Tobacco Control Plan

Lord O'Shaughnessy Excerpts

Thursday 23rd February 2017 Lords Chamber

[Lord Rennard]

To ask Her Majesty’s Government whether they will maintain their commitment to reducing smoking prevalence by publishing the latest Tobacco Control Plan for England without delay.

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

My Lords, the Government remain committed to reducing the harm caused by tobacco. We should be proud of the progress we have made in reducing smoking rates to a record low in this country. Our new tobacco control plan will build on this success. We are at an advanced stage of development of the plan, and we will be publishing it shortly.

[Lord Rennard (LD)]

My Lords, in the north-east of England smoking rates have fallen by about one-third in recent years, thanks in part to the very cost-effective mass media campaigns run by Fresh North East, the regional tobacco control office. Nationally, though, funding for such cost-effective campaigns has been reduced to less than one-quarter of pre-2010 levels. Can the Minister reassure the House that the funding for such cost-effective campaigns will be restored in the new tobacco control plan?

[Lord O’Shaughnessy]

The noble Lord is quite right to highlight the effectiveness of mass media campaigns, and they will continue to be part of the new tobacco control plan. These include Public Health England’s Stoptober campaign and the health harm campaigns. The noble Lord gives us an example of an effective local campaign. I would also highlight the “16 Cancers” campaign in Yorkshire and Humber, which saw 740,000 smokers recalling the campaign and half of them taking a quit-related action.

[Lord Faulkner of Worcester (Lab)]

My Lords, the Minister will be aware that in her first major speech as Prime Minister Theresa May committed the Government to fighting against the burning injustice that if you are born poor you will die on average nine years earlier than others. Bearing in mind that the difference in life expectancy is due to much higher rates of smoking among poorer people, will the Minister confirm that the target of reducing smoking among poorer people is absolutely at the forefront of the Government’s priorities?

[Lord O’Shaughnessy]

The noble Lord makes an extremely important point. There are big variations in levels of smoking, not just by socioeconomic group. I was disturbed to see that 37% of people with mental health conditions smoke, which is twice the overall prevalence. We also know that there is a huge variation in the number of women who smoke when pregnant. Targeting that variation, which has a number of dimensions, will be a core part of the strategy.

[Lord Patel (CB)]

My Lords, there are 4,500 admissions to hospitals per day of people suffering from smoking-related diseases, and over 80,000 people per year die from such diseases. I know the Government have stated their plan for a policy that will reduce this harm. In that context, does the Minister think there might be lessons for us to learn from Finland’s plan to be tobacco-free?

[Lord O’Shaughnessy]

I will certainly look at what they are doing in Finland. I was not aware of that, and it is a very ambitious goal. As a former smoker, I have to say I know the benefits both in health terms and in my pocket from reducing smoking. It is essential that we continue on the trajectory of reducing smoking that has been going for a long time. England is a world leader in this area, and we should recognise that. There has been huge success but clearly there is a lot more to do.

[Lord Ribeiro (Con)]

My Lords, in a recent survey the British Thoracic Society found that 72% of hospital patients who smoked were not asked if they wanted to quit. Will my noble friend assure me that the promised tobacco control plan will ensure that hospital patients who smoke will get the support they need to quit?

[Lord O’Shaughnessy]

My noble friend makes an excellent point. Indeed, the Royal College of Surgeons of Edinburgh has just started a campaign to encourage clinicians to help their patients to stop smoking, and making sure that that happens is clearly going to have benefits for the kind of major surgery that some of the people who are suffering severe effects of smoking will need to have.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I noted that the Minister said the tobacco control plan will be published shortly and that it was in an advanced state of preparation. That was the same answer that his honourable friend the Public Health Minister gave in another place on 15 November 2016. The last tobacco control plan actually ran out at the end of 2015, so the new one is 14 months late. When exactly will it be published, and what has been the delay? Could the reason have been the decimation of the public health budget for local authorities, which has had a devastating effect, with reductions in preventive programmes at a local level?

[Lord O'Shaughnessy]

I understand the frustration at the delay in publishing the plan. That does not mean that action has not been taking place: all the action set in train under the previous plan has been taking place throughout that period. As I said, the new plan will be published shortly. I look to my noble friend Lord Ahmad, who has given several master classes in the use of words to describe “shortly” in different ways. I will save a few of those for any future Questions and stick with “shortly” for now.

[Baroness Brinton (LD)]

My Lords, the most recent report on child uptake of smoking by area shows some alarming figures of how many children start smoking every day. Given that it has been 100 days since the Government said that they would publish a new report, 67 children a day in London have taken up smoking, which makes 6,700 children in London alone. Do the Government not recognise the urgency of the plan’s publication, not just for the wider protection of our country but specifically for the most vulnerable of our children?

[Lord O'Shaughnessy]

I agree with the noble Baroness. It is worth pointing out that 8% of 15 year-olds smoke, which is obviously eight percentage points too high, but it is down from 15% in 2009, so things are moving in the right direction, although we are absolutely not complacent about it. We have taken action that is reducing the number of children who smoke. In particular, we have banned displays in small shops, which normalise that activity for children, who might be with their parents and see them—marketing is very clever at catching the eye. That is happening. As I said, we will be publishing the plan shortly and it will have reducing smoking among children as a key part.

[Lord Lawson of Blaby (Con)]

My Lords, given that the Royal College of Physicians has agreed that electronic cigarettes are the most effective way of getting smokers away from the habit of smoking tobacco, will the Minister ensure that when the much-desired great repeal Bill comes along, dealing with the adverse effect of the tobacco products directive, which prevents the transition to e-cigarettes, will be a high priority?

[Lord O'Shaughnessy]

My noble friend is right to raise the issue of e-cigarettes. Something like half the 2.8 million current users of e-cigarettes are no longer smoking tobacco, so it has proved to be an extremely effective way of helping people to stop smoking. The UK has one of the most welcoming approaches to e-cigarettes in the world. We have a proactive approach of encouraging smokers to switch to vaping, and ensuring that that continues will be a part of the plan.

[Baroness Farrington of Ribbleton (Lab)]

My Lords, I declare my interest. Will the Minister have regard to a comment from a grandson? I asked him whether he smoked. He said that most of his friends did, but he did not because he thought it was something old ladies do. He was very polite about it and said he did not want to be rude. Would it not be better to discourage young people by showing pictures of old ladies smoking, because none of the young people concerned want to look like old ladies?

[Lord O'Shaughnessy]

I would not like to comment on the particular instance to which the noble Baroness refers, but she is quite right about role models. Part of the importance of ensuring that there is no longer smoking in public places is that we do not want young people to think that it is normal, as it were, to smoke but something, whether it is for old ladies or not, that should not be done.

National Health Service Commissioning Board (Additional Functions) Regulations 2017

Lord O'Shaughnessy Excerpts

Thursday 23rd February 2017 Lords Chamber

Moved by

[Lord O’Shaughnessy]

That the draft Regulations laid before the House on 9 January be approved. Considered in Grand Committee on 21 February.

Motion agreed.

Health Service Medical Supplies (Costs) Bill

Lord O'Shaughnessy Excerpts

3rd reading (Minutes of Proceedings): House of Lords
Thursday 23rd February 2017 Lords Chamber

Moved by

[Lord O’Shaughnessy]

That the Bill be now read a third time.

Clause 9: Provision of information to Secretary of State and disclosure

Amendment 1

Moved by

[Lord O’Shaughnessy]

1: Clause 9, page 7, line 38, leave out “UK health service products” and insert “a particular UK health service product”

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

My Lords, there are two sets of amendments within this grouping. The first comprises small amendments relating to the circumstances in which the Government would be required to provide producers with an information notice. The second relates to the arrangements required for implementation of the legislation in Northern Ireland.

I turn, first, to Amendments 1 and 2. Amendment 1 clarifies that an information notice is required in respect of the costs incurred by a company in connection with the manufacturing, distribution or supply of a particular UK health service product. Amendment 2 is a technical drafting change to further clarify the intent of this clause and the type of transaction being contemplated.

On Report, I tabled amendments to the information requirements that would necessitate the Government issuing an information notice if they wanted UK producers to provide certain cost and profit information. This was in response to reasonable concerns raised by several noble Lords that attributing costs and profits to individual products, as opposed to simple aggregate-level data, would be burdensome for companies. The amendments that I have brought forward today reinforce these information notice procedures by clarifying that they apply to cost and profit information relating to individual products but not to aggregate-level data across a portfolio of products supplied by a company to the health service.

As I explained on Report, we already collect cost, sales and profit information on an annual basis under our voluntary scheme, the PPRS. This information is supplied at an aggregate level across a range of branded medicines supplied by a company to the health service. Clearly we need to be able to continue to collect these data in a routine way in order to maintain the voluntary scheme, and indeed to collect a similar type of routine aggregate-level company information in any future statutory scheme.

These amendments enable us to continue with the current approach to collecting company-level data in a non-bureaucratic way while, critically, ensuring that the information notice procedure, which was a concern of noble Lords, is focused on the area which we know is the greatest burden to companies—providing cost information on a product-by-product basis. I am pleased to say that my officials have discussed these amendments with the ABPI, the trade body for the pharmaceutical industry, which is content that they address industry concerns.

I now turn to Amendments 3, 4, 5 and 6. As noble Lords know, most of the Bill extends to England, Scotland, Wales and Northern Ireland, with some elements extending only to England and Wales or only to Scotland. A legislative consent Motion is required from Scotland, Wales and Northern Ireland for the matters in the Bill that are devolved.

I am bringing forward these technical amendments to address the fact that the Northern Ireland Assembly was not able to complete the passage of its legislative consent Motion on the Bill before it dissolved, although significant progress had been made, with the relevant committee having given approval. Our amendments therefore seek to change the Bill to enable the Northern Ireland components to be commenced separately through regulations. These components of the Bill will be commenced only after legislative consent has been secured.

[Lord Lansley (Con)]

My Lords, I do not propose to detain the House. I merely wish to thank my noble friend the Minister for the further clarification that Amendments 1 and 2, in particular, give to Clause 9.

I was among those who raised a concern. Although the industry completely understood that in order to make the PPRS effective there was a requirement for a scheme for the acquisition of data in aggregate, as my noble friend described, the powers would have enabled there to be a lot of demands for information which went beyond what had previously been required and which had the potential to be very intrusive. Under those circumstances, an information notice system, with proper details supplied to companies and with a potential appeal right, was required. We discussed that and I am very grateful to the Minister for taking it on board and putting in place something which I think will give considerable reassurance to the industry that the scheme will not be as burdensome as it could have been.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, I too welcome the amendments. Clearly, the Opposition will support them. I must remind the House of my presidency of the Health Care Supply Association and GS1 UK.

First, I thank the Minister and his officials for their warm co-operation. The ability to have a number of meetings has been much appreciated. This has been a very good example of cross-House co-operation. Various noble Lords, including the noble Lord, Lord Warner, and the noble Baroness, Lady Walmsley, worked very hard together on the core issue of ensuring that NHS patients get access to effective new medicines. I say to the Minister that I hope Clause 3 will remain in the Bill when it comes back to your Lordships’ House, if indeed it needs to come back—I take the point of the noble Baroness, Lady Walmsley, that this House has done the job it is here to do: it has revised and scrutinised the legislation. I would have thought that the other place should simply accept the Bill as it is, and I hope the Minister will be able to confirm that when he responds. I also thank my noble friend Lady Wheeler for her tremendous support, and Dan Stevens, our health researcher.

It seems to me that the Minister has shown himself adept at handling health legislation in your Lordships’ House, and so we look forward to the next health Bill. If he is looking for suggestions, we are going to have the great repeal Bill and perhaps we can look forward also to the repeal of the Health and Social Care Act 2012. That would bring great joy to many.

[Lord O'Shaughnessy]

I am very grateful to noble Lords for their support for these amendments. I am also grateful to my noble friend Lord Lansley, one of the architects of this new approach to information notices; that was extremely useful and we have ended up in a good place. I am grateful to the noble Baroness, Lady Walmsley, who I have enjoyed getting to know through the process of this Bill. She is quite right to emphasise the vital role that this House plays through its proper constitutional role in revising legislation—I will not say anything more than that. I thank the noble Lords, Lord Warner and Lord Hunt, both of whom have been in my shoes in the past. Good will will certainly operate, and I hope that both noble Lords, and indeed the noble Baroness, Lady Wheeler, have found me to be open, open-minded and willing to work with them. Throughout the passage of the Bill I have been keen to ensure that it is a proportionate response to tackle this challenge, and I think we are all agreed on that.

