely be a poorer or more disadvantaged family, is receiving support from a family nurse partnership, then the nurses that are delivering that can also deliver the health visit and some of the early reviews, so it is a mixed picture. The number of family nurse partnership places has increased over the past few years as well.

There are a couple of final issues. Breastfeeding is part of health visitor training and indeed their mandate is to encourage greater breastfeeding. I am not aware of the specifics of the variability. I shall certainly look into that. It is a critical part of maternal and child health and to be encouraged. I know that there are variations from one part of the country to another. Whether they are due to training and workforce or to other cultural or longer-term issues is a different question and it is bound to be more challenging in some areas than others.

The noble Baroness, Lady Walmsley, asked about the age range. It is important for the health visiting service to stick to what it does best. I certainly recognise the picture she is describing, having worked in primary schools. There is an increase in children coming unprepared to school, or increasingly to nurseries, whether in their eating habits or toilet habits or whatever it is. The increase in formal childcare places that has been made available to both three year-olds and disadvantaged two year-olds will go some way to addressing that but I shall certainly keep an eye on that issue.

[Baroness Walmsley]

Sorry to spring this on the noble Lord but there was something that I forgot to ask him. He mentioned the accessibility of school nurses. The fact is that if a school nurse is looking after five schools they are not terribly accessible. I wonder if he might write to me as to whether there are any plans to increase the number of school nurses, because that is part of increasing the child’s health right the way through the age range.

[Lord O'Shaughnessy]

Yes, I shall certainly be happy to do that, probably looking at it in the round in terms of all the local health support that is available for school-age children. I hope, in responding, that I have been able to talk to all the points that have been made by noble Lords in this debate. I am glad that we all agree that health visitor support to families is vital and is about giving children the best possible start in life. It is why the Government have taken this action to continue to ensure the provision of the five mandatory health and development assessments and reviews so that this service continues to be provided for all families with children aged nought to five. I beg to move.

Motion agreed.

Alcohol Abuse

Lord O'Shaughnessy Excerpts

Thursday 30th March 2017 Grand Committee

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

My Lords, I congratulate the noble Lord, Lord Brooke, on securing this important debate and on his obvious tenacity in pursuing this issue. I am sure that this will be the first of many occasions we will have to discuss this matter. I also thank all noble Lords for a wide-ranging, well-informed and informative debate.

I think all noble Lords accept that the vast majority of people who consume alcohol—whether in my noble friend Lord Smith’s clubs or elsewhere—do so as a pleasurable and indeed even positive part of their social lives. However, we also know there are very serious harms and health costs associated with alcohol misuse, which is estimated, as the noble Lord, Lord Brooke, and other noble Lords have pointed out, to cost the NHS around £3.5 billion a year. The recent Public Health England evidence review tells us that alcohol is now the leading risk factor for ill-health, early mortality and disability among 15 to 49 year-olds in England, causing 169,000 years of working life lost. That is more than the 10 most frequent cancer types combined—a truly alarming figure. As the noble Lord, Lord Colwyn, pointed out, that is having an effect in specific areas such as increases in oral cancers.

Alcohol misuse is also a significant contributor to some 60 health conditions, including circulatory and digestive diseases, liver disease, a number of cancers, as has been said, and depression. Alcohol-related deaths have increased in recent history, particularly deaths due to liver disease, which saw a 400% increase between 1970 and 2008. As several noble Lords have pointed out, that is in contrast to trends seen across much of western Europe and, as my noble friend Lady Berridge pointed out, it is also in contrast to outcomes in many minorities in the UK. It is not so much a British problem as a problem of certain communities within Britain.

In the UK, there are currently more than 10 million people drinking at levels that increase risk to their health. Those health risks, as the noble Baroness, Lady Walmsley, pointed out, are both mental and physical. They lead to more than 1 million hospital admissions annually, half of which occur in the most deprived communities, so this is also an issue of social justice. My noble friend Lord Smith was right to point out the work that the police, the ambulance service and other public services do to deal with—mopping up, sometimes physically as well as figuratively—the results of alcohol misuse. I take this opportunity to pay tribute to their work; they often have to deal with both physical and verbal violence in doing so.

We also know the tragedies that can occur from mothers drinking alcohol during pregnancy, leading to problems after birth. This is not just a UK but a global issue. To address the challenges of the prevalence of fetal alcohol syndrome disorders, the WHO is starting a global prevalence study. We will consider lessons from this for further work in the UK.

It is also important to recognise the devastating impact that addiction has on individuals and their families. It is unacceptable that children have to bear the brunt of their parents’ conditions. I was shocked to learn that, according to Alcohol Concern, 93,500 babies under the age of one, which I make to be about a sixth or seventh of the cohort, live in a family where a parent is a problem drinker. As the noble Baroness, Lady Walmsley, pointed out, there is a link to domestic violence which affects not just children but also partners. My colleague, the Minister for Public Health and Innovation, recently met with members of the All-Party Parliamentary Group on Children of Alcoholics to set out our plans to work with MPs, health professionals and those affected to reduce the harms of addiction and support those who need it. I am sure that noble Lords will agree that that is an important mission.

However, I am glad to say that we can also observe some promising trends regarding alcohol. As my noble friend Lord Smith pointed out, the figures for alcohol crimes and deaths are down, although there are other problems which we have talked about. People aged under 18 are drinking less, which stands in stark contrast to the data for the over-65s who are drinking more—I am not looking at anyone here—and there has been a huge increase in the number of hospital admissions for the over 65s in recent years of more than 130%. Nevertheless, there has also been a steady reduction in alcohol-related road traffic accidents.

We also have social action campaigns, such as Alcohol Concern’s dry January, in which I have taken part over the past few years, as I am sure other noble Lords have too, which are starting to change attitudes. The point that my noble friend Lady Berridge made about minority and religious groups leading the way was incredibly important. I accept her point about the need for appropriate analysis of how to communicate with those communities. We were unable to get the information, admittedly at short order, that she wanted, but I shall certainly write to her and put a copy of the letter in the Library for noble Lords. She makes an important point and she may have highlighted a weakness in the current strategy.

We have also seen real progress through working in partnership with industry: 1.3 billion units of alcohol have been removed from the market by improving the choice of lower alcohol products; nearly 80% of bottles and cans now display unit content and pregnancy warnings on their labels; and we have published guidance on updating the health information contained on labels better to reflect the latest advice on alcohol published by the UK Chief Medical Officer.

Several noble Lords asked about calories and labelling. This is an area where the European Commission is looking at legislation. It is not always the fastest moving institution in the world, and we have of course just signalled our intention to leave the European Union, but we will certainly look at that legislation as it comes through. It is fair to say—although I am not in a position to make a commitment at this point—that the UK has been a leader in this kind of area, not just on drink but on smoking as well, and I hope that, looking ahead, we would continue that leadership position.

An essential part of our strategy to tackle alcohol harms is the provision of high-quality, evidence-based treatment services. Local government now has the responsibility to improve people’s health, in particular on the public health side. This includes tackling problem drinking and commissioning appropriate prevention and treatment services for the local population’s needs. Several noble Lords asked about addiction and spending on cessation services, which increased from 2014-15 to 2015-16, even within the context of challenging budgets for public health. I see this as a positive move, but it is something to be kept under review.