To conclude, I am delighted that we have come this far on the scrutiny of the Bill and are now debating the final amendments to bring it to a close. As we end Third Reading I would like to take this opportunity to place on record my thanks to all noble Lords who have taken part in the debates, beyond those I mentioned just now, throughout all stages in this House. It is fair to say that the collected efforts of this House in bringing together different views have paid dividends in the improvements that we have seen. It has been a good example of the rigour and attention to detail that this House is known for.

I particularly thank the many officials involved in the Bill, who have worked not only to support me but to ensure that noble Lords are briefed and that any concerns are addressed, within what at times have been very tight timescales. They have done a tremendous job and I am sure the House will join me in paying tribute to them.

Although this may not be the final word on the Bill, I am convinced that the House is sending it back to the other place having been significantly improved in key respects.

Amendment 1 agreed.

Moved by

[Lord O'Shaughnessy]

2: Clause 9, page 7, line 39, leave out from “transaction” to end of line 40 and insert “between the producer and a UK producer for that product)”

--- Later in debate ---

Moved by

[Lord O'Shaughnessy]

3: Clause 13, page 14, line 34, after “10” insert “and 11(19)”

National Health Service: Nurses

Lord O'Shaughnessy Excerpts

Wednesday 22nd February 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what plans they have to eradicate the shortage of trained nurses in the National Health Service and care sector.

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

My Lords, this Government have undertaken work to increase the number of trained nurses. We now have a record number of nurses working in the NHS. By increasing the number of training places for both new nurses and nurses returning to practice, we continue to support the growth of our nursing workforce in the health and care sectors.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply but I cannot share his wing-and-a-prayer approach to the drastic shortage of nurses we face. Bearing in mind that the NHS alone is short of 24,000 nurses, and the 23% reduction in nursing applications as of this autumn, does the Minister not agree that they should reinstate the bursary scheme at university for nurses, or at least promise nurses who qualify and spend a number of years working in the health service that they will have their tuition fees reimbursed?

[Lord O'Shaughnessy]

I am sorry that the noble Lord takes such a negative view of the changes we are making. There are actually 6,500 more full-time equivalent nurses and health visitors than there were in 2010. There has been a 15% increase in the number of training places and of course, through our reforms which he just mentioned, we are taking the cap off the amount of training places that can be offered.

[Baroness Gardner of Parkes (Con)]

My Lords, can the Minister tell us how the apprenticeship scheme is going, because a lot of damage was done when Tony Blair said that you had to have five A-levels to become a nurse? We hope that this apprenticeship scheme will counteract that.

[Lord O'Shaughnessy]

I am grateful to my noble friend for mentioning the nursing degree apprenticeship, which was announced at the end of last year. The first nurses should be in place from September of this year. Once established, this apprenticeship route could allow up to 1,000 additional nurses to join the NHS every year.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, are there any plans for post-qualification training grants for specialist nurses in some of the shortage areas, such as psychiatric nursing, and/or golden handcuffs to keep them in their jobs?

[Lord O'Shaughnessy]

The noble Baroness is quite right to raise the issue of retaining nurses and bringing them back into the profession. That is why, last year, to aid retention, there was an average 3% increase in pay for nurses. Health Education England has also introduced a return to practice campaign, which has brought 900 nurses back to the front line in the last three years.

[Baroness Pitkeathley (Lab)]

My Lords, we hear constantly that better integration between health and social care is the way to solve the problems that both services are currently experiencing. What progress is being made with training nurses who can work across both health and community services?

[Lord O'Shaughnessy]

The noble Baroness makes a very good point. In fact, the workforce figures out today, which show the increases I have described, also show an increase in the number of nurses with general qualifications who are capable of working across multiple specialties and different sectors.

[Lord Ribeiro (Con)]

My Lords, mindful of the fact that we have taken the decision to leave the European Union and realising that many of our nurses come from overseas, and more recently from Europe, surely the time to start increasing nursing numbers is now, to make sure that we deal with any shortfall that may come after 2020.

[Lord O'Shaughnessy]

My noble friend makes an excellent point. Currently, around 7% of nurses are EU nationals. There has not been a drop-off in the number of EU nationals joining the NHS workforce since the referendum; nevertheless, it is clearly sensible to reduce our reliance on overseas nurses each year. We are doing that through additional training places and through retention and return to work schemes.

[Baroness Masham of Ilton (CB)]

My Lords, does the Minister agree that there is a shortage of district nurses, who are important in rural areas, and that many of them are coming up to retirement age?

[Lord O'Shaughnessy]

I thank the noble Baroness for making that point. The issue of retirement ages has come up previously in Questions, and I had a look at the profiling of nursing. It similar to the profiling of other healthcare professions and other public sector professions, so there is a weighting towards older age groups, but it is not an acute problem particular to nursing. The noble Baroness is quite right that there have been reductions in the number of district nurses, but there have also been increases in other kinds of nurses, particularly health visitors offering community services. There is some overlap in the kind of services they provide.

[Lord Davies of Stamford]

The Minister tried to answer my question in terms of percentages, but it would be nice to have the absolute number of members of the nursing profession currently in the NHS who are citizens of other EU countries. What measures are the Government taking to reassure these nurses that their contribution is strongly valued and that we want them to remain doing the excellent job they are now doing for the health of this country?

[Lord O'Shaughnessy]

In answer to the noble Lord’s first question, I think the figure is 22,227 EU nationals, so I hope that satisfies him on that point. Of course, they do a fantastic job, as do all NHS and care staff, and they deserve the highest praise. The noble Lord will also know that we are keen to reassure them of their status as part of the EU negotiations, but, of necessity, that has to be a reciprocal arrangement.

[Lord McColl of Dulwich (Con)]

Will the Minister support my attempt to find out what makes so many young nurses leave the profession?

[Lord O'Shaughnessy]

I thank my noble friend for that question. We should be looking at attrition rates in training and in the profession itself, and I would certainly be happy to work with him on that. I know he is particularly anxious about the turnover of nurses within certain training settings.

[Lord Hunt of Kings Heath (Lab)]

My Lords, what is the current deficit that NHS providers are running in the health service? Can the Minister assure me that the NHS will actually have the money to spend on more nurses next year?

[Lord O'Shaughnessy]

I do not have to hand the figures the noble Lord asks for. He will know that the Government are putting in £10 billion over the five-year forward view period in order to support the world-class NHS that we all want to see.

National Health Service Commissioning Board (Additional Functions) Regulations 2017

Lord O'Shaughnessy Excerpts

Tuesday 21st February 2017 Grand Committee

Moved by

[Lord O’Shaughnessy]

That the Grand Committee do consider the National Health Service Commissioning Board (Additional Functions) Regulations 2017.

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

My Lords, these regulations will confer on the NHS Commissioning Board, more commonly known as NHS England, new functions covering the work currently undertaken by the Department of Health’s Commercial Medicines Unit.

The principal function of the Commercial Medicines Unit is to procure, conclude and manage procurement framework agreements with suppliers of services, drugs, medicines or other substances or products. These framework agreements are for the use, in the main, of NHS trusts and NHS foundation trusts. In securing competitive prices for these products and services, these framework agreements enable considerable savings to be made by the NHS.

The final report of the Carter review, on hospital productivity, suggested that the Commercial Medicines Unit might be best located within the NHS. After due consideration, the Department of Health and NHS England came to the view that the potential benefits could be realised if the majority of the unit’s work transferred to NHS England. The NHS Act 2006 does not provide NHS England with the necessary powers to undertake this work, so regulations are required to enable this transfer.

The regulations before us confer three additional functions on NHS England. First, they confer a power to conclude and manage framework agreements, which will enable NHS England to take on the functions from the Commercial Medicines Unit. Secondly, they impose a duty to provide assistance to the Secretary of State in relation to the exercise of the first function. This will ensure that the important contribution made by the Commercial Medicines Unit to other health priorities continues. Thirdly, they impose a duty to consult and collaborate with the registered pharmacists of every NHS trust and NHS foundation trust in relation to the exercise of the first function. These stakeholders play a vital role in the work of the Commercial Medicines Unit, and this duty will ensure that this role continues under NHS England. The Government consider that these regulations will bring together related procurement and commissioning functions within NHS England, which will enable the sharing of expertise and support the realisation of various benefits, including better use of NHS resources. I commend the regulations to the Committee.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for his comprehensive introduction to the regulations before us this afternoon. I was interested when in his opening remarks he referred to the NHS Commissioning Board, more commonly known as NHS England. What struck me is that, when challenged on NHS funding, the Minister and his predecessor have been fond of saying that the NHS got the extra money that it had asked for. But what he really meant to say is that the NHS Commissioning Board put forward a five-year forward plan which talked about a £30 billion gap between the resource needed and the resource that was likely to be got, on the projections then published. We know that it was then told by the Treasury how much it could actually ask for. When we come to debate the NHS and its funding, it would give a much better reflection of the actual position if the Minister were to say that the figure which the Government have produced is what the NHS Commissioning Board was told to put into the five-year forward view.

I was puzzled by the way in which NHS England changed the name of its organisation to be that. Much of the two years we spent debating the 2012 Act was around the work of the NHS Commissioning Board. I was a little surprised that a quango took it upon itself simply to change its name and give itself the kind of title to which, statutorily, it clearly had no right—nor is it in its remit. It is interesting that when it comes to regulations such as these, which we have frequently, they have to relate to the NHS Commissioning Board. I suspect that very few people know what it is. At the end of the day, either the Government should regularise this by legislating to call NHS England by that name or it should revert to being the NHS Commissioning Board. As a matter of principle and practice, it is not a good idea to use a name that has not been given in legislation.

These are interesting regulations because, in a way, they take us back to our debates in relation to the Health Service Medical Supplies (Costs) Bill. Much of those debates have been on the cost of medicines, and the operation of the PPRS scheme and the statutory scheme alongside it. I guess that the question I would put to the Minister is: since negotiations with the pharmaceutical industry currently lie principally with the Department of Health, what implications does the transfer of this unit to NHS England have for the department’s own capacity to negotiate agreements in future? Does it essentially mean that NHS England will take over those negotiations?

I have obviously seen the Explanatory Memorandum and the reference back to the Carter report. I understand the reasons why my noble friend Lord Carter, thought that the CMU would be best placed within NHS England. But does this transfer equate at all to the recommendation in the Accelerated Access Review, which called for the creation of a strategic commercial unit to be established within NHS England? Would I be right in thinking that the transfer of the CMU is, in essence, the strategic commercial unit that the accelerated access review called for? What it actually said is that it wanted an SCU to,

“have the capacity and capability to consider a range of flexible pricing models as part of a commercial dialogue with innovators”,

and envisaged:

“Win-win scenarios, where innovators benefit from earlier, and, in some cases, guaranteed market access and the NHS and patients benefit from better value through a reduced price”.


In a sense, that takes us back to our debates during the passage of the Bill about whether we can develop more of a win-win relationship with innovators so that patients get access to innovation at a much earlier stage—but also, because the NHS is moving from a culture that is very often opposed to the introduction of innovation to one that embraces innovation, it therefore gets the advantage of better value for money in the end. If that is not to be the case, does the Minister think that the CMU has the capacity, capability and expertise to agree new and innovative commercial arrangements with companies? Will those processes support improved patient access to medicines and will NHS England consult on any new methodology or guides that will support the commercial unit role? How will the reconstituted CMU within the NHS interact with NICE and the adoption of NICE-approved medicines? If it has an active role, will that affect a patient’s right to NICE-approved medicines as covered by the NHS constitution?

Clearly, the experience of companies dealing with NHS England at the moment is that it is inflexible and is interested not in quality and outcome but simply in price. I have had many representations to that effect. My understanding is that NHS England simply has not got the capacity to negotiate these rather more innovative approaches to innovation, adoption and value for money. At heart, the question is this: will the transfer of the CMU to NHS England enhance the capacity of that organisation to move from a crude bottom-line approach to purchasing to one which looks at best value, innovation and adoption?

Apart from that, I will be interested in the Minister’s responses. As this is about procurement, I should remind the Committee of my presidency of the Health Care Supply Association and of GS1, the bar-coding association.

[Lord O'Shaughnessy]

I am grateful to the noble Lord for his questioning which was, as usual, precise. I will attempt to respond to his questions as best I can. I shall start where he started. I do not think I can take any blame for any confusion that may be caused around rebranding the NHS Commissioning Board Authority as NHS England. It clearly has a commissioning role, and in that commissioning role there is clearly a good fit with procurement. That is what the noble Lord, Lord Carter, concluded. Bringing together specialised commissioning, general procurement capacity and the role of the CMU was a good fit and it might deliver better value for money for the NHS, which I know the noble Lord wants as much as I do, so we can clear that out of the way.