The NHS remains critical to preventing alcohol harms. There is a new scheme to incentivise investment in alcohol interventions. The national Commissioning for Quality and Innovation indicator has been developed, and in the way beloved of the NHS, it has been given the acronym CQUIN. It links a proportion of service providers’ income to the achievement of national and local quality improvement goals. The practical effect of that is that every in-patient in community, mental health and from 2018-19 to acute hospitals, will be asked about their alcohol consumption and, where appropriate, will receive an evidence-based brief intervention or a referral to specialist services. The noble Baroness, Lady Walmsley, pointed out that the evidence shows that people who receive a brief intervention are twice as likely to have moderated their drinking six to 12 months after the intervention when compared to drinkers receiving no intervention, so it is obviously a low-cost but highly effective action.

In addition, as my noble friend Lady Chisholm mentioned, by 2018, around 60,000 doctors will have been trained to recognise, assess and understand the management of alcohol use and its associated problems. My noble friend Lord Colwyn pointed out that dentists have a vital role in prevention and spotting early problems. The new dental contract means that there has been an increasing number of patient episodes, and Public Health England has developed an alcohol training resource for dental teams. I would be interested, as a follow-up, to find out if that has been successfully adopted within the profession that he represents.

Furthermore, the inclusion of alcohol assessment and advice in the NHS health check, which is offered to all adults in England aged 40 to 74, means that GPs and other healthcare professionals can offer advice to promote a healthier lifestyle. Since we mandated the alcohol assessment and advice component, nearly 5 million people have had a check. Referral to alcohol services following an NHS health check is around three times higher than among those receiving standard care, which is yet another example of how a small nudge in the right direction can make a great impact.

Several noble Lords talked about providing people with the right information so that they can make informed choices. Last year, Public Health England launched the One You campaign to help motivate people to improve their health through action on the main risk factors. This includes a drinks tracker app to help drinkers identify risky behaviour and lower their alcohol consumption and a new “days off” app to encourage people not to drink alcohol for a number of days a week, in line with the CMO’s recommendations.

My noble friend Lady Chisholm and the noble Baroness, Lady Walmsley, asked about education. PSHE is obviously a critical part of making sure that young people are informed about their choices. There has been a review of the PSHE curriculum—we have seen a strengthening of PSHE in recent announcements by the Secretary of State for Education. There must be, at least in part I think, some impact on the positive trends that we are seeing among young people in lower drinking, although it is of course hard to isolate what exactly causes that. We know, however, from the smoking environment that constant public health campaigns do have that impact, particularly for younger people. It is also notable that while the incidence of mental illness has unfortunately and sadly increased among young people, there has not been the same increase in drinking. That is an interesting inverse correlation that is worthy of further investigation.

Several noble Lords asked about the affordability of alcohol. In this context you think of Hogarth’s “Gin Lane” and “Beer Street”, and the important role that taxation has historically played in changing drinking habits. The UK currently has the fourth highest duty on spirits among EU member states, and higher-strength beer and cider are already taxed more than equivalent lower-strength products. In relation to a move in the direction that the noble Lord, Lord Brooke, pointed to, noble Lords may know that it was announced in the Budget that duty rates on beer, cider, wine and spirits will increase by RPI inflation. In addition, a consultation is currently seeking views on the introduction of a new band to target cheap, high-strength white ciders which are a particular problem among young people. It is also seeking views on the impact of a new lower-strength still wine band to encourage production and consumption of lower-strength wine—another point talked about by the noble Lord, Lord Brooke. It is worth touching briefly on minimum pricing. I am afraid that my answers are entirely predictable on this issue. We await the conclusion of the court case. I will, however, look at the IFS report that was mentioned and we will keep a close eye on that issue going forward.

The noble Baroness, Lady Walmsley, asked about advertising, as, I believe, did the noble Lord, Lord Hunt. The Advertising Standards Authority has a vigorous approach to preventing advertising to children and young people, but I am assured that it is kept under review to make sure that it is having an impact. Again, it is worth investigating whether that has had an impact on the lower instances of drinking among young people.

It would be wrong for Ministers to restrict the treatments offered to young people. That is a clinical decision, although I know that clinicians are increasingly trying to change the behaviours of smokers and drinkers before providing significant treatments. There is also a link between drinking and depression, as the noble Lord rightly pointed out.

I close by again congratulating the noble Lord, Lord Brooke, on securing this debate on such an important subject. Alcohol misuse has a significant impact on people’s health, the NHS, the wider care system and society in general. I also believe, however, that progress is being made. The Government remain deeply committed to ensuring that people are given the information and support—and if necessary the treatment—that they need to reduce harms from alcohol. I look forward to working with the noble Lord and all noble Lords to reduce alcohol misuse in the years ahead.

Committee adjourned at 5.58 pm.

Gene Editing: Agriculture and Medicine

Lord O'Shaughnessy Excerpts

Monday 27th March 2017 Lords Chamber

[Viscount Ridley]

To ask Her Majesty’s Government whether they have plans to encourage gene editing in agriculture and medicine.

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

My Lords, the UK is a world leader in the understanding of genetics, which is already leading to significant advances in medicine and agriculture. Gene editing has the potential to accelerate progress in both areas, saving lives and improving quality of life. The Government continue to support the assessment, refinement and use of genetic editing techniques.

[Viscount Ridley (Con)]

I thank my noble friend for that reply. Is he aware of widespread concern that, although we are pioneering and leading this essential work using CRISPR and TALEN to edit genes so as to help in both agriculture and medicine, we are falling behind in the race to apply this technology because the use of gene editing in cell therapy for cancer and in producing better crop plants requires and could be encouraged by better regulation? I declare my interests as listed in the register.

[Lord O'Shaughnessy]

My noble friend is a leading advocate of this technology and is correct that getting the regulation right is absolutely important. It is currently regulated at the EU level, and there is debate on and an inquiry by the European Court of Justice into current exemptions for gene editing. We support the current exemptions, although others have challenged them. But it is also important to recognise that any discussion about gene editing, whether in agriculture or especially in a human health setting, involves big ethical questions and it is only right that we tread carefully as we move ahead.

[Baroness Walmsley (LD)]

My Lords, given the potential of gene editing of non-reproductive cells for treating HIV, sickle cell, haemophilia and, as the noble Viscount said, cancer, what plans do the Government have to ensure continued research in this important and valuable area after Brexit?

[Lord O'Shaughnessy]

The noble Baroness is quite right to talk about the important therapeutic benefits that can come. I do not think this has anything to do with Brexit, other than the fact that the UK has been and continues to be a leader in the world of genomic sequencing, which of course enables us to identify the genetic issues that lead to some of the diseases and illnesses she has described. Within our regulatory framework, it is possible to use gene editing for therapeutic reasons but in ways that do not impact on inheritability, which is of course ethically an incredibly difficult question.

[Lord Winston (Lab)]

My Lords, can the Minister confirm that the Government have no plans to extend gene editing to germ cells, as was suggested in the Times only three weeks ago, with the idea that we could wipe out genetic disease using gene editing? This seems an extremely dangerous idea, given that there are epigenetic and other issues with gene editing, which may not be quite as precise and effective as is sometimes claimed.

[Lord O'Shaughnessy]

The noble Lord is quite right to make that point. So-called germline gene editing, which creates the opportunity to pass on changes to later generations, is highly controversial. It is illegal in this country and there are no plans to change that position.

[Lord Patel (CB)]

My Lords, I would like to take the discussion about regulation further. The question that the noble Lord, Lord Winston, just asked emphasises that we need a regulation in place now that is balanced, so that we can allow the researchers to progress further, including if necessary to demonstrate why germline gene editing may be necessary but should not be allowed. We lead the world in immune gene editing, as shown in the example of Layla, a one year-old girl who was treated for acute megaloblastic leukaemia, which was the first such case in the world. Does the Minister think it right to ask the appropriate departments in those agencies to produce something now on the regulation of gene editing that would be appropriate for Parliament to discuss?

[Lord O’Shaughnessy]

My noble friend is right to highlight the potential of gene editing by referring to that life-saving treatment of a girl with leukaemia. We have a world-leading regulatory climate and there are strict rules governing research in this area: for example, research involving the use of embryos is allowed up until 14 days but not beyond. We should certainly carry on with that research—indeed, we have a more permissive regulatory environment than in much of the world. As my noble friend rightly points out, we need to do that with the purpose of respecting life and of course reducing harm, driven by the desire to do so.

[Baroness Wheeler (Lab)]

My Lords, HIV has been mentioned. The Minister will know that the results from the gene-editing clinical trial for people who are HIV positive have shown promise, particularly regarding the use of zinc fingers, which can find specific sites in DNA that can then be edited. Research is in its very early stages but has shown the potential to increase resistance to the virus, with the ultimate goal of weaning some people off antiretroviral drugs. What are the Government doing to support and take forward this important research?

[Lord O’Shaughnessy]

As we have discussed, there is huge potential regarding illnesses such as HIV. Clinical trials of gene therapies involving gene editing are still at an early stage, and are receiving support from the National Institute for Health Research. Any applications that go beyond the experimental and research stage would inevitably have to go through the Medicines and Healthcare products Regulatory Agency regarding safety and clinical potential. So the right system exists, investment is taking place at the early stage of research and before anything is done to any scale, it must be subject to the proper discussion and scrutiny.

[Baroness Hayman (CB)]

My Lords, as the Minister said, we have an enormously strong agriculture and genetic technology science base in this country. While this is not a magic bullet for food production, it could be a very important weapon in our armoury for meeting the world population’s future food needs. Given that, will he undertake that centres like the John Innes Centre in Norwich will continue to receive government support to develop genetic technology in agriculture, within a strong and ethical regulatory framework?

--- Later in debate ---

[Lord O’Shaughnessy]

The noble Baroness will forgive me if I do not stray too far outside my brief and into agriculture, except to say that the research councils are putting a huge amount of investment into the kind of research she is describing, both for agriculture and for human health, and that will continue.

Social Care in England: Older People

Lord O'Shaughnessy Excerpts

Monday 20th March 2017 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what is their response to Age UK’s report on the state of social care in England The Health and Care of Older People in England 2017.

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

My Lords, social care is a priority for this Government. That is why the Chancellor announced that local authorities in England will receive an extra £2 billion for social care in the next three years. This funding will allow councils to support more people, sustain a diverse market and ease pressures on the NHS.

[Baroness Wheeler (Lab)]

My Lords, before I respond, on behalf of the whole House I congratulate Dame Vera Lynn on her 100th birthday. I was not born during the war but as a post-war child I remember how people spoke and felt about her, and I send her our warm thanks.

Back to business. The Age UK report gives a very sobering picture of the scale of the unmet demand and likely future demand for social care, and the Minister knows that the extra £2 billion he spoke of spread over the next three years is the shortest of short-term solutions. I want to focus on the report’s assessment that the number of older people with unmet social care needs—defined as whether someone can carry out everyday activities such as washing, dressing, eating and using the toilet—has now grown to 1.2 million. This is an 18% increase since last year and nearly a 50% increase since 2010. It means that one in eight older people is living with some level of unmet need regarding vital everyday tasks. Can the Minister confirm that the Government’s Green Paper will acknowledge this level of demand and need, and that their long-term funding solutions will have to address this issue, as well as the provision of long-term care?

[Lord O'Shaughnessy]

The noble Baroness is quite right that there is a growing need for care for older people because of our ageing and growing population. I am sure she welcomes the additional funding announced in the Budget. It brings to over £9 billion the additional funding announced since 2015 for social care for the next three years, and that will make a big difference to meeting the kinds of care needs that she is talking about. She talked about the difference between the short term and the long term. That is why the other crucial part of the Budget announcement concerned the Green Paper. This will be ambitious in scope, with the intention of creating a fairer and more sustainable system of the kind I am sure she wants to see.

[Lord Watts (Lab)]

My Lords, does the Minister agree that the Government’s decision to cut spending to local authorities’ care services has created this crisis?

[Lord O'Shaughnessy]

Much more funding is now going into the social care system to reflect the additional needs of the ageing population. I am looking forwards in thinking about the extra £9 billion that will be provided. We also have over 150,000 more care workers helping people in the system, whether in residential care homes and nursing homes or at home through domiciliary care.

[Baroness Brinton (LD)]

My Lords, after the publication of the Dilnot commission report nearly six years ago, the noble Lord, Lord Lansley, in another role, and the then Chancellor congratulated the commission on its report being a valuable contribution to meeting the long-term challenge of an ageing population. A Green Paper being seen as the beginning of this process six years on is way too late. I repeat the question that I asked the noble Lord last week: can he confirm that the Treasury will specifically be involved in looking at the funding of social care in the future?

[Lord O'Shaughnessy]

The noble Baroness is quite right to point out that Dilnot was an important move. It is also fair to say that several Governments, including 13 years of a Labour Government, failed to make any significant progress on this issue. We now have a Green Paper coming forward that is, of course, looking at a sustainable and fair care system, and that must also include looking at funding.

[Baroness Greengross (CB)]

My Lords, in spite of what the Minister said, we know that many home care companies say that their biggest problem is the recruitment and retention of carers. The Centre for Workforce Intelligence estimates that at least 2 million more will be needed by 2025, both in home care and in care homes, to cope with the growing demand. Can the Minister tell us how that demand is going to be met?

[Lord O'Shaughnessy]

There are two distinct issues here: carers and care workers. To attract more care workers into the system we have introduced the national living wage, which will make a difference in pay for about 900,000 people. The noble Baroness is quite right about carers. There are millions of carers in the country, and we will be bringing forward a carers strategy this year, which will address some of the issues she talks about.

[Lord Cormack (Con)]

Will my noble friend first of all associate this side of the House with the warm tributes to Dame Vera Lynn? Will he also tell the House how many care workers are from other countries within the European Union? What are we doing to ensure that we do not have a haemorrhaging of those upon whom our old people depend?

[Lord O'Shaughnessy]

I of course associate myself with the comments made by the noble Baroness and apologise for not saying so before. However, I am not going to sing in tribute.

Around 17% of the care workforce comes from abroad and some 7% of the total are from the EU. The key is to make sure that we have, as far as possible, a care system that attracts workers domestically. We are doing that through improving the training packages available and through better pay under the national living wage, which I mentioned.

[Baroness Pitkeathley (Lab)]

My Lords, we heard this morning that the domiciliary care scene is under pressure and many domiciliary care agencies are in fact not tendering for contracts. The care home sector is also under pressure. The people who are not giving up, as the Minister points out, are the family carers— 6 million of whom are picking up the pieces from an inadequate social care system. May I press him a little more on the carers strategy, please? It was due to be published last September. Has he a date yet?

--- Later in debate ---

[Lord O'Shaughnessy]

On care homes, it is true that some care providers are exiting the system. However, there is the same number of beds and, indeed, there are more nursing homes. So there is churn in the system and there are more home care agencies than there were in 2010. I say that only to point out that it is a changing picture. On carers, she is quite right: this is a long overdue strategy and it will be published shortly.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister explain why the number of mental health and community nurses in England fell between 2010-11 and 2015-16 by 13% to 33,000, as is clearly outlined in the Age UK report? Further, could he explain the recent significant cut in funding at HEE for post-qualifying nurse education, which includes the preparation of district nurses and advanced mental health nurse practitioners? If more people are to be cared for at home, the false separation between social and health care must be acknowledged, particularly if you want to achieve some of what is outlined in the STPs, which we are going to talk about later.