The noble Lord’s big question was about enhancing the capacity of NHS England to become more sophisticated. In one sense, he is getting slightly ahead of things because the regulations do not transfer the entirety of the functionality. Some of the functionality will continue to be in the department as it pertains to public health responsibilities—vaccination, for example, or the procurement of emergency treatments. However, those that are to do with the ordinary activities of the health service are moving over. From that point of view, therefore, there is no change: the framework agreements transfer and people transfer. It is simply transferring a unit from one place to another, but clearly with the idea that there will be an enhancement in everyday activities as a result.

The noble Lord is quite right to refer to the issue of access—we talked about that a lot during the Bill’s passage—and it may well be that in future, when we are thinking about what comes after the PPRS, the kind of things that he is talking about would be within the remit. It would be wrong for me to comment on that now, not least because the PPRS commits us to certain activities and behaviours on simplicity of pricing discounts and so on, and clearly the kinds of things he is talking about—the more sophisticated value-based pricing models—do not currently fall within that scope. I am clear, however, that the Government and the department will continue to take a lead in any future discussions about replacements that leverage capacity across the system.

In answer to a couple of the noble Lord’s other questions, there is no particular impact on NICE from these regulations. We know that within the PPRS there is a commitment to fund after three months: that is part of the agreement. I hope, therefore, that he is reassured about that. To repeat, this is, in essence, quite a simple measure that takes a set of responsibilities from one place to another with the aim of providing greater efficiency—by procuring framework agreements, and so on. That is separate, in a way, to what we have been discussing in the Bill, but it may be that in future the transfer and enhancement of that capacity could set the tone for the kind of negotiations that he would like. However, I hope that he will understand that it would not be right for me to make any commitment on that at the moment, bearing in mind the relationships that we have. If he is satisfied with those responses, I commend the order.

Motion agreed.

Hospital Beds: Availability

Lord O'Shaughnessy Excerpts

Thursday 9th February 2017 Lords Chamber

[Lord Dubs]

To ask Her Majesty’s Government what is their estimate of the number of hospital beds currently occupied by persons who could be discharged.

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

My Lords, the most recently published figures—for the last Thursday of December 2016—reported that 6,191 people who were occupying hospital beds were ready to return home or transfer to another form of care.

[Lord Dubs (Lab)]

My Lords, I thank the Minister for that reply. I am extremely puzzled because the official NHS figures I have been looking at suggest that, in November, there were 200,000 people blocking beds. What is more significant, all the experts say that the actual number of bed-blockers is three times the size of the official figure. Bed-blocking means that people are not given the best possible care and beds are blocked for others who could be admitted. Surely we have to solve this problem quickly.

[Lord O'Shaughnessy]

My Lords, the figures that the noble Lord is referring to are across the whole month. He may be aware that new figures have been published today, which show that an increasing proportion of delayed transfers is due to the availability of social care packages. He will also know that this reflects the changing nature of the patient demographic, which is becoming older and frailer. I agree with him that this needs addressing urgently, which is why the Government took action in the Autumn Statement to increase social care funding. We need to address the wide variation in the rate of delayed discharge from local authority to local authority. As the Prime Minister has said, in the long run we need a more sustainable solution.

[Lord Skelmersdale (Con)]

My Lords, although all Governments have made great strides in recent years in combining health and social care, is it not now obvious that the only way to complete this process is to have a unified budget?

[Lord O'Shaughnessy]

I thank my noble friend for that question. He is quite right that integration of services is the main thrust of policy and has been under successive Governments. This is happening in two ways. First, the Better Care Fund is pooling health and social care budgets at local authority level in order to achieve what he is asking for. Also, NHS England is producing sustainability and transformation plans, several of which are moving towards what is called an accountable care organisation, whereby a single grouping takes responsibility for all the healthcare needs of a population, rather than it being split into different services.

[Baroness Walmsley (LD)]

My Lords, integration is of course very important, but has the Minister ever met anybody in the health service who does not believe that you will never fix the pressures in the health service until you put more money into social care? That means helping areas with low-value properties, not just those with high-value properties, such as in leafy Surrey.

[Lord O'Shaughnessy]

The noble Baroness is of course quite right about the need for more money. I re-emphasise that an additional £7 billion or more for social care is going to councils during this Parliament. Councils have the ability to raise council tax, although the leverage obviously varies from place to place. This is why the Better Care Fund was created—to provide extra help to areas that do not get the same income from council tax increases as the better-off places.

[Lord Crisp (CB)]

My Lords, a year ago, the Royal College of Psychiatrists published a report which showed that about one-fifth of adult mental health beds were occupied by people who were ready for discharge or who should not have been admitted in the first place. They were only admitted because there were no adequate facilities in the community. Could the Minister tell us what the figure is today and what is being done about mental health specifically?

[Lord O'Shaughnessy]

The noble Lord is quite right to raise the issue of mental health. I do not have the specific figure with me but I will write to him with it. We know that there has been a historic disparity between the two services. This was recognised by the Prime Minister in a very important speech she gave a few weeks ago, setting out some of the ways in which the Government are doing more on this. However, there is clearly a lot more to do.

[Baroness Gardner of Parkes (Con)]

What is the situation of people providing care at home on behalf of councils? Many carers I know are called out at 10 or 11 at night to receive someone who has just been sent home from hospital. However, they are not really trained themselves; they are trained only by the care agency. Is it not time that we provided them with proper training, particularly as so many of them have come from the Philippines and other such places and we are not sure what the future holds for them?

[Lord O'Shaughnessy]

My noble friend is quite right that there has been an increasing prevalence of domiciliary care, which involves carers caring for patients in their own homes. Making sure that those patients can get home at a good time that works for them and those who support them is clearly a critical part of dealing with this delayed discharge issue.

[Baroness Wheeler (Lab)]

My Lords, the Minister was talking about care workers rather than carers. He has focused on social care but Nuffield Trust research shows that the proportion of discharge delays due to the unavailability of social care has grown by 84% in six years, but also that 57% of delays occurred because of problems in the NHS itself. This is because of a lack of local NHS community or rehabilitation services, and of the availability of home support therapies or access to diagnostic and other services. Are STPs going to be able to tackle this, given the scale of cuts that will need to be made? Is the Minister confident that last year’s NAO report, which warned that the Department of Health and NHS England rely “too easily” on differing local circumstances as a “catch-all excuse” for not improving NHS performance, is being addressed?

[Lord O'Shaughnessy]

The noble Baroness is quite right that there is increasing pressure on the health service. There have been 3.5 million more hospital admissions in the last 10 years and 2.4 million more A&E attendances in the last five years, so there is huge extra pressure. The number of acute beds has been dropping for a long time but at a slower rate in more recent years. Clearly, making sure that the right level of community care is available—step-down or interim care between hospital and home—will be incredibly important, particularly with a growing and ageing population.

[Viscount Waverley (CB)]

My Lords, surely enough is enough. Is it not high time for an unfettered look again at the health service—bottom-up rather than top-down, and therefore undertaken not by a royal commission, perhaps, but by an independent body such as the Academy of Medical Sciences?

[Lord O'Shaughnessy]

A number of investigations and reviews into the future of health and social care are taking place. I quite agree with the noble Lord that a royal commission is not necessary. What we all need to do in government and through the arm’s-length bodies involved in healthcare is to make sure that we are providing the 2.7 million staff, who are doing a brilliant job every day in supporting our health and care services, with the money and assistance they need to continue to deliver world-class healthcare.

[Lord McColl of Dulwich (Con)]

My Lords, does the Minister agree that it is not so much a question of old people getting older, because old people have always got older; rather, the difference in the last 30 years is the grotesque increase in the number of young people getting fatter and fatter?

[Lord O'Shaughnessy]

There are some long-term public health challenges, involving not just obesity but alcohol. But there is also good news: fewer people are smoking. I think that sometimes, young people—I do not know if I count any more—

[Noble Lords]

No.

[Lord O'Shaughnessy]

No? I do here. If we look at what are sometimes called transgressive behaviours among the under-20s—obesity, smoking, drinking and so on—they seem a lot healthier and more sensible than I was in my youth.

Mental Health: Young People

Lord O'Shaughnessy Excerpts

Thursday 9th February 2017 Grand Committee

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

My Lords, I pay tribute to the noble Baroness, Lady Massey, both for bringing about this debate and for the work she has done over many years in promoting the issues of mental health and mental well-being. I am extremely grateful to all noble Lords for this well-informed and passionate debate, and will try to respond in my speech to as many questions as possible.

I also welcome the report from the Association for Young People’s Health, and thank the parents in the YoungMinds network for their courage and honesty in discussing the very difficult issues they face in raising children with mental health problems. Parents deal with so much, often under the radar, and they deserve our praise and admiration. As the noble Lord, Lord Hastings, said, the concept of being a parent, in the sense of parenting as an activity, goes much wider. As my noble friend Lady Redfern said, mental health problems are everyone’s problems.

We must be clear, as noble Lords have been very clear today, that there is a real and growing problem with mental illness among young people in this country. It is estimated that around one in 10 children and young people have a diagnosable mental health disorder. That is three children in every class, a fact worth reflecting on for a moment. A new report out today from the Varkey Foundation paints an alarming picture of young people’s mental well-being in this country as compared to other countries.

When I was growing up, self-harm was a problem, but on a very small scale. However, over the last 10 years the figure has increased by 68% and, as the right reverend Prelate the Bishop of St Albans, said, it now affects boys as well as girls. Around 8,000 children under the age of 10 have severe depression—another heart-rending statistic—and the number of 15 and 16 year-olds with depression nearly doubled between the 1980s and the 2000s.

As the noble Lord, Lord Giddens, said, eating disorders are some of the most dangerous mental illnesses, and their prevalence continues to rise. There are multiple, sometimes competing, explanations for why this might be so, which several noble Lords have discussed today, whether family breakdown, as my noble friend Lord Farmer mentioned, the increased use of drink and drugs, the appalling rate of mental illness among children in care, or the effects of consumerism, as the noble Lord, Lord Giddens, set out. This means that a broad-based approach is needed. There is, unfortunately, no silver bullet. But there is hope.

While the trends have largely been negative in terms of the prevalence of mental illness, a sea-change in attitudes is taking place. As the noble Lord, Lord Cashman, described so eloquently, this has particular impacts on certain groups, particularly on minorities, whether according to sexual preference or ethnic minorities. Through concerted efforts by medical professionals, parents, young people themselves, campaigners, politicians and even the Royal Family, we are at last confronting the stigma of mental illness. It is finally becoming acceptable to admit mental health problems without it connoting some kind of personal weakness, as my noble friend Lady Chisholm, pointed out.

Government policy has both led and evolved in response to this change. I am very proud to serve a Prime Minister who is deeply committed to ending “burning injustices”. What greater injustice could there be than to receive inferior healthcare because your needs are mental, not physical? The previous Conservative and Liberal Democrat Government legislated to create parity of esteem for mental and physical health in 2012, and since then the Government have introduced the first mental health waiting time targets and have begun to roll out a series of initiatives—supported by an additional £1.4 billion—to support those suffering from mental illness, including support for young people suffering from eating disorders and to support perinatal mental health, which the noble Baroness, Lady Tyler, highlighted as being so critical.

However, it is important to acknowledge that there is much more do to. There are concerns that funding is not getting through to the front line, as the noble Lord, Lord Patel, said—and as other Peers have said in other debates—and it must be admitted, as my noble friend Lady Fall pointed out, that the performance of child and adolescent mental health services is patchy. Care also needs to be delivered closer to home wherever possible, as my noble friend pointed out. The Government are aware of these criticisms and are working hard with NHS and local authority partners to address them.

The report we are discussing today revolves around the role of parents, and some of the quotes in it are, quite frankly, heart-breaking. They lay bare the helplessness and frustration that many parents feel. As some noble Lords may know, I have spent the last few years working in education and in schools we always talk about parents as being the “first educators”. That is relevant here because in health we can think of them as the “first carers”—the first line of both defence and action, as the noble Baroness, Lady Tyler, pointed out. Government policy must be geared to strengthening parents’ ability to provide the love and support that makes young people more resilient, and to arming them with the skills and knowledge needed to identify and respond to the signs of mental illness when it occurs. The noble Baroness, Lady Massey, asked for my personal support in making sure that there is increasing support for parents through government policy and I am happy to give it.

There are some good examples of government policies that are working in this area. The Department for Work and Pensions supports parenting classes aimed at reducing family conflict, which has been raised as an issue. The Department for Education supports the YoungMinds Parents’ Helpline and the MindEd website, which provide parents with guidance on a range of parenting issues related to mental health. There is also the Family Test, which was introduced by the previous Government and which my noble friend Lord Farmer was instrumental in bringing about.