[Lord O'Shaughnessy]

Changes are going on in the nursing workforce and the noble Baroness is right about the cases she points out. It is also worth pointing out that there has been an increase in the number of nurses with general qualifications who are able to work across both health and care, which is important for integration. She will know that there have been changes in the way nursing training has been funded, both in the way she said and in bursaries. However, we are committed to increasing the number of training places available for nurses.

NHS: Sustainability and Transformation Plans

Lord O'Shaughnessy Excerpts

Monday 20th March 2017 Lords Chamber

[Baroness Pitkeathley]

To ask Her Majesty’s Government what assessment they have made of the impact of any hospital closures resulting from the implementation of Sustainability and Transformation Plans on Accident and Emergency departments.

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

My Lords, sustainability and transformation plans, or STPs, are about local health stakeholders coming together to make sure that NHS services are placed on a sustainable footing and are being transformed for the future. Any significant changes outlined in the STPs will have to meet the four reconfiguration tests of strong public and patient engagement, a clear clinical evidence base, support for patient choice and support from clinicians.

[Baroness Pitkeathley (Lab)]

I thank the Minister for his reply but, in view of the problems about which we heard in the last Question and the fact that accident and emergency departments and other hospital services deal with many social care needs, does the Minister agree that it is vital that there is sufficient capacity in the community to manage the demands for community services which closures will inevitably cause, and that this must be established before any closures take place? Will the Minister therefore tell the House specifically when, by whom and how this assessment of the adequacy of community services will take place?

[Lord O'Shaughnessy]

As the noble Baroness has pointed out, it is important that there is sufficient capacity in the social care service and in the NHS. In fact, the NHS accounts for more of the delayed discharges, for example, than does social care. Simon Stevens, the head of NHS England, has been clear that, in addition to the four reconfiguration tests, any bed closures would need to show that there was redundancy in the system, that there is alternative provision—to come to the noble Baroness’s point—and that there is clear potential for efficiency. It is clear that the STPs must be able to plan ahead and provide alternatives if there are going to be changes to A&E or other services.

[Baroness Walmsley (LD)]

My Lords, given that 50% to 60% of patients attending A&E in some hospitals hit the four-hour target, how many more hospitals will hit the target when some adjoining hospitals close their A&E departments? This does not sound like excess capacity.

[Lord O'Shaughnessy]

The noble Baroness is right to point out that the four-hour target is critical for the NHS and it is committed to making sure that that target is hit. Some A&E closures have been mooted but only seven areas, according to the Health Service Journal, have clear proposals, and that is before there has been any public engagement and any application of the reconfiguration test. I point the noble Baroness to the comments of Simon Stevens about the importance of demonstrating alternative provision and that it cannot be a case of closing beds without that being in place.

[The Countess of Mar (CB)]

My Lords, I ask the Minister not to forget people living in rural communities, who are already disadvantaged regarding social care because their carers are not paid for their travelling. If hospitals are to close it will mean that they and their relations will have to travel further. It is therefore important, first, that they do not have to go into hospital unless it is absolutely necessary and, secondly, that they have the right sort of care.

[Lord O'Shaughnessy]

The noble Countess is right. Additional funding in the Budget will mean that local authorities and the NHS have more resources to account for things such as travel costs and unit care costs for care workers. Some of the STPs are dealing with urban areas and some with more rural areas. All the plans within those configurations have to take account of public engagement. As I have said, there cannot be changes without meeting the reconfiguration tests that we have set out, which must account for local circumstances.

[Baroness Altmann (Con)]

My Lords, can my noble friend assure the House that the reviews of social care will include looking at the impact of the withdrawal by councils of help for those with moderate needs in order to focus social care on those with substantial needs? Has the emergency admission of elderly people who were not given the care that they might have needed had an impact on A&E services in certain areas? Further, will the demographics of ageing populations be taken into account when looking at the closure of A&E departments?

[Lord O’Shaughnessy]

My noble friend is quite right to bring the attention of the House to the effect of standards. The Care Act 2014 introduced for the first time national standards as well as much greater transparency in the provision of care. What the announcement in the Budget of additional funding for social care allows for is particularly a focus on the interface between the NHS and social care, which is where the issue of delayed transfers can arise. I can provide my noble friend with a reassurance that the Green Paper will be looking at this issue in the round, carrying on from the work done in the Budget to try to address the interface between the social care and health systems.

[Baroness Wheeler (Lab)]

My Lords, what is the Minister’s response to the key questions asked in the recent King’s Fund progress assessment on how STPs are to be funded and how integrated care is to be delivered in the context of having, in its words, a,

“‘workaround’ … of the complex and fragmented organisational arrangements that are the legacy of the Health and Social Care Act 2012‘”,

and when the NHS is under huge pressure to make £22 billion of efficiency savings and to improve performance? Does this not show that the thinking and modelling behind STPs are deeply flawed?

[Lord O’Shaughnessy]

I am sorry to hear the noble Baroness say that about the STPs, which have received support from the King’s Fund and NHS clinical commissioners. I hope that she is also aware that in the Budget the Chancellor announced £325 million of capital spending to support the strongest STPs, those which are capable of providing the kind of integration she has talked about and are delivering the highest levels of performance.

[Lord Blunkett (Lab)]

My Lords, will the Minister share with us whether the department has provided advice or best practice in the localities on the first test of the service reconfiguration? A great deal of disquiet has emerged about a lack of engagement of key partners, never mind mobilising the support of the wider community.

[Lord O’Shaughnessy]

The noble Lord is quite right to bring up the issue of engagement. Those STPs which have been completed and published in draft form are now going through the engagement process. They are also being stress tested by NHS England and NHS Improvement to provide exactly the kind of scrutiny that he has talked about. Finally, in addition to the tests I have mentioned, there can be no significant service reconfigurations or bed closures without passing those tests and without public consultation to provide precisely the reassurance that these changes are about delivering national standards—they are not about trying to find a way around them.

Adult Social Care: Funding

Lord O'Shaughnessy Excerpts

Thursday 16th March 2017 Lords Chamber

[Lord Warner]

To ask Her Majesty’s Government when they expect to produce their proposals for a longer-term solution to the funding of adult social care.

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

My Lords, in order to meet the demographic challenges facing this country, the Government are committed to establishing a fairer and more sustainable system for funding adult social care. We will bring forward proposals in a Green Paper later this year.

[Lord Warner (CB)]

I thank the Minister for that Answer, but can he confirm that the review which is ongoing will examine the lessons from Japan and Germany, where populations and politicians have recognised that, as we live longer, we have to prepare earlier for funding our long-term care? Can he also assure the House that, in securing a new funding system for social care, regard will be paid to the impact of that on the long-term sustainability of the NHS?

[Lord O'Shaughnessy]

The noble Lord has done much work on the sustainability of social care, including his work on the Dilnot commission. He is quite right to point out that there are lessons to be learned from other countries, and certainly we will be learning them from Japan, Germany and elsewhere. He will know that the measures announced in the Budget are specifically designed not only to help adult social care but also to help the interface between the NHS and social care to provide exactly the kind of sustainability he is talking about.

[Baroness Pitkeathley (Lab)]

My Lords, some of us in this House are veterans of social care reviews that have led to very little change. Can the Minister therefore tell the House whether he is confident that the Green Paper will lead to urgent action? Will it consider controversial issues such as helping families prepare for care, savings products in the insurance market and perhaps even care vouchers?