The NHS England Five Year Forward View for mental health has put mental illness at the forefront of NHS reforms. The noble Lords, Lord Cashman and Lord Giddens, asked about waiting time targets for eating disorders; these will be in place from April 2017. There is more funding, but there are challenges, as we know, in getting it through to the front line. I will respond to the question of the noble Lord, Lord Patel, later.

I think we have also launched today the next stage of piloting the single point of contact, which will benefit children in 1,200 more schools. The voluntary sector is doing pioneering work in this area, whether through Place2Be’s counselling services or through the proposals for a new national parenting trust emerging from the Legatum Institute, where I used to be a senior fellow, and which will provide parent support groups to help parents in a very challenging time of life.

I am delighted that the Government have committed to creating a joint Department for Education and Department of Health Green Paper on children and young people’s mental health. The aim is to publish it this year. I am also clear that this will succeed only if it boosts parents’ ability to support their children to deal successfully with mental illness. It is essential to involve parents in that policy-making. Mental health is being transformed in this country through local transformation plans which have parents and young people themselves taking part in the design of policies.

I take the opportunity to respond to some of the specific questions noble Lords have raised. My noble friend Lady Chisholm asked about mental health training for GPs. That is something NHS England is working on actively with the Royal College of General Practitioners. She will also be aware, I hope, of the Prime Minister’s really important and signal announcement, which outlined that there would be mental health training for mental health first aid in secondary schools. However, I very much take the point of the noble Baroness, Lady Lane-Fox, who talked about that going into primary schools too.

The noble Baroness, Lady Lane-Fox, also talked about the impact of social media and social networks. My oldest child is nearly nine years old and I am frankly terrified by the prospect of her joining social media. There is a kind of fascination with devices and everything that goes beyond it. You try to explain to them that there may be more bad out there than good, but they are desperate to be part of it.

The Prime Minister announced initiatives on digital mental health services, but clearly there is much more that we can do through the Green Paper and she was quite right to point out that businesses need to take responsibility, too, whether that means the social media businesses themselves—I can imagine that she is a forceful advocate for that on the board of Twitter—or other businesses. The Prime Minister has asked the noble Lord, Lord Stevenson, and Paul Farmer from Mind to carry out a review on mental health in the workplace.

The right reverend Prelate the Bishop of St Albans asked about support for parents. Some 90% of the local transformation plans that I have mentioned have parenting and early years programmes. Clearly, for this to be an effective strategy, it must involve getting to parents and families early, before problems arise, so that parents and young people, as they get older, have the skills they need to spot and deal with mental illnesses as they arrive.

My noble friend Lord Farmer asked what else the Government are doing to support families. There is a troubled families programme and, since 2010, there has also been the healthy child programme, which provides health visitor support in the home. As well as that, there is the Family Nurse Partnership, which provides targeted support for young mothers who are vulnerable.

The noble Lord, Lord Cashman, highlighted the issue of LGBTI people suffering from worse mental health. I admit that is something I was not aware of prior to this debate. I am grateful to him for raising it. I understand that in general there is a problem in mental health, in both prevalence and treatment, when it comes to equalities issues, which fall under my brief. That is something I will certainly look into. It is critical that we reflect that in policy.

The noble Lord also raised mandatory sex and relationships education and PSHE. That is a debate I engaged with when I was on the Back Benches. I do not want to reprise the whole argument now, not least because I am in a rather different role, but the issue is one of quality, not necessarily making something compulsory if it is not very good. We need to focus on making it good, then the argument to make it compulsory may be easier to make.

I hope I have answered the questions asked by the noble Lord, Lord Giddens, on waiting times targets. I apologise: it was my noble friend Lady Fall who made the point about this applying to primary schools. She also asked about drop-in centres. I hope she will have noticed that in the Prime Minister’s announcement on mental health there was rather an interesting and innovative idea about supporting crisis cafés and drop-in centres, which are precisely the kind of informal setting that it might be easier for a young person to access to get the support they need.

There is so much more that could be said on this subject. I hope I have given noble Lords confidence that the Government are taking this seriously. We have this wonderful opportunity of a Green Paper. We have to develop it. I do not know what a pre Green Paper is called, but we are in that phase. It feels to me that there is a large and important bucket that can be filled with brilliant ideas. I have some more ideas for how we might do that, but I hope this is the first of many debates on this issue. I am absolutely open to all Peers to discuss ideas they may have to make that a real milestone in mental health services, mental health treatment and building resilience in this country. I look forward to working with noble Lords to make sure parents play a central role in that strategy.

Nursing and Midwifery: Student Applications

Lord O'Shaughnessy Excerpts

Tuesday 7th February 2017 Lords Chamber

[Lord Watson of Invergowrie]

To ask Her Majesty’s Government what assessment they have made of the reduction in the number of applications by students in England for nursing and midwifery courses at British universities beginning in 2017 compared to courses beginning in 2016.

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

My Lords, at this stage of the application cycle, based on the data published by the Universities and Colleges Admissions Service on 2 February, Health Education England is confident that the NHS will be able to fill the number of nursing and midwifery places in England.

[Lord Watson of Invergowrie (Lab)]

My Lords, the nursing and midwifery workforce already has severe shortages, fewer EU nurses are coming to work in the NHS because of the referendum, and by 2020 nearly half the workforce will be eligible for retirement. What do the Government do? They end the long-established practice of providing student nurses with bursaries and tell them to take out loans, which will amount to £50,000 by the time they qualify. Last week, that had the predictable outcome, despite what the Minister says, of 10,000 fewer applications being received than at the same stage last year—I stress that it is at the same stage—which is a 23% drop from last year. In Scotland, where bursaries still apply, the figure was 4%. The Minister is new to his post and therefore cannot be held responsible for this bursary decision, but will he bring fresh thinking to the nursing supply crisis and get the Government to reverse this disastrous policy?

--- Later in debate ---

[Lord O'Shaughnessy]

I am sorry to hear that the noble Lord no longer supports a higher education policy of loans and fees that was originally instigated by a Labour Government. He is right about the differing impacts in Scotland and Wales, which have different systems. He also knows that, whenever fees have been introduced in the past, there has been a dip and then a rebound. Two of those rises in fees happened under Labour Governments. There are around 37,000 applicants for around 23,000 places at this point in the cycle. As he knows, there will be further applications directly to universities and through clearing. He may also be reassured by the words of the head of policy at the Council of Deans of Health, which represents the universities affected. She said:

“The scale of the fall in application numbers is not the critical factor for universities or the health and social care sector. Courses that were previously heavily oversubscribed can survive a significant dip in application numbers as long as the quality of applicants is good, and our members report that this remains so”.

[Baroness Walmsley (LD)]

My Lords, filling the places is one matter, but the level of attrition is another, and that is dreadful. Apparently, one in four student nurses leaves during their training, and in the first two years after qualification two out of five leave the profession. Part of the problem is that the data are not consistently collected. If they were, we would be able to know which settings are very poor at keeping their young nurses. Will the Government do something about collecting those data in a consistent way so that something can be done about the level of attrition?

[Lord O'Shaughnessy]

The noble Baroness makes an important point about attrition. It is one of the reasons that, within the new package of support, there is extra support for living expenses, both for mature students, who feature particularly in the case of nursing, and in cases of hardship.

[Baroness Butler-Sloss (CB)]

My Lords, has the Minister seen the fifth annual State of Maternity Services Report from the Royal College of Midwives—I attended its launch this morning—in which there are very careful data about the fact that too many midwives are aged over 50, a considerable number are over 60 and there are not sufficient to take their places? The Government should worry about this.

[Lord O'Shaughnessy]

I am grateful to the noble and learned Baroness for bringing up that issue. I have not seen the report, but I shall certainly look at it. It is true that, across the public sector, there is an issue with an ageing workforce. To some extent, that will be addressed by the fact that we will all be working until we are older. The Government will also be introducing increases to the number of training places, which was a critical reason for moving from a bursary to a fee-based system. The bursary system involved a cap; we are now able to release that cap and bring more numbers through in the training.

[Baroness Chisholm of Owlpen (Con)]

My Lords, as a very old retired nurse, can I ask my noble friend what the Government are doing to encourage an alternative route into nursing like the back to nursing course, which I took when my children were old enough to allow me to go back to work?

[Lord O'Shaughnessy]

I thank my noble friend for that question. There are a couple of new opportunities: one is nursing associates and the other, in common with changes across the public sector, is that there are up to 1,000 new nursing degree apprenticeships providing alternative routes into nursing for those who do not want to go down the university route.

[Lord Campbell-Savours (Lab)]

My Lords, the Minister referred to clearing in his original reply. If, after clearing, there is still a substantial reduction in applications, will the Government then review the position?

[Lord O'Shaughnessy]

That is a hypothetical situation. Health Education England remains confident that we will fill the places. Critically, the universities—I mentioned the Council of Deans of Health—also think that we will still fill them.

[The Earl of Listowel (CB)]

My Lords, is the Minister aware of the increasing concern about perinatal mental health for mothers and the great importance of this to the future well-being of their children? In this context, is he concerned that there should be continuity of care for such mothers and that we therefore must avoid at all costs finding ourselves in a situation where there are not enough midwives to give that continuity to these mothers?

[Lord O'Shaughnessy]

I thank the noble Earl for that question. He is quite right that continuity of care is important. That is why we have brought about these changes to lift the cap on the number of places and become less reliant on foreign nurses filling those positions. It is also the reason, as he knows and I hope would welcome, that the Government have introduced a mental health strategy and are spending considerably more on it, with a Green Paper to come later this year.

[Lord Harrison (Lab)]

My Lords, given the ageing profile of the current midwives workforce, and given that the Minister has acknowledged this and said that he will go back and re-examine the figures, is it not a perilous time to change the basis of midwives’ recruitment?

[Lord O'Shaughnessy]

The Government took the decision to change to a fee-based system precisely because a bursary-based system involves caps and only so many places can be commissioned. A fee-based system allows the cap to be removed, with the intention of increasing the places available by up to 10,000 people a year, which will increase the flow into the profession to address precisely the issue that the noble Lord raises.

[Baroness Hayman (CB)]

My Lords, can the Minister tell the House whether his department undertook a risk analysis of changing the basis of the funding for nursing education at a time when the age profile was as has been described, and when the security of the EU nurses on whom the NHS depends at the moment—and will do so for the continuing future—is so damaged by the uncertainty of their immigration status? If such risk analysis was not undertaken, might it be done now?

[Lord O'Shaughnessy]

As the noble Baroness will know, Health Education England is responsible for commissioning medical training places, and I am sure that all necessary impact and risk assessments would have been carried out at the time. As the noble Lord opposite recognised, I was not in post at that point, but I will certainly look at it. I would be surprised if that was not the case.

Health Service Medical Supplies (Costs) Bill

Lord O'Shaughnessy Excerpts

Report stage (Hansard): House of Lords
Tuesday 7th February 2017 Lords Chamber

Moved by

[Lord O'Shaughnessy]

1: Before Clause 1, insert the following new Clause—
“Remuneration for persons providing special medicinal products: England
In section 164 of the National Health Service Act 2006 (remuneration for persons providing pharmaceutical services), after subsection (8) insert—“(8A) Regulations may impose requirements in relation to remuneration in respect of special medicinal products.(8B) Such regulations may, for example, require determining authorities to ensure—(a) that remuneration is to be calculated by reference to the outcome of prescribed procedures, or(b) that determinations do not provide for or permit remuneration to be paid in prescribed circumstances.(8C) Procedures prescribed by virtue of subsection (8B)(a) may include the person to whom remuneration is payable, a health service body or a determining authority—(a) carrying out inquiries to ensure that remuneration is reasonable, or(b) estimating an amount of remuneration that is reasonable (whether or not the estimated amount corresponds exactly to expenses in respect of which remuneration is to be paid).(8D) Circumstances prescribed by virtue of subsection (8B)(b) may include circumstances in which special medicinal products are made available to persons who provide pharmaceutical services under this Part—(a) by a health service body, or(b) under an arrangement for the supply of special medicinal products to which a health service body is a party.(8E) In subsections (8A) to (8D)—“health service body” has the meaning given by section 9(4);“special medicinal product” means a product which is a special medicinal product for the purposes of regulation 167 of the Human Medicines Regulations 2012 (S.I. 2012/ 1916).””

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

My Lords, I am bringing forward this amendment and others in this group in response to the matters relating to specials raised in Committee by the noble Baroness, Lady Finlay, who regrettably is not able to be here with us today, the noble Baroness, Lady Masham, and others. I must thank noble Lords for the work they have done to explore these issues by bringing them forward for debate in a most constructive manner. I also take this opportunity at the start of Report to thank noble Lords for the generally constructive debate in Committee, and in other meetings since then.