--- Later in debate ---

[Lord O'Shaughnessy]

The noble Baroness is quite right that this issue has not been dealt with properly over a long time. The Green Paper has a wide remit and therefore will look at all the issues that she has brought to the attention of the House.

[Lord Skelmersdale]

My Lords, in a recent answer to a supplementary question, the Minister agreed with me that social care and health would operate properly only when they were under the same budget. Will the Green Paper go a little further and consider bringing them under the same management?

[Lord O'Shaughnessy]

As I said to the noble Baroness, Lady Pitkeathley, the Green Paper has a wide remit. It is trying to provide a comprehensive solution to social care funding, which has unfortunately eluded many Governments. In doing so, it naturally needs to look particularly at the interaction between health and social care. For many people now there is no particular distinction between those as they follow their journey, as it were, through the health and care system. The important thing is that the care is joined up and is of high quality.

[Lord Foulkes of Cumnock (Lab)]

My Lords, is the Minister aware that he does not need to go as far as Germany and Japan to find good examples of this? Could he go up to Scotland, in particular to Ayrshire, and talk to Ian Welsh, the chair of the NHS health and social care partnership? That is a very good example of two bodies working together under a joint budget and joint administration. If the Minister were to take a few days off and go up there, I think he would find it very valuable.

[Lord O'Shaughnessy]

I will speak to the Chief Whip about taking a few days off. I thank the noble Lord for bringing that point to my attention. As he says, there are examples in the UK—in Scotland, England and Wales, and of course Northern Ireland has a joined-up system too—so clearly there are lessons to be learned from home.

[Baroness Brinton (LD)]

My Lords, following the push by Norman Lamb MP for this review that the Government have been talking about and putting into the long grass, the independent specialist group that he convened gave its interim report this morning. It makes it absolutely clear that we have to look at how the NHS and social care are paid for. Can the Minister give an assurance that the Green Paper will address those Treasury issues, as well as the issues of care and the relationship between the NHS and social care?

[Lord O'Shaughnessy]

As I have said to several noble Lords, the intention of the review is to put the adult social care system on a sustainable and long-term basis and to make sure that it is fair and transparent and that it delivers high-quality care. It will address all the issues required to do that.

[Lord Lansley (Con)]

My Lords, will my noble friend acknowledge that he does not start this process with anything like a blank sheet? In particular, does he recognise that there is continuing merit in the recommendations of the Dilnot commission? I will not elaborate on that, save to say that they include the fact that it was a manifesto commitment of the Government at the last election.

[Lord O'Shaughnessy]

I thank my noble friend for bringing that to the House’s attention—some might describe it as a hospital pass, if noble Lords will excuse the pun. The Government remain committed to implementing Dilnot from April 2020. My noble friend is quite right that this is not a blank sheet of paper. There have been some really important reforms over the last seven years, including the better care fund and the Care Act. In the Budget, we have more funding for the short-term sustainability of the social care system, as well as a commitment to the Green Paper.

[Lord Crisp (CB)]

My Lords, I would like to ask a question about children’s social care, where I notice there is also a problem. For example, in the last year local authority support for palliative care services for children was cut by two-thirds, and it now provides only 1% of the expenditure on children’s social care. First, does the Minister acknowledge that there is a problem here as well and, secondly, what are the Government going to do about it?

[Lord O'Shaughnessy]

The issue of children’s palliative care came up in the debate the other evening on palliative care. A review is taking place with the charitable sector of the distribution of funding, particularly for children’s hospices, over the next year. In terms of children’s social care—this may come as a surprise to some noble Lords; it certainly did to me—the fastest-growing part of the adult social care budget is for adults with learning disabilities. Of course, that often comes in at the point at which people leave the children’s social care system and the school system and move into the adult social care sector, so there is an important point about continuity from one to the other.

[Baroness Wheeler (Lab)]

My Lords, does the noble Lord accept that the domiciliary care of people in their homes is in deep crisis, with 400 care home businesses declared insolvent since 2010? Large providers such as Mitie have recently been selling their home care health business—it sold it off for just £2, plus a £10 million pay-off to the new outsourcing firm for business trading losses and other costs. What impact do the Government assess that the £2 billion Budget cash spread over three years will have on halting home closures and reducing the risk of industry collapse? Will the future Green Paper look at finding a new, more sustainable model for providing and funding residential and domiciliary care?

[Lord O'Shaughnessy]

The noble Baroness brings up the issue of care homes closing. Inevitably, there is churn in the system. There has been a stable number of residential care home and nursing home beds, which is one metric. The other is the fact that there are many more home care agencies, with a lot more domiciliary care going on, and over 150,000 more social care jobs, so I do not think that the picture is quite as the noble Baroness described it. However, making sure that we have a sustainable system is at the heart of the Green Paper plans.

End of Life Care

Lord O'Shaughnessy Excerpts

Tuesday 14th March 2017 Lords Chamber

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

My Lords, I thank the noble Baroness, Lady Finlay, for precipitating the debate. In many ways this is the most difficult of all subjects to discuss. I pay tribute to her courage and leadership in the work she has done to bring it to the fore and to make it an issue of such public policy importance.

As the noble Lord, Lord Carlile, said in his speech, in recent years there has been a much greater focus on improving the quality of people’s experiences of end-of-life care—to help them, as my right honourable friend the former Health Minister, Ben Gummer, put it in his foreword to the Government’s response, to experience a “good death”, or as the noble Baroness, Lady Finlay, put it, gentle dying. As the noble Baroness said, bad care should never happen. We know that many people in England already receive good end-of-life care and internationally we continue to lead in the overall quality of end-of-life care provided. That is the result of sustained effort over recent years to improve people’s experiences of end-of-life care. I join all noble Lords in thanking the staff who work in our health and care system, and the many charities that have been mentioned tonight and others besides that support people at the end of their lives.

However, as we recognised in our response to the independent review of choice in end-of-life care, and as all noble Lords have rightly argued, there is too much unacceptable variation in quality and provision. This can have real consequences for the care that some people receive at this all-important time in their lives. I thank deeply the noble Baroness, Lady Masham, for sharing the moving story of her husband’s death and the noble Baroness, Lady Massey, for sharing the story of her brother’s death. I and, I know, the whole House will agree wholeheartedly with them that the description of what end-of-life care should be like, with compassion at its heart, is what motivates us. That is what sits behind everything the Government are trying to do and is what motivates people who work in this important sector.

To address the issue of variation and to provide the kind of patient choice that the noble Baroness, Lady Meacher, called for, last year we set out our ambition for everybody approaching the end of life to receive high-quality care that reflects their individual needs, choices and preferences. I thank my noble friend Lord Suri and other noble Lords for welcoming these plans. The plan is based on six commitments, setting out what all people at the end of their life should be able to expect from care. They include honest discussions between care professionals and dying people, and dying people making informed choices about their care. The noble Baroness, Lady Meacher, brought out a helpful statistic that while 82% of people have strong views, they may not be informed of the choices available to them. The third commitment is personalised care plans for all; then there is discussion of personalised care plans with care professionals, the involvement of family and carers in dying people’s care, and a key contact so dying people know who to contact at any time of day.

These commitments apply to all end-of-life care, whether delivered in a hospital, a hospice, or as part of a community service in a care home or a person’s own home. They apply to all parts of the country and underpin local plans to deliver end-of-life care in every clinical commissioning group.

The national end-of-life care programme board has been set up to oversee the implementation of this plan. It is chaired by Sir Bruce Keogh, NHS England’s medical director. We have also called on local health and care leaders, including commissioners and all health and well-being board chairs, to prioritise improvements to end-of-life care in their plans to improve local services. We are taking a number of specific actions to support these commitments. I will give a few examples.