A special is a medicine manufactured to meet the specific needs of a specific patient. By nature they are bespoke and therefore do not have the same economies of scale during manufacture and distribution as licensed medicines. In Committee, the noble Baroness, Lady Finlay, presented a strong case that the current arrangements for reimbursement of specials are not sufficiently effective at securing value for money for the NHS. In England, reimbursement prices for the most commonly prescribed specials are listed in the drug tariff. Those reimbursement prices are based on sales and volume data, which the department currently obtains from specials manufacturers under a voluntary agreement. By setting a reimbursement price we encourage pharmacy contractors to source products as cheaply as possible because it allows them to earn margin, which in turn creates competition in the market. As a result, reimbursement prices decrease. Since these reimbursement arrangements were introduced in 2011, we have observed that in England the average cost for specials listed in the drug tariff decreased by 39% between 2011 and 2016.

Basing reimbursement prices on selling prices from more manufacturers than we do now would make the reimbursement system more robust. For specials, we currently rely on information from those manufacturers that have signed up to our voluntary agreement. There have been talks with NHS manufacturers to provide information on a voluntary basis. However, we have not been successful so far in securing data from NHS manufacturers on this basis. The Bill would enable us to retrieve information from all manufacturers, including NHS manufacturers. Once we receive data from NHS manufacturers, we will be able to assess whether it is appropriate to include them in calculating reimbursement prices.

However, through our very constructive debates on previous stages of the Bill and the further discussions I have had with the noble Baronesses, Lady Finlay and Lady Masham, I am persuaded that we need to do more. The unique nature of specials and their manufacturing arrangements means that we need to do more to ensure that the prices paid by the NHS represent good value for money for all these products. I am therefore bringing forward amendments that will enable alternative approaches to be developed to address this issue.

The amendments make changes to Section 164 of the NHS Act, which relates to the remuneration of persons providing pharmaceutical services. Proposed new subsection (8A) provides for a new regulation-making power in respect of special medicines. This would enable us to develop options that will secure the improved value for money that we all wish to see. Proposed new subsections (8B), (8C) and (8D) go on to provide illustrations of how that power might be used but do not restrict its application to those approaches.

A number of different options may be considered. The example the noble Baroness, Lady Finlay, gave in Committee, drawing on the Scottish experience of using a quotes-based system, may be one option, although we recognise the potential difficulties with such an approach—in particular, the burden it may place on the pharmacist, who has to seek the quotes, and the potential delay it may cause to patients getting their medicines. We will draw on the Scottish experience and the knowledge and expertise of stakeholders to develop and clarify the options.

I reassure noble Lords that we are legally obliged to consult the body that represents those providing pharmaceutical services—dispensing contractors—the Pharmaceutical Services Negotiating Committee, and will consult other interested stakeholders before making a decision.

I hope your Lordships will understand that, at this stage, I am bringing forward a legislative framework which I believe to be fully justified by the need for action that was so clearly expressed by the noble Baronesses, Lady Finlay and Lady Masham, and other noble Lords. The detail of any new arrangements will need to be drawn up and consulted on with those who represent providers of pharmaceutical services, but I can give every assurance that I fully intend to explore the options provided by these powers to improve value for money for the NHS, which I know we all wish to see.

I thank the noble Baronesses, Lady Finlay and Lady Masham, and other noble Lords for bringing this matter forward. I beg to move.

[Baroness Masham of Ilton (CB)]

My Lords, I thank the Minister for his helpfulness and the work he has done on this amendment about specials. I also thank him on behalf of my noble friend Lady Finlay of Llandaff, who has to help her pregnant daughter who has had an emergency health problem. She had hoped to be here. I hope this amendment will help patients get the specials they need at a reasonable price.

[Baroness Wheeler (Lab)]

My Lords, I am the third person to congratulate the Minister. I add the support of these Benches for these amendments, which address unlicensed special medicines, and I congratulate the noble Baroness, Lady Finlay, on her tenacity in pursuing this issue and securing an important concession from the Government. I am sorry she cannot be here, but we can be pretty sure she will be reading Hansard to make sure we have got it right.

It has been hard to understand why the Government were refusing to recognise the need for urgent action on medicinal specials, particularly in view of the substantial price variation between hospital and community care, the many patients in community and primary care who are currently denied access to some specials, and the potential savings across the NHS that introducing a cheaper and more cost-effective whole-market procurement system will provide.

We are very pleased that the Minister has now recognised the need for the Bill to address this important issue in England and Wales. I welcome the legislative framework he has presented. As he pointed out, he has an extensive consultation exercise to conduct on all parts of the Bill, and this will certainly be included in that.

[Lord O'Shaughnessy]

I am truly touched to have been thanked personally by proxy by two noble Baronesses. I am grateful for that, and I am grateful for the support for these amendments, which are a testament to the tenacity of the noble Baroness, Lady Finlay.

I do not think it is quite fair to say that the Government did not recognise the need for action. The amendments tabled by the noble Baroness, Lady Finlay, disinterred a work programme that had been put on pause in order to deal with the Bill and discovered that lots of interesting work and thinking was going on, so we have been able to bring that to the fore, which is a fantastic thing, and the way legislation should work.

Amendment 1 agreed.

Moved by

[Lord O'Shaughnessy]

2: Before Clause 1, insert the following new Clause—
“Remuneration for persons providing special medicinal products: Wales
In section 88 of the National Health Service (Wales) Act 2006 (remuneration for persons providing pharmaceutical services), after subsection (8) insert—“(8A) Regulations may impose requirements in relation to remuneration in respect of special medicinal products.(8B) Such regulations may, for example, require determining authorities to ensure—(a) that remuneration is to be calculated by reference to the outcome of prescribed procedures, or(b) that determinations do not provide for or permit remuneration to be paid in prescribed circumstances.(8C) Procedures prescribed by virtue of subsection (8B)(a) may include the person to whom remuneration is payable, a health service body or a determining authority—(a) carrying out inquiries to ensure that remuneration is reasonable, or(b) estimating an amount of remuneration that is reasonable (whether or not the estimated amount corresponds exactly to expenses in respect of which remuneration is to be paid).(8D) Circumstances prescribed by virtue of subsection (8B)(b) may include circumstances in which special medicinal products are made available to persons who provide pharmaceutical services under this Part—(a) by a health service body, or(b) under an arrangement for the supply of special medicinal products to which a health service body is a party.(8E) In subsections (8A) to (8D)—“health service body” has the meaning given by section 7(4);“special medicinal product” means a product which is a special medicinal product for the purposes of regulation 167 of the Human Medicines Regulations 2012 (S.I. 2012/ 1916).””

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[Lord Patel (CB)]

My Lords, I support this amendment, to which I have added my name. I do not agree with the noble Lord, Lord Lansley, that the second part of the amendment is not crucial. I take a completely opposite view. I consider that that is the crucial part of the amendment. The proposed new paragraph (b) refers to the need to,

“ensure that patients have rapid clinical access to new clinically effective and cost-effective medicines and treatments approved by the National Institute for Health and Care Excellence through their technology appraisal process”.

The terms “clinically effective” and “cost-effective” are important. I would insert the word “thorough” so that the amendment reads “thorough technology appraisal process”. That is what NICE does. That is what we set it up to do. Parliament agreed that if NICE approved a drug that was cost effective and clinically effective, it should be available to patients. Now we are saying that that should occur only if certain provisions apply, and in certain circumstances they do not. So what are we saying? What message are we sending out if NHS patients cannot get medicines and treatments that are deemed to be clinically effective and cost effective, including drugs and treatments developed by our own scientists and produced by our own life sciences industry? People from our own industry have told me that when the NICE-approved drug is not available in the United Kingdom and we try to market it in other countries, their competitors say, “Why is it not available in your country when you’re trying to persuade us to use it?”. As has been said, many drugs are often available in countries such as Germany, France, Canada, Austria and many others that are not available in the United Kingdom. The noble Lord, Lord Hunt of Kings Heath, mentioned cancer drugs that are not available. Some would say that that leads to the poor cancer outcomes in our country compared with those in some other countries.

Recent proposed changes relate to the budget impact threshold of £20 million over two years. The noble Lord, Lord Lansley, is right that this sword has two sharp edges. Whichever way you tackle it, the patient gets hurt. Around 20% of new treatments with a positive NICE recommendation could have their introduction delayed if we adopt NHS England’s new proposals. For example, about 35,000 patients suffer from secondary or metastatic breast cancer. However, a drug costing £1.56 per patient per day would meet the budget impact threshold of £20 million. It would therefore be delayed for introduction to treat these 35,000 patients. For most of them, their life—quality life—could be prolonged by about six months to a year, but they will be dead before the drug is made available at a cost of £1.56 per patient per day. That is what this proposal of £20 million means. It is a budget impact threshold.

People with rare diseases will fare even worse. There are about 7,000 known rare diseases. Treatment exists for only about 5% of those patients. The British company Shire, for example, has about 30 products in its pipeline to treat rare diseases. But why would it manufacture them at some cost when it might find that it falls foul of the new arrangements even if the new drugs prove effective?

I recognise the economic challenges that the NHS faces. I have heard the 20,000 pages of evidence given to the committee that I chair on your Lordships’ behalf and which we will soon be publishing. We need a system that prepares the United Kingdom to deliver the next generations of innovative medicines, including gene and cell therapy. If we are going to do that, it is important that pharma and the industry have certainty of patient access. That is crucial when companies make decisions on new investments in research and manufacturing.

Regarding proposed new paragraph (a), I would simply say that as we prepare to leave the EU, the delivery of an internationally competitive industrial environment for the bioscience and life science sectors is more important than ever. By making it more difficult for patients to access highly innovative, first-to-market, cost-effective and clinically effective medical products, we not only deny our patients the treatment they need but risk the future of our world-leading life science industry. I am sure we do not want to do that.

The Prime Minister’s industrial strategy, which will invest in science, research and innovation, has already been mentioned. The life science sector—not the pharma industry, which the noble Lord, Lord Warner, mentioned —brings in over £60 billion a year and employs over 220,000 people. British science, with investment in genomics, gene sequences, diagnostics, and now the production of gene and cell therapy, is again investing huge sums of money. To promote this, the Higher Education and Research Bill, which is currently going through your Lordships’ House, creates UK Research and Innovation to do research and innovate therapies, all of it in life science. As to our charity sector, the Wellcome Trust invests probably in the region of £1.3 billion a year in science, which will go to innovation. Cancer Research UK is about to announce four grand challenges. It makes awards of £20 million to find causes and treatments for cancer, and the British Heart Foundation also makes an enormous investment.

Hitherto we have had a pact that operates for the public, the NHS, the scientists and the industry on the availability of medicines and treatments for both diagnosis and treatment, delivered at a cost that is fair, transparent and appropriate. When we break that pact by not making available treatments to patients even though they are cost effective and clinically effective, we are denying treatment to many patients. The fundamental basis of the pact—which Parliament approved when agreeing to how NICE should operate—is that if NICE deems that a medicine is cost effective and clinically effective, patients should get it. That is why I strongly support the amendment.

[Lord O'Shaughnessy]

My Lords, I am grateful for the quality of the debate on this amendment. Before I turn to the specifics of the amendment, I join noble Lords in reflecting on the success of the UK life sciences industry. The UK has a lot to be proud of. We have a world-class science base and an excellent reputation for the quality and rigour of our clinical trials and the data they produce. The UK has one of the strongest life sciences industries in the world, generating turnover of more than £60 billion each year. Indeed, it is our most productive industry. This Government are deeply committed to supporting that industry to flourish and, in doing so, to provide jobs and transform the health of the nation. That is why it was a Conservative-led Government which introduced the first life sciences strategy in 2011.

More recently, we have introduced a range of measures through the taxation system to create good conditions for business growth and to encourage business investment. These include: R&D tax credits for small and medium-sized enterprises; R&D expenditure credit for larger firms; the patent box; a permanent annual investment allowance; and the seed enterprise investment scheme, the enterprise investment scheme and the venture capital trust scheme, as well as entrepreneurs’ relief.

Take just one of those examples: the patent box. Phased in from 2013, under a Conservative-led Government, it incentivises companies to develop and manufacture new, innovative patented products in the UK by giving an effective 10% corporation tax rate on UK profits derived from the product’s qualifying UK and EU patents and equivalent forms of intellectual property. In 2013-14, a total of 700 companies claimed relief under the patent box, with a total value of £342.9 million, with 64% of those in manufacturing. In 2013, GSK decided to invest more than £500 million in the UK after the patent box was announced. Its CEO Sir Andrew Witty said:

“The introduction of the patent box has transformed the way in which we view the UK as a location for new investments”.