To improve the quality of care in hospitals, all NHS trusts that have a poor CQC end-of-life care rating been visited by NHS Improvement to support them to improve their offer.

Several noble Lords have highlighted the importance of training. Health Education England is changing its training standards so that care workers have the right skills mix, including, I hope, digital skills, as the noble Baroness, Lady Lane-Fox, pointed out. I will check that that is the case. They should have the right training to support honest conversations and personalised care. NHS England is currently working with two new care model sites in Airedale and Southend to test an innovative approach to serious illness conversations, in which clinicians are trained to support people with serious illnesses to discuss what is important to them.

I thank the right reverend Prelate the Bishop of Durham for highlighting the important and very powerful impact that chaplains have on people at the end of their lives. They provide an invaluable service. I will write to Sir Bruce Keogh, who, as I mentioned, is chairing the national board, to emphasise the important role that chaplaincy can and must play in provision of end-of-life care for people with or without a religious belief.

On greater personalisation of care and care planning, NHS England is working to ensure that shared digital palliative and end-of-life care records will have been rolled out to the majority of local areas by 2018 and all areas by 2020 to enable preferences to be recorded, shared and achieved more easily. As the noble Baroness, Lady Lane-Fox, highlighted, good data and digital provision can help enormously to improve end-of-life care. I am encouraged by the work that she is doing, although alarmed by the statistics that she mentioned about care homes not having wi-fi—that has been addressed in hospitals but not in that setting, and is something that I will investigate.

To improve access to urgent clinical advice and support for end-of-life care, including expert advice on specialist palliative care, NHS England is ensuring that each clinical advisory hub across the country will include clear and explicit processes for access to palliative care and will be accessible to individuals who need the service, their families and professionals involved in their care.

Several noble Lords mentioned the importance of good commissioning, including the noble Baroness, Lady Meacher, who demonstrated the impact that good commissioning can have on improving outcomes and quality of life. In line with the plans we are setting out in the government response, we are also taking a number of actions to improve the way in which care is planned and commissioned. This includes work between NHS England’s regional offices and local commissioners to put end-of-life care at the centre of activity as part of local sustainability and transformation plans.

The noble Baronesses, Lady Wheeler, Lady Meacher and Lady Walmsley, all mentioned sustainability and transformation plans—indeed, the noble Baroness, Lady Finlay, mentioned them both today and in an earlier debate on this issue. The plans are now being consulted on, so this is now an opportunity to make sure that they properly represent all the imperatives that they should. The national programme board, chaired by Sir Bruce Keogh, is preparing a support offer to those STPs that have not yet planned for it well to make sure that it is done properly.

The noble Baroness, Lady Walmsley, asked about care currencies. She was quite right about the tendency to jargon in this area; it is described as a specialist palliative care currency model, I am afraid, so it is worse than she feared. But the idea is a good one—she highlighted the importance of it—which is to provide a level of transparency and certainty on the kind of funding that will follow. It will not be precisely payment by results or payment by outcome, because of the importance of the charitable sector, but it will provide greater transparency and certainty on the funding of hospices. We aim to publish that shortly.

The government response has made key commitments on holding the system to account for the improvements that we want to see, including addressing unacceptable variation. It includes introducing a separate priority area within the CCG improvement and assessment framework for end-of-life care, as the noble Baroness, Lady Walmsley, pointed out. We are also developing new metrics for end-of-life care that have been put forward for potential inclusion, which will allow us to hold CCGs to account for their performance in this area.

Several noble Lords referred to children’s hospices. In a difficult subject, the heart-breaking idea of tiny children with short lives and life-limiting conditions makes it even harder. I agree with all noble Lords about the importance of palliative care for children. Some £11 million is available through the children’s hospice and hospice-at-home grant which goes to support children’s hospices on top of what clinical commissioning groups do. NHS England is engaging in consultation with Together for Short Lives on its 2017-18 grant allocation. It is intended that this new palliative care currency will also help to provide greater transparency, clarity and consistency for the funding of all hospices, both for adults and for children.

The noble Baroness, Lady Finlay, asked about better outcomes for dying people. There are now new NHS clinical guidelines that those working in the sector must follow, as I am sure she will know. We have also commissioned the charity Sands to develop a standard bereavement pathway so that there is greater consistency across the country. The noble Baroness asked about a framework funding model. I hope that I have addressed her questions on that in describing the palliative care currencies, which will be published shortly.

The noble Lord, Lord Rees, asked about more resources. There was of course an announcement in the Budget of additional support for social care, which I realise is not the same as end-of-life care, but does incorporate people who are at the end of their lives if they are in a care setting. I hope this was welcome. We also have an important commitment to a long-term solution for care, and a further Green Paper to follow on that issue. For that to be truly comprehensive and sustainable, it must also incorporate a sustainable regime for end-of-life care within those kinds of settings, so I hope noble Lords will welcome the announcement that that will be coming later this year.

To conclude, I thank the noble Baroness, Lady Finlay, for highlighting this incredibly important issue. I remember as a teenager reading A Happy Death by Albert Camus. As a teenager, I think you veer between being horrified by the idea of death and thinking that it will never happen to you; and then you grow up. While I may no longer be an existentialist, I still agree that a happy death—gentle dying—is the right outcome that we want to achieve universally in this country. We are starting from a point of variation and, as the noble Baroness said, there is bad care and there should not be bad care. We are fully committed to working with all people in the care sector, with carers, to ensure that anyone with a terminal illness has access to the high-quality, personalised care that they deserve.

House adjourned at 10.01 pm.

Nursing and Midwifery (Amendment) Order 2017

Lord O'Shaughnessy Excerpts

Tuesday 28th February 2017 Lords Chamber

Moved by

[Lord O'Shaughnessy]

That the draft Order laid before the House on 25 January be approved.

Relevant document: 22nd Report from the Secondary Legislation Scrutiny Committee

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

My Lords, I am grateful to the noble Lord, Lord Hunt, for his interest in this matter, and although naturally I am disappointed by his amendment to the Motion, I will use the opportunity afforded by it to aim to reassure him and all noble Lords that the proposed changes in this order are consistent with the Government’s commitment to strengthening the midwifery profession while also ensuring public protection. In addition, I am aware that the Secondary Legislation Scrutiny Committee has brought this order to the special attention of the House, and I will address the concerns of the committee in my remarks.

I know that the House will agree that it is vital for all women to be able to give birth in a safe, high-quality environment. This Government are committed to ensuring maternity services are the best and safest they can be. However, it is also true that things can and do go wrong, often with devastating impacts on mothers and babies but also on husbands, partners, parents, siblings and extended family members. Any good system of policy and regulation must promote best practice while also preparing to respond to mistakes when they happen.

In October 2016, Safer Maternity Care was published. It set out an action plan for the Government’s vision to make NHS maternity services some of the safest in the world and to achieve our national ambition to halve, by 2030, the rates of stillbirths, neonatal deaths and brain injuries that occur during or soon after birth and maternal deaths, with an interim aim of a reduction of 20% by 2020. Midwives are key to achieving this ambition. Because of this Government’s actions, there are more than 2,100 additional full-time equivalent midwives on our maternity units since 2010, and a further 6,300 are in training.

Midwives do a critically important job caring for mothers and babies and I pay tribute to the work that they do, which my family has been privileged to benefit from. However, when mistakes are made, it is right that they must be properly investigated. This order is before noble Lords partly in response to concerns raised during investigations into systematic failures in the care of mothers and babies at Morecambe Bay NHS Foundation Trust. As noble Lords know, following the completion of a number of investigations into complaints from families of those affected by the tragic events at Morecambe Bay, the Parliamentary and Health Service Ombudsman highlighted that,

“the midwifery supervision and regulatory arrangements at the local level failed to identify poor midwifery practice”.

A subsequent report by the King’s Fund described the system of local investigations as a “sub-FTP”—fitness-to-practise—“investigatory process”, which,

“causes confusion … and can result in a lack of clarity for providers over their responsibility”.

Similar concerns were raised in Dr Bill Kirkup’s Morecambe Bay investigation report, which referenced the,

“remarkable conflicts of interest inherent in a single individual combining the roles of risk manager, supervisor of midwives, senior midwife and staff-side representative”.

The report also stated that,

“the supervisory system as applied in Morecambe Bay … lacked objectivity and failed repeatedly to identify the evident problems in the unit or alert others to them”.

All three reports that I have just quoted from recommended that urgent change was needed to ensure a clear separation between regulation and supervision of midwives.

--- Later in debate ---

[Lord O'Shaughnessy]

I thank noble Lords for an extremely high-quality and very well-informed debate on both this order and the amendment. I will do my best to deal with the many questions and important issues that were raised by noble Lords.

First, I welcome the welcome that this order has broadly received. As the noble Lord, Lord Willis, pointed out, the separation of the professional interest and regulatory functions is best practice; that is how we expect regulation to take place these days. Unfortunately, in Morecambe Bay that lack of separation was one of the contributing factors, and that obviously has been a spur to change. I also welcome the words of support for the fitness-to-practise changes, which I think will bring in a quicker, more flexible and more proportionate system.

I turn to some of the points made by the noble Lord, Lord Hunt. There is undoubtedly an issue about the workforce, as he pointed out. There has been an increase in the number of births, and more is being done both to recruit existing staff and to retain them. But at the heart of this are three issues. The first is the point about silos versus integrated care. Of course we all want integrated care; that is the direction of travel. At the same time, necessary changes are taking place to the regulatory structure to deliver the kind of separation and clarity that we also want to happen. The concern being raised is whether, in doing so, we will in some way change the status of the profession, if you like—not intentionally, but by virtue of the removal of various statutory arrangements and so on. I can understand why some might draw that conclusion, but it is clearly not the intention of what is happening here, and I hope to set out a few reasons why that is the case.

The proposed changes do not alter the status of midwifery as a distinct profession with its own standards. There will be no change to the protected title of midwife, and delivering a baby remains a protected function for a midwife or medical practitioner; it is incredibly important to set that out at the beginning. As the noble Lord, Lord Hunt, pointed out, there are various tiers of representation, if you like, below Chief Nursing Officer: head of maternity, NHS England regional heads, deputy heads and so on. I do not know the specific reason why that is called maternity, not midwifery. I imagine that it might be because of integrated care and because, although it might have midwifery as the major focus of it, it might also involve other aspects of the birthing arrangements. I shall certainly endeavour to find out and write to the noble Lord about it.

The other issues were around whether the profession is getting the attention and respect that it deserves and indeed is properly represented at the right levels and in the right bodies. There is a midwife on the NMC. That is not a statutory requirement but the council ensures that it happens. It is also fair to say that we have a Secretary of State who is taking the issue of maternity safety incredibly seriously. I mentioned the national ambition, but we also had the publication of Safer Maternity Care in October and I will come on to some of the issues raised by my noble friend Lady Cumberlege as well. A lot is going on to support the profession.

One important part of that is making sure that this new supervisory function takes place properly and replaces statutory supervision. I quite understand why noble Lords will be concerned that that should take place. While on the one hand we have all agreed that the separation of regulation and supervision needs to happen and that the order creates greater clarity, there must be something to replace the supervisory arrangements that we agree need to change.

I reassure noble Lords that the four countries in the UK have been working together since 2015 to take account of the new employer-led models of supervision. In England, the NHS has evaluated the model in seven pilot sites to inform the model and its implementation, and there has been an education programme. Those pilots began last November and will complete in March, so they are informing the arrangements that go on in England. In the other countries, systemic reviews of the new system are taking place, on slightly different timeframes in different countries. But I reassure noble Lords that that will be happening. Not only is there preparation for the new system, there will be reviews into its effectiveness. Given all the points noble Lords have made about our experiences in Morecambe Bay and elsewhere, it is clearly essential that that happens.

A reasonable question was asked by the noble Baroness, Lady Walmsley, and my noble friend Lady Cumberlege about whether midwifery issues would be properly dealt with by the NMC and whether it has the capacity to do so, given its past problems. It received a much more positive performance review from the Professional Standards Authority, which found improvements down the line. Clearly, there is still one outstanding issue resulting from Morecambe Bay, but it is now an improved regulator and we can have confidence that it will do the kind of job that we now ask it to do.

My noble friend Lady Cumberlege raised the issue of the right level of insurance for independent midwives. I know that is incredibly important for maternal choice. Insurance is clearly a hot topic at the moment, but I will certainly write to her and find out exactly what the regulator is doing to give proper guidance, because that must happen. She is quite right to raise the example of Sweden. We know that there is a lot more to be done to improve maternity services in this country. Change is going on. My noble friend also mentioned the consultation going on with regard to regulatory redress. There needs to be a change of culture so that it is less adversarial and less litigious, and designed to increase learning and bring that to bear much more quickly on the process. We are undertaking that set of reforms and I pay huge tribute to her for her work in making that happen. My noble friend asked a set of other questions and I will certainly write to her so that I can answer her properly if I have not done so in the answers I have given already.

I end by paying tribute to the profession itself. The noble Lord, Lord Willis, made an excellent point, which goes beyond the scope of the order but is important. There is more that midwives can—indeed, must—do if we are to have a properly integrated system. We all want a healthcare system that, in the end, involves a personalised pathway. Whatever your experience, whether you are an older person, a young person, a mother or whatever, you can have someone by your side, leading you through that experience. Clearly, many pregnant women will want that to be a midwife, so I absolutely take the point about integrating with health visitors and many others besides. I hope changes are going on. That is perhaps not a subject for debate tonight but for another time. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his amendment.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to the Minister. I totally agree with the noble Baroness, Lady Walmsley, about the importance of the midwife being an integral part of the team. The noble Lord, Lord Willis, is right, as is the Minister, that one of the lessons of Morecambe Bay is the problem of different professions being completely unable to relate and talk to each other. Frankly, this is an issue that the health service suffers from and the Minister is right that, in a sense, it could be argued that the NMC is putting forward a more integrated approach to regulation. The risk is that, because of the disparity between the number of nurses and midwives—and we have often seen this before—integration could mean the marginalisation of certain people. This is the risk that we need to guard against—the unintended consequence.

The Minister has given a very good assurance that this matter will be kept under clear review; he emphasised that this would be a proper review and I very much welcome that. However, I still believe that, in the end, the answer to the question that he posed—“Are midwives around the right table?”—is that the experience of the health service is that they are never around the table at all. This is the problem. Whether the meetings are at board level of an English NHS trust, at the top level of the senior management team of a regional office of NHS Executive, at the NHS Executive itself, or at the department, they are never there. The big problem of how we get midwifery input at those top levels is one that we are still struggling with.

It is ironic that, having debated only two weeks ago the need for an approach to health regulation that covers all professions, we are now debating one profession. The noble Baroness, Lady Cumberlege, is absolutely right about this. I am indebted to the barrister Kenneth Hamer from Henderson Chambers who wrote to me after our last debate to point out that the Supreme Court is now using the Law Commission’s work on regulation to inform its own judgments. If there is any argument for the Government to produce a Bill in relation to unified health regulation very quickly, that is it.