The Government’s R&D tax credit is one of the biggest sources of financial support for innovative UK companies and one of the most competitive in the world. It is widely commended and, in 2014-15, almost 21,000 companies claimed tax relief, totalling £2.45 billion, with R&D expenditure used to make these claims reaching £21.8 billion. The Autumn Statement announced £4 billion of additional investment in R&D, specifically targeting industry-academia collaboration, which is so important in the life sciences. We would expect the life sciences industry to be a substantial beneficiary. I am sure your Lordships will agree that these are bold, new, high-value measures which demonstrate that the Government are serious about attracting inwards R&D investment into cutting-edge industries like the life sciences.

This determined action is reaping rewards. The UK ranks top in major European economies for foreign direct investment projects in the life sciences. Just last week, Danish drugs company Novo Nordisk announced a new £115 million investment in a science research centre in Oxford. This comes on top of £275 million additional investment announced by GSK in June and AstraZeneca reaffirming its commitment to a £390 million investment in establishing headquarters and a research centre in Cambridge. As the noble Lord, Lord Patel, mentioned, we are also working on the creation of UK Research and Innovation to enhance this further. These are examples of the positive policy changes that are supporting the life sciences industry and transforming the health of our nation.

Looking ahead, Professor Sir John Bell, whom several noble Lords have mentioned, has agreed to lead the development of a new life sciences strategy for the long-term success of the UK. The formation of the strategy will bring together broad representation from across the sector, including from industry, charities, academia and the health and care system. It is aligned with the industrial strategy announced recently by the Department for Business, Energy and Industrial Strategy. The strategy will outline what the life sciences industry can deliver for the UK economy and for UK patients and set out what actions government needs to take to set the framework on the road to success. Building on a sector deal for this diverse and complex sector, the life sciences strategy will be bold and ambitious as befits the needs of a global Britain. We will seek to make the UK the global home of medical innovation, creating jobs, improving health outcomes and transforming the NHS.

As all noble Lords have mentioned in the debate today, the issue of access to or uptake of new medicines in the NHS must be a key part of that life sciences offer. I recognise and share the desire of noble Lords to ensure that the NHS is at the forefront of innovation, and that medicines which have been approved by NICE are made available quickly to the patients who could benefit from them. This Government have been very active in improving access, and have already taken a number of important steps to do so. The early access to medicines scheme, introduced in 2014, provides a platform for drugs that do not yet have a licence to get to patients at a much faster rate than before. We have now seen 29 promising innovative medicine designations, and 10 positive scientific opinions have been awarded by the MHRA, the regulator. As my noble friend Lord Lansley mentioned—and I must give him credit for the introduction of this policy—the cancer drugs fund, created in 2011 and renewed in 2016, has provided over 95,000 patients with access to innovative cancer drugs that would otherwise not have been available.

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[Lord O’Shaughnessy]

The treatments become available throughout the NHS from three months after the appraisal.

[Lord Hunt of Kings Heath]

My Lords, given that I took the order through Parliament many years ago, I can confirm that the whole intention was that the NHS had 90 days to prepare for funding a medicine that had been designated by NICE as both clinically and cost effective. The problem is that, subsequently, in particular over the past few years, clinical commissioning groups have done everything they can to avoid this responsibility. Alongside that, the purity of the 90-day rule is being eaten into, and that is at the heart of the concern of this amendment.

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[Lord O'Shaughnessy]

My Lords, I am grateful to my noble friend Lord Lansley for bringing this amendment and for the opportunity to talk about the intentions of the Bill. He is quite right to highlight that the reason for bringing the Bill forward is to stop the behaviour of switching between schemes in order to reduce liabilities. That has characterised behaviour in the past few years and has had an impact on the successful operation of the PPRS. I will discuss the PPRS towards the end of my speech.

Amendment 4 is about the relationship between the voluntary and statutory schemes. I thank noble Lords for their views in this area. This amendment would require us to secure that, for any given product, the voluntary and statutory schemes would have an equivalent impact. It presents a slightly different approach to securing equivalence between the voluntary and statutory schemes, but I understand that, fundamentally, equivalence is what the amendment is seeking to achieve. I gave my views on this matter in Committee and I am happy to respond in similar terms on this occasion.

The Government’s intention is for the two schemes to deliver a broadly equivalent level of savings as a proportion of the total sales covered by each scheme. However, to require the terms of each scheme to be the same, in so far as possible, is inappropriate and would restrict the scope of the two schemes to operate in a complementary manner. Requiring equivalence to operate at product level, as the amendment suggests, would be even more restrictive.

The voluntary scheme is a matter for negotiation with industry. As such, there is scope to have a range of measures included that reflect the priorities of both sides at any point. It may be helpful to the House if I reiterate some of the examples I set out in Committee. The current voluntary scheme, the PPRS, includes a range of provisions, developed through negotiation with industry, that sit alongside the payment mechanism. This includes price modulation, which enables companies to put prices up and down as long as the overall effect across their portfolio is neutral. This has commercial value to companies, which may be willing to accept a higher payment percentage as a result.

In another example, while new medicines in the PPRS are excluded from PPRS payments, the PPRS payment percentage level itself is set at a level to achieve the agreed level of savings across both new and older medicines. This means that each company’s share of the income due to government will vary depending on the balance of new and old products in their portfolio, with companies that have mainly new products paying less than companies with mainly old products. However, it would be very challenging to replicate this model in the statutory scheme, as many fewer companies are affected by the statutory scheme regulations than are members of the PPRS. As a result, there is a much smaller pool of companies with older products. To achieve the same level of savings overall from the statutory scheme as from the PPRS while exempting newer products would require an extremely high payment percentage. This provides an example of where minor differences in terms may be required in order to deliver an equivalent level of savings across the two schemes overall. As noble Lords know, as we discussed in Committee and as I now repeat, the detail of how any future statutory scheme will work will be subject to further consultation.

As was discussed here and in the Commons, the freedom to negotiate the voluntary scheme has been valued greatly by both industry and government. As the noble Lord, Lord Hunt, reminded us, I said as much in Committee. Our intention for the future of the PPRS is to work collaboratively and constructively with industry on future medicines pricing arrangements when the current PPRS comes to an end.

[Lord Hunt of Kings Heath]

This time, will NHS England be a full partner in the discussions and negotiations? Clearly, unless it owns the solution as well, you have the problem that an agreement can be reached but it does not quite translate itself into action on the ground. I realise that this is traditionally a negotiation between the Department of Health and the industry but it would be useful if NHS England were fully part of that.

[Lord O'Shaughnessy]

The noble Lord makes an excellent point. Clearly, as the budget holder, NHS England ultimately must be a key part of negotiations for any future schemes. We intend that any future voluntary scheme should be established through negotiation in this way, but linking the payment mechanisms would inevitably place a restriction on that freedom.

I am grateful to my noble friend for raising this issue and I hope I have reassured him on equivalence, while also explaining why I believe the amendment goes too far by focusing specifically on products. On that basis, I ask my noble friend to withdraw his amendment.

[Lord Lansley]

I am grateful to my noble friend for his helpful response setting out the Government’s continuing position. The exchange with the noble Lord, Lord Hunt, was also useful. I said in debate on the previous group that earlier engagement and development of NHS England’s role in trying to assess what is a reasonable price and what is the value proposition in relation to new medicines that are being adopted by the NHS would be helpful at the same time in trying to develop the shape of a new voluntary scheme. I am sure that the industry, having been frustrated in the outcome of the 2014 PPRS, would want the principles for 2019 to be broadly similar: freedom of pricing and introduction; the ability to modulate prices in the way my noble friend referred to; the Government’s desire for a stable overall budgetary outcome; but also access to new medicines and diffusion across the NHS.

If we are going to meet those principles together—and balance them, as we discussed in the last group—NHS England should be at the table when the scheme is being designed. I am sure it was frustrating in the previous scheme that Scotland and Wales had identifiable resources for access to new medicines and NHS England had those resources but not in an identifiable form. It would be helpful for the new scheme to see the rebate, if it is rebated scheme, being specifically directed towards promoting access. I do not think that that is an unreasonable objective.

That said, the Minister has very kindly reiterated that the Government consider it desirable to have broadly equivalent proportions of sales in the two schemes being rebated and not disaggregated to product level. I can see that if you disaggregate to product level, you have a problem with price modulation between products for companies. That is a practical issue. However, as an inevitable consequence of the Government’s approach to equivalence, the schemes will not be the same. Generally speaking, once the legislation goes through, the statutory scheme will be less attractive.

That may well be the Government’s intention. Indeed, the Government may well like to have a situation where they can encourage companies to provide the necessary payments back through the rebate in the voluntary scheme with the threat of putting them into the statutory scheme. That might be something that the Government have occasionally thought of doing. I do not think that it is a desirable situation. The effort—I put it at no more than that—to define the equivalence of the two schemes should be a continuing effort. I know my noble friend the Minister has that in mind. It is not his intention to create two schemes that diverge in ways that could potentially be difficult for the industry if the Government were so minded in that direction.

It has been a useful debate but I certainly do not want to pursue it any further. We have had two opportunities to explore important issues that, frankly, we should attempt to resolve in the design of the new scheme rather than in legislation. I beg leave to withdraw Amendment 4.

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[Lord Lansley]

Amendment 5 refers back to the discussion we had on Amendment 3 about the duties that the Secretary of State must meet in relation to the scheme. This is another aspect of that but a more particular one.

In Committee, I explored the idea that the Secretary of State should pursue through the voluntary scheme—or indeed the statutory scheme, as necessary—pricing that was related to value. There were a number of criteria for what value is. In response to that, my noble friend said that many of the aspects that constitute value are reflected in existing statutory duties. For example, in Section 266(4) of the National Health Service Act, which is concerned with the price control mechanisms we are amending through this legislation, the Government are required to bear in mind,

“the need for medicinal products to be available to the health service on reasonable terms”—

the value proposition and access proposition that we have just been debating—and,

“the costs of research and development”,

which of course are important to the industry in promoting innovation. We do not need to replicate those. But my noble friend the Minister also said that there were other statutory duties: for example, that under Section 233 of the Health and Social Care Act NICE is required to have regard to,

“the broad balance between the benefits and costs of provision … the degree of need … and … the desirability of promoting innovation”—

all of which are indeed very much part of the overall value proposition. But because they are statutory duties relating to NICE, they are not necessarily factors that the Secretary of State must have regard to in the formulation of the PPRS, which is what we are dealing with here.

The purpose of Amendment 5 is to say that there are these existing statutory duties applicable to the Secretary of State. Separately, there are statutory duties applicable to the National Institute for Health and Care Excellence. The Secretary of State, when making a scheme and reporting on such to Parliament, should state how those statutory duties, both in respect of the Secretary of State and as they might impact on NICE, could be met through the design of the scheme. In that sense, it is a mechanism for trying to ensure that the value proposition gets to the heart of the assessment of what the price control mechanism should seek to achieve. I beg to move.

[Lord O'Shaughnessy]

I am grateful to my noble friend for his amendment and for raising the issue of reporting requirements and how that relates to the responsibilities of NICE.

Under the current PPRS, the Department of Health regularly publishes information relating to the operation of the voluntary scheme. For a future statutory scheme, as my noble friend is aware, the illustrative regulations, which we have published alongside the Bill to assist in scrutinising the provisions, already include regulations for both the statutory scheme, in Regulation 32, and the information regulations, in Regulation 14, for an annual review of the regulations and a requirement to publish our report of each review. Our illustrative regulations require an annual review to,

“set out the objectives intended to be achieved … assess the extent to which these objectives are achieved; and … assess whether those objectives remain appropriate”.

These requirements will be tested through the consultation on the regulations and we will of course take account of those views.

I assure my noble friend that that review would take into account the duties under Section 266(4), which currently are,

“the need for medicinal products to be available for the health service on reasonable terms, and … the costs of research and development”.

Of course, subject to further consideration of the Bill, there may be further duties. I accept that reporting is an important principle but setting out the requirements in primary legislation is too restrictive. Over time, it is to be expected that both the statutory scheme and the information requirements will be amended through their respective regulations to reflect changing circumstances. It is essential that the review and reporting arrangements be able to be similarly flexed, so that they remain appropriate to the schemes in operation. My noble friend has suggested that we report every time there is a new voluntary or statutory scheme. I believe the annual reviews as set out in the illustrative regulations would provide more frequent review than the amendment proposes, at least for the statutory scheme.

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Moved by

[Lord O'Shaughnessy]

6: Clause 5, page 4, line 6, at end insert—
“( ) In section 272(6)(orders, regulations, rules and directions subject to affirmative procedure), after paragraph (a) insert—“(aa) the first order under section 260,”.”

[Lord O'Shaughnessy]

My Lords, in Committee we debated the Government’s existing powers to control the prices of medical supplies. I have listened carefully to the concerns expressed by noble Lords and tabled this government amendment to address them. Before I go into more detail about the amendment, I would like to take the opportunity to address some concerns raised in Committee about the definitions used in the Bill, including that of medical supplies.

The Bill refers to health service products, which is the overarching term for medicines, medical supplies and other related products used in the health service. The term “medical supplies” is used in the NHS Act 2006 and the existing definition covers a broad range of medical supplies, from bandages to MRI scanners. It could include ambulances, to answer a question asked in Committee by the noble Lord, Lord Warner. “Other related products” are those which are not medicines or medical supplies but are prescribed in the NHS—for example, vitamins. The Government have powers to control the costs of health service medicines and the prices of medical supplies. If the Government were to introduce any controls on those prices then we would, of course, need to define which supplies the control would apply to. This would be done within the regulations. Similarly, in the information regulations we will specify which medical supplies and other related products will be covered. These regulations will, of course, be subject to consultation.

The illustrative regulations published alongside the Bill give examples of the categories of medical supplies and other related products on which we would expect information to be kept, recorded and provided. For example, one category includes those medical supplies and other related products listed in the drug tariffs. As noble Lords know, the illustrative regulations are not in their final form and have been provided to demonstrate how we would specify which products are covered by the regulations. We have already started discussions with representative bodies of the medical devices industry about how we could restrict the types of medical supplies and other related products that the regulations cover. It is not our current intention, for example, to include ambulances in the regulations. We will carry a formal consultation to consider the products that need to be covered.

While I am still on definitions—please bear with me—the Bill also refers to UK health service products and English health service products. This reflects that the Bill has some aspects that are reserved and others that are devolved. While medicine pricing is a reserved matter with respect to Scotland and Wales, reimbursement is a devolved matter. I acknowledge that the distinction between reserved and non-reserved matters adds complexities, not least for me, but I assure noble Lords that the definitions are consistent and in line with the existing provisions of the NHS Act 2006. I hope that this explanation helps noble Lords to understand those definitions.

Regarding Amendment 6, which I have tabled, I understand the views expressed by some Peers asking why the Government need the powers to control prices of medical supplies when they are not using those powers. In the words of the noble Lord, Lord Hunt, it is a question of proportionality. At this moment, the Government have no immediate concerns about the prices of medical supplies as it appears that the market is generally competitive. Nevertheless, noble Lords will be aware of the work of the noble Lord, Lord Carter, on efficiency and variation in the NHS—indeed, it has been referenced today—and the work being done to implement that report. He concluded that there is considerable variation between trusts on the value that they extract from the procurement of goods and services, so while the market may be competitive the NHS could be getting better value for money for the products it buys. This is one area where the information powers in the Bill, which will not be burdensome, could help the NHS to save money. Again, I know that we all share this goal.

We also know that markets can dysfunction for any number of reasons and that competition will not always operate to control prices. This is the unfortunate situation we have found ourselves in with unbranded generic medicines, which the powers in the Bill will help us to deal with. I continue to believe that the Government should have the ability to intervene but only when a market is not working. As noble Lords know, as part of the 2006 Act the Government already have the power to introduce price control schemes into the medical supplies sector but concern was expressed in Committee that these powers, and how they are developed in the Bill, are not proportionate. As I have set out, we have no concerns about the current operation of the medical supplies market, so noble Lords justifiably asked whether some additional threshold or hurdle should be required before the introduction of any price control scheme in this sector.

I have listened to their concerns, which have much merit, and so have tabled this government amendment so that the first order to control the prices of medical supplies would be subject to the affirmative procedure. The order would then require the formal approval of both Houses of Parliament before it becomes law and there would be debates on the proposals, in which the Government would have to justify their case for action. This means that if the Government want to introduce a pricing scheme, they would have to convince Parliament that there were sufficient grounds for doing so. I am very grateful to many noble Lords for their engagement on this issue and I trust this amendment meets the concerns raised. I hope that noble Lords across the House will be able to agree to it.

[Lord Warner]

My Lords, I am grateful to the Government for taking some modest steps in the direction we were asking them to take in Committee. My sympathies are entirely with the Minister, who had to bring forward this amendment and explain it in the way he did. It shows what a tangle the Government have got themselves into by taking some powers which they are not sure they will need but which the noble Lord, Lord Carter, may suggest they need. It represents a decision by the Government that, when they think the NHS cannot tender and run a proper competition, they will be willing to step in to control the price of a product when the NHS has failed to do proper purchasing.

This is a pretty big step because the noble Lord, Lord Carter, has shown that chunks of the NHS are not terribly good at tendering and purchasing. Are we now going into the kind of Soviet era that the noble Lord, Lord Hunt, painted a picture of on a previous amendment, in which the Government are going to step in whenever they have evidence that there is a pretty lousy trust down in Little Cullompton or wherever and start to control the price of a number of medical devices? I do not think I have exaggerated where the Government are using this legislation to take them. It seems pretty peculiar. Can the Minister reassure me about whether the Government have big plans to go about this and tell me what evidence they have that it is a serious problem?

[Lord O'Shaughnessy]

I thank the noble Lord, Lord Warner, for the lukewarm endorsement of an attempt to improve the Bill. We seem to have zipped from socialism to communism, which for a Conservative is a fairly terrifying idea. The noble Lord raises an important point. I am not in a position to comment on the provenance of the Bill as I was not around. He is right to focus on the issues of procurement and competition. It must be the policy intention to make sure that competition works the best it can. In the generics market, we found an instance of where that is not working. Through the much-referred-to Sir John Bell, the industrial strategy is looking at issues around the manufacture of generics, biosimilars and so on, which, as the noble Baroness, Lady Walmsley, said earlier, has the ability to reduce prices through competition.

Equally with procurement, there is the NHS supply chain. The feedback is that it could do a lot better. A lot of work is going on on the future operating model—another piece of jargon. It is a thorough piece of work that is getting a lot of scrutiny to make sure that it can deliver the kind of savings that the noble Lord talks about. I agree that there are other things that a Government must do to make markets work better. It is for that reason that I insisted that the amendments we have brought forward today should involve an affirmative resolution. When they introduce the first scheme, the Government are going to have to justify exactly what they have done to make competition work, why the procurement is not working and what is going on. Obviously, I cannot anticipate at this point what that might look like. Given the experience we have had with generics, I do not think it unreasonable for that power to be there. Indeed, the power is already in the 2006 Act. This Bill circumscribes that power and makes it more reasonable. I hope I have been able to persuade the noble Lord, Lord Warner, that we are not slipping into communism, that the Government are taking a reasonable approach that understands the importance of markets, and that this power would be used only in situations where it could be justified when interventions to improve competition and procurement have not worked.

Amendment 6 agreed.

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[Lord Warner]

My Lords, from time to time I have been approached by plasma companies and vaccine companies about supply issues, particularly where there have been changes in the structure of the industry and a reduction in the number of producers of some of these products, and sometimes on the point of whether British companies may start to go out of business because of some of those structural changes. My question to the Minister is whether the amendment would actually help enable the Secretary of State to deal with some of those supply problems when this becomes an issue. It becomes an issue for those patients who really need that particular product when no other will do. Is this the kind of amendment that would help with these supply problem areas, which to my knowledge have been experienced from time to time, particularly in plasma and vaccine areas?

[Lord O'Shaughnessy]

My Lords, I am grateful to my noble friend for his amendment and for providing the opportunity to talk about this important issue. It is important to note that the substance of this amendment is different from the substance of the amendment that was tabled in Committee, which would have given a blanket exclusion, while this is much more about providing the Secretary of State with the opportunity to exercise his or her judgment to exempt a product.

I absolutely appreciate the intent of the amendment, and reassure my noble friend that we believe it unnecessary. Due to the powers in the 2006 Act, the Secretary of State already has the ability to exempt individual products or groups of products from the terms of any statutory scheme, so this amendment would duplicate existing powers. For example, the Secretary of State uses these powers in the current statutory scheme to exempt products already under a contract or framework agreement. It is currently the Government’s intention that under the new statutory scheme, products procured under framework agreements that were entered into prior to the regulations coming into force would be exempt from the pricing controls and payment mechanism. However, branded products procured after the regulations come into force would be subject to the pricing controls and payment mechanism. Like any other cost, companies would be able to take this into account when proposing a price in response to a new tender. The regulations will of course be subject to consultation.

The point here is that there may well be cases where an exemption is required, and noble Lords have given examples of what that might look like. I hope your Lordships would agree that it would not be responsible for me to try and set out a list of them now, but clearly there will be occasions where that might be necessary. Any statutory scheme must of course also be sensitive—as indeed the legislation demands that it is—to the differing R&D costs that apply to the development of different medicines.

I hope that provides some reassurance on the points that noble Lords have made. We would be able to use the powers that already exist in the creation of the new statutory scheme for whichever purposes are desired at the time. On that basis, I ask my noble friend to withdraw his amendment. I hope those reassurances have done the trick.

[Baroness Walmsley]

My Lords, before the noble Lord sits down, is he able to respond to the issue about biosimilars, which I raised in an earlier debate and which the noble Lord, Lord Hunt, has just raised?

[Lord O'Shaughnessy]

I thought I had, when I talked about taking into account the differing R&D costs, which I think was the substance of the point made by the noble Baroness and the noble Lord, Lord Hunt. We have to take into account both getting a good price and the R&D costs, and that needs to be reflected within a statutory scheme, and would clearly apply to the case in point.

[Lord Lansley]

I am grateful to my noble friend and completely understand that at this stage it would be inappropriate to try and itemise in any way how the Secretary of State’s discretion to exempt products or categories of products could be used. I am grateful for what my noble friend said because it is clear that while some companies opt into the voluntary scheme, we will arrive at a situation where, in effect—force majeure—other companies with other products are in the statutory scheme without any choice in the matter. They should come out of this debate with the confidence that they can make their case to the Government. We have seen some really good examples, and I am grateful to the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt. Biosimilars clearly have a case to make about the structure of the scheme and how it applies to them in relation to this.

As the noble Lord, Lord Warner, mentioned, the cost structure of plasma product therapies and things of that kind is very different from the cost structure of many other branded medicines that enjoy their patent life. To that extent, recognising their cost structure might require an exemption from the PPRS as it stands at the moment. We cannot just seek some of those products, particularly some of the blood products we are talking about, in isolation in Britain. There is a limited supply. We import them from abroad, and there are sometimes higher prices in other markets. It is absolutely necessary for us sometimes to say, for security of supply reasons, that this product, this tender process or this framework agreement for the delivery of products of this kind is exempted from the PPRS in the future. It does not automatically follow that they will be included. However, I gather from what my noble friend says that the power is there to do this and that this will be considered, as and when, on its merits. On that basis I certainly seek leave to withdraw Amendment 7.

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[Lord O'Shaughnessy]

My Lords, I am grateful to the noble Lord, Lord Hunt, for his amendments. I shall speak to government Amendments 9, 11, 25 and 26 relating to information notices and appeals, and will refer to Amendments 8, 10 and 12 tabled by the noble Lord.

We had a good discussion in Committee about the information powers. My noble friend Lord Lansley proposed information notices with a right of appeal; the noble Lord, Lord Warner, proposed to place certain restrictions around the Government’s ability to collect information on profits; and the noble Lord, Lord Hunt, proposed that those restrictions be in the form of “triggers”. As I hope noble Lords will know from the individual meetings that I have had the chance to have with them, I have been listening carefully to what has been said and I am conscious of the importance of proportionality in the Bill. In particular, I have reflected on the suggestion from the noble Lord, Lord Hunt, that we may be able to combine these different ideas into a workable solution that would deliver the sort of safeguards that I believe noble Lords are seeking. The government amendments that I have tabled would do precisely that.

There was broad agreement in Committee that the Government should be able to collect the information required to reimburse community pharmacies and to operate our cost-control schemes for medicines as effectively as possible. That includes straightforward information about sales income actually received or the amount actually paid in relation to health service products at each point in the supply chain. We already collect much of this information now under a mix of voluntary and statutory arrangements, including scheme M, scheme W and the community pharmacy margin survey.

We have discussed previously that our current arrangements need to be strengthened. The changes proposed by the Bill would allow us to expand routine collections to inform reimbursement prices. They would enable us to use data from more companies, make the reimbursement of community pharmacies fairer and more robust and set reimbursement prices for more products. Setting reimbursement prices leads to more competition—whose merits we have discussed—as pharmacies are incentivised to source the products as cheaply as possible, allowing them to retain a margin. That in turn helps us to keep the drugs bill down.