On the loss of the midwifery supervisor, everyone agrees that the regulatory function needs to be separated off, and it is absolutely right that that is what the NMC should be concerned with. But there is concern about the loss of the supervisor at the local level. For me, the issue is safety. We know that NHS trusts are coming under huge pressure in relation to staffing levels from NHS Improvement because of pressure to reduce the deficit. The question, which I pose rhetorically, is who, given this pressure and given that midwifery does not have a voice at the board table, is going to defend the safety of the profession in terms of numbers when it comes to kind of hard decisions that are going to be made? That is my concern and frankly it has not been answered.

On the NMC’s performance, I remain of the view that the current chief executive has done a very good job trying to deal with the huge problems that she inherited. I hope that, whatever review is undertaken, it will not destabilise the NMC and that she will be given the time she needs to continue to make improvements.

The Minister said that he would exchange letters on the issue of independent midwives. I hope he will agree to go a little bit further and discuss this matter with his noble friend and the NMC. This issue has now been around for years, but it could clearly be sorted. A number of people are involved—the department, NHS England, the NMC and, I suspect, the NHS Litigation Authority—but if Ministers banged their heads together this would be sorted; that needs to happen. Frankly, even post the calamity of the 2012 Act, which has created such a discordant structure, Ministers can, in the end, determine something to happen here. That is what we need.

There is no question about it: I am not interested in silo professional behaviour or in whether a statutory committee is the right way to go forward. But I am convinced that the voice of midwifery needs to be heard at the highest level. I hope that this excellent debate—I am grateful to the Minister, too, for his response—has been helpful in just making that point. I shall not press my amendment to the Motion.

Abortion (Disability Equality) Bill [HL]

Lord O'Shaughnessy Excerpts

Report stage (Hansard): House of Lords
Friday 24th February 2017 Lords Chamber

[Baroness Gale (Lab)]

My Lords, we have had a thorough debate on this amendment and I thank my noble friend Lord Winston, who has such great expertise in this field, for his clarity in explaining why he wishes to move this amendment.

This is a sensitive matter with strongly held views on both sides. The noble Baroness, Lady Tonge, mentioned a woman’s right to choose: many people hold that view. My noble friend Lady Massey said that this was not a political issue. I agree that it is not a political issue. Whenever these matters are debated, in both Houses, Members have to make up their own mind; I think that that is the right thing to do. The term “back-street abortionist” has been used several times this afternoon. Many of us remember those days and absolutely no one wants to go back to a time when women were put at such great risk.

The noble Baroness, Lady O’Loan, mentioned Northern Ireland. We may be debating that later, on other amendments, but I take her point. The arguments have been well rehearsed on both sides of the debate today and from the Front Bench I can say only that the Opposition still fully support the Abortion Act 1967.

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

My Lords, I start by joining other noble Lords in congratulating my noble friend Lord Shinkwin on steering the Bill through its Lords stages so far and on his engagement with noble Lords on the Bill. It raises important and sensitive issues about disability rights and abortion and it is quite right and proper that these are discussed and scrutinised at length by your Lordships. I am also grateful to the noble Lord, Lord Winston, for his amendment and for the scientific authority which he brings to the issues. I commend all noble Lords for the quality of the debate we have had on this amendment.

As I set out in Committee, the issue of abortion is a matter of conscience for noble Lords, as the noble Lord, Lord Alton, and the noble Baroness, Lady Massey, reminded us. The decisions that we take on this transcend the normal political or partisan divides and it is for that reason that the Government have taken and continue to take a neutral position on this issue and on the Bill. The Government do not, therefore, have a position on the amendment of the noble Lord, Lord Winston, or on those that will follow in the House today. I do not intend to comment on subsequent amendments unless there are specific points that noble Lords wish to put directly to me and to which I can respond.

I do, however, wish to make one point that I believe is germane to the issues under discussion in this amendment and, indeed, in the Bill in general, and that is that it is vital that we have accurate statistics on and evidence for the reasons for termination of pregnancy. Officials are working directly with hospital staff to improve reporting on abortions. We have also reminded all doctors involved in abortion care of their legal responsibility under the Abortion Act 1967 and the Abortion Regulations 1991 to submit form HSA4, the abortion notification form, within 14 days of a termination.

Overall, between 2013 and 2015, there was an 18% increase in the number of reported ground E abortions. While we obviously cannot claim that this increase is solely the result of increased reporting of these abortions, as opposed to increased instances, we do know that this is the case in some of the units that officials have been working directly with. The department will continue to monitor carefully levels of underreporting of abortions for foetal abnormality.

The noble Baroness, Lady Stroud, asked about palliative care for babies. I fear that I do not have that information to hand but I will be happy to write to her on the issue.

[Lord Shinkwin]

My Lords, I thank all noble Lords who have expressed support for my Bill and I thank the noble Lord, Lord Winston, for his medical lecture on so-called serious foetal anomalies. I address the noble Lord, Lord Winston, with respect but I also address him and all other noble Lords as an equal. I should say at the outset that I totally reject the very premise of this amendment. Other noble Lords have already explained why the amendment is totally inappropriate and, indeed, crassly insensitive, from a Northern Ireland perspective in particular, when it is linked to Amendment 8. I offer a disabled person’s perspective on why it is unacceptable. I have been consistently clear that the purpose of my Bill—a disability rights Bill—is to bring the law as it applies to disability discrimination before birth into line with the laws that your Lordships’ House has already passed to counter disability discrimination after birth.

Noble Lords will know that I accepted an amendment in Committee for an impact review as a logical amendment to a logical Bill. However, in the context of a Bill which promotes disability equality where discrimination begins before birth, this cynical amendment is not remotely logical. Indeed, it runs counter to the very essence of my Bill. The amendment reinforces discrimination because it singles out even more acutely a particular group for destruction on grounds of disability. It seeks to legitimise their destruction after 24 weeks with terminology that commands no clinical consensus and despite the fact that cell-free foetal DNA can first be detected in maternal blood as early as seven weeks’ gestation, which means that genetic or chromosomal abnormalities are being detected well in advance of 24 weeks. So what justification is there for abortion after 24 weeks on the grounds of so-called serious foetal anomaly?

Some noble Lords have seen that I recently asked the Department of Health about the number of fatal foetal abnormalities diagnosed in each of the past five years. The answer was that the information is not collected centrally. I followed up and asked about the number of fatal foetal abnormalities diagnosed after 24 weeks in each of the past five years. The answer was the same: the information is not collected centrally. I find that revealing, not because information is being concealed but because it reflects the reality—the truth of the situation.

Those noble Lords who were invited to attend a meeting on this issue, which I understand was held somewhere in the House on Wednesday, could be forgiven for thinking that there is some medical authority—some clear medical consensus—behind the definition of “fatal foetal abnormality”. There is not because there is not an agreed definition. Indeed, the consensus is that what is considered fatal or life-limiting involves a degree of subjective judgment which is influenced by understandings and by the availability of technology, both of which can change with time. The noble Lords who received the invitation to that meeting might also have got the impression, as was intended by the wording of the invitation, that those 230 disabled babies aborted after 24 weeks in 2015 had all been diagnosed with severe or fatal foetal abnormalities. They were not. Of the 659 babies aborted for the crime of having Down’s syndrome, for example, two were aborted at 25 weeks, one at 26 weeks, one at 28, one at 30, another at 31, three at 32 weeks, two at 33, two at 34—and one at 39 weeks.