However, I have heard the concerns raised by noble Lords in relation to the collection of information on the profits associated with particular products. The noble Lord, Lord Warner, spoke about his concern that it would be burdensome for the pharmaceutical industry to apportion certain operating, development or manufacturing costs to individual products. The government amendments that I have tabled would address that concern. Amendments 11, 25 and 26 would introduce the requirement in regulations for the Secretary of State to issue an information notice for the collection of information on the costs incurred by a producer in connection with the manufacturing, distribution or supply of UK health service products. The exception to that requirement would be information on the amounts actually paid for purchasing health service products from an organisation in the supply chain. As I set out earlier, our current routine collections already cover the acquisition costs of the products themselves, as distinct from the overheads incurred by an organisation in supplying them.

Amendment 9 makes clear that in order to collect information in relation to certain types of profit made by suppliers, the Government would by necessity need to collect information on certain costs. I know that the collection of information on profit has been of concern to some Peers. Taken together, these amendments therefore make clear that the Government would be required to issue an information notice before they could collect particular types of profit-related information.

I have sympathy for the amendments from the noble Lord, Lord Hunt, that would restrict the term “profit” to aggregate UK profit. However, this approach may mean that we would be unable to collect information on the purchase costs and sales revenues that we currently collect and use to inform the reimbursement of community pharmacies and ensure that our reimbursement arrangements deliver value for money. I hope he would be willing to support the Government’s approach, which addresses the concerns raised by the pharmaceutical industry without undermining our ability to reimburse community pharmacies effectively. It might be worth adding at this point that I have had the opportunity to meet a couple of representative groups and explain the approach that we were taking in order to provide proportionality, and that approach was welcomed by those groups.

I should point out that in drafting Amendment 11 the Government have omitted to reflect that under the voluntary scheme, on a routine basis, we already obtain information from companies on profits and costs, including the costs of manufacture, R&D and distribution. This is company-level information, not product-level information. I will therefore bring forward a small amendment to Amendment 11 at Third Reading to reflect this, which would enable the Government to obtain that information on a routine basis under a future statutory scheme. I believe this would also be in line with the intention behind Amendment 8 from the noble Lord, Lord Hunt, which distinguishes between company-level or aggregated information on the one hand and information on individual products on the other.

I turn to the circumstances in which the Government may wish to collect information on costs via an information notice. In Committee we spoke about triggers, and the noble Lord, Lord Hunt, has tabled amendments along those lines. I have thought about this carefully but have concluded that we cannot set particular conditions for when we issue information notices. First, we cannot predict all the circumstances where this or a future Government may need to investigate further the value for money of a particular product or supply chain. Secondly, we may want to issue an information notice when we have an information gap and cannot properly assess whether a product or the supply chain is delivering good value for money. It would be a Catch-22 situation if we were to have triggers for an information notice in legislation that would allow us to issue an information notice only when we already had the evidence. I trust noble Lords will understand the Government’s concerns about triggers for an information notice.

However, in Committee I said I would provide examples of when the Government may wish to collect information about costs. These include where companies in the statutory scheme ask for a price increase for a particular product and we want to assess whether that is justified; where we have concerns about the high price of an unbranded generic medicine and want to assess whether the prices are warranted; or where the Government have no visibility over costs in the supply chain and want to assure ourselves that the market is working effectively. These are only some examples but I hope they illustrate where the Government may benefit from more information than that which is collected routinely to run our community pharmacy reimbursement system and to operate our cost-control schemes for medicines. The information notice would of course clearly set out what information would need to be provided, the form and manner in which the information would need to be supplied, the period of time that that information would need to cover and the date by which that information would need to be supplied. It would inform those issued with an information notice of their right of appeal.

The government amendments would introduce a right of appeal for those served with an information notice, an important point made by my noble friend Lord Lansley in Committee. UK producers could appeal an information notice if they believed the request was beyond the powers in the NHS Act 2006. That is in addition to the existing appeal mechanism against any enforcement decision made by the Government when a company refuses to submit information.

I thank noble Lords, especially my noble friend Lord Lansley and the noble Lords Lord Warner and Lord Hunt, for helping to shape these amendments. I hope that through the government amendments I have reflected the concerns raised in Committee, and that the House will agree them. I also hope I have addressed the amendments tabled by the noble Lord, Lord Hunt, and I ask him to withdraw his amendment and instead support the Government’s amendments.

[Lord Lansley]

My Lords, I reciprocate my noble friend’s thanks. In Committee he said he was going to think very carefully about the subject of information and the circumstances in which it is required from companies. Having done so and engaged us in a conversation about it, he has come forward with an amendment that seems specifically designed to meet the concerns raised in Committee. From my point of view, and this is very simply put, there must be a general scheme to acquire information, but when one goes beyond it the company has a right to expect that the information notice must be specific, itemised and additional, and that, as is now provided for, there should be a right of appeal in relation to that. My noble friend has very kindly listened and brought forward an amendment to do in substance the things that we were looking for, so I am grateful to him.

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Moved by

[Lord O'Shaughnessy]

9: Clause 6, page 5, line 37, at end insert “(including, in relation to profits, the costs incurred by the producer in connection with the manufacturing, distribution or supply of the products)”

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Moved by

[Lord O'Shaughnessy]

11: Clause 6, page 5, leave out lines 46 to 48 and insert—
“(5) Regulations under this section must require the Secretary of State to give a UK producer an information notice if information is required in respect of the costs incurred by the producer in connection with the manufacturing, distribution or supply of UK health service products (other than costs which relate to any transaction with a UK producer for those products).(5A) An information notice is a notice stating—(a) the period in relation to or for which, or intervals at which, information is required to be provided,(b) the form and manner in which information is required to be provided,(c) the time at which or period within which information is required to be provided, and(d) that a right of appeal is conferred by virtue of section 265(5A).(5B) Regulations under this section may require information which does not fall within subsection (5) to be provided—(a) in relation to or for a prescribed period or at prescribed intervals,(b) in a prescribed form and manner, and(c) at a prescribed time or within a prescribed period.”

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Moved by

[Lord O'Shaughnessy]

13: Clause 6, page 7, leave out line 22 and insert—
“(l) such of the following as may be prescribed—(i) an NHS foundation trust;(ii) any health service body within the meaning of section 9(4)(not falling within any of paragraphs (a) to (k) above).”

[Lord O'Shaughnessy]

My Lords, I beg to move Amendment 13 and am grateful to the noble Baroness, Lady Walmsley, for putting her name to this amendment and to the others in my name.

The amendments relate to the report and recommendations of the Delegated Powers and Regulatory Reform Committee, and I am extremely grateful to the committee for its scrutiny of the Bill—which, I believe, together with the government amendments, will lead to improved legislation. In my response to the committee, I confirmed that the Government would accept all four recommendations and would table amendments to take forward these actions. Once again, I am grateful for the work of the noble Baronesses, Lady Walmsley and Lady Finlay, and the noble Lord, Lord Hunt, for continuing to highlight the issues raised in the report.

I shall take each recommendation in turn. First, the committee concluded that the general power in new Section 264B(1)(l) proposed in Clause 6 to prescribe in regulations any person to whom information may be supplied is too wide, with insufficient justification. The government amendment clarifies this issue by confining the ability to prescribe in regulations to any health service body already listed in Section 9 of the NHS Act 2006 and NHS foundation trusts which are not listed in Section 9. This would have the effect of enabling government to prescribe in regulations the sharing of data with other health service bodies such as clinical commissioning groups, but not enabling other persons to be included by means of subsection (1)(l). We have made this change, as we would want to be able to share information with local health bodies, such as CCGs or hospital trusts, if we had concerns about prices—but not with others.

The committee concluded that the power in Clause 7 to enable Welsh Ministers to make regulations that make provision for payment of a penalty if a provider of pharmaceutical or primary medical services contravenes regulations requiring them to record and provide information about health service products which are required for the health service in Wales, should be consistent with similar provisions in the 2006 Act. In particular, the committee recommended that the maximum penalty which may be imposed under what would be Section 201A of the National Health Service (Wales) Act should be set out in the Bill, and that a power to increase this maximum by regulations should be made subject to the affirmative regulations. I am pleased to say that, following discussions with the Welsh Government, an amendment has been tabled which would amend Section 201A(5) to introduce maximum penalties into the National Health Service (Wales) Act 2006. We will amend the Bill to enable through regulations the power to increase the maximum penalty, and these regulations will be subject to the affirmative procedure.

Noble Lords will appreciate that, in the case of penalties, the powers in relation to Wales are different from those in relation to the UK as a whole in so far as Welsh Ministers will be able to impose penalties only on providers of pharmaceutical and primary medical services. By contrast, the 2006 Act allows for penalties to be imposed on manufacturers and distributers, and the size of any penalty should reflect this. It would therefore be disproportionate if the level of maximum fine allowed for in the 2006 Act were to be replicated in the NHS Wales Act. To address these concerns, the government amendment would limit the single penalty to £10,000 and the daily penalty to £100.

I turn to the amendment which would remove the provisions allowing Welsh Ministers to disclose information to persons prescribed in regulations. Welsh Ministers have agreed that the Bill should be amended to limit the types of bodies with whom information may be shared. The government amendment would specify the following persons to whom information may be disclosed by virtue of Section 201A. They include: a local health board or other person appointed under Section 88(3)(b) of the National Health Service (Wales) Act 2006 to exercise the functions of a determining authority under Part 7 of that Act; a National Health Service trust established under Section 18 of the National Health Service (Wales) Act 2006; any person who provides services to Welsh Ministers or to any person falling within paragraph (a) or (b); and any body that appears to the Welsh Ministers appropriate to represent Part 4 providers or Part 7 providers, as defined by Section 201A(8).

I turn to the amendment from the noble Lord, Lord Hunt, which seek to put those bodies that represent UK producers on the face of the Bill instead of in regulations. The Government will prescribe these bodies in regulations; the illustrative regulations we published merely provided some examples of representative bodies that the Secretary of State may disclose information to, and I assure the noble Lord that further work will be done on this list. We will discuss the list with stakeholders and we will, of course, publicly consult on the list to ensure that we get it right. I know that that was a concern of his.

Finally, we are proposing to table technical amendments to the Bill at Third Reading to reflect the fact that the Northern Ireland Assembly was not able to pass its legislative consent Motion on the Bill before it dissolved, despite the relevant committee having approved it. We will seek to amend the Bill to enable the Northern Ireland components of the Bill to be commenced separately through regulations once it has been possible to secure legislative consent.

As I hope your Lordships will see, the Government have addressed the concerns of the DPRRC. I also hope that I have addressed the concerns of the noble Baronesses, Lady Walmsley and Lady Finlay, and the noble Lord, Lord Hunt. I ask noble Lords who have tabled amendments not to press them and support the amendments in my name and those of the noble Baroness, Lady Walmsley.

[Baroness Walmsley]

My Lords, I am grateful to the Minister for what he has just said and for the conversations that we had about this group of amendments at Richmond House. As noble Lords will see, I have added my name to the government amendments in this group, because they achieve exactly what I was hoping to achieve when I tabled amendments in Committee. I am grateful to the noble Baroness, Lady Finlay of Llandaff, for supporting me in that intention. Unfortunately, when I withdrew my amendments in favour of the Government’s amendments, my message to the noble Baroness, Lady Finlay, did not get through, so she has unfortunately failed to withdraw her name. That is why she has asked me that, when the amendments in her name come to be put in order, I should make it clear on her behalf that they are not moved, which will achieve our joint intention. I know that the committee is also grateful to the Minister for hearing our concerns and taking action.

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Moved by

[Lord O'Shaughnessy]

15: Clause 7, page 9, line 32, at end insert—
“(5A) The penalty may be—(a) a single penalty not exceeding £10,000, or(b) a daily penalty not exceeding £100 for every day on which the contravention occurs or continues.”

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Moved by

[Lord O'Shaughnessy]

17: Clause 7, page 9, line 41, at end insert—
“(7A) The Welsh Ministers may by regulations increase (or further increase) either of the sums mentioned in subsection (5A).”

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Moved by

[Lord O'Shaughnessy]

19: Clause 7, page 10, line 11, leave out from “any” to end of line 12 and insert “of the following persons—
(a) a Local Health Board or other person appointed under section 88(3)(b) to exercise the functions of a determining authority under Part 7;(b) an NHS trust established under section 18;(c) any person who provides services to the Welsh Ministers or to any person falling within paragraph (a) or (b);(d) any body which appears to the Welsh Ministers appropriate to represent Part 4 providers or Part 7 providers (as defined by section 201A(8)).”

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Moved by

[Lord O'Shaughnessy]

21: Clause 7, page 10, line 19, leave out “or 201B”

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Moved by

[Lord O'Shaughnessy]

25: Clause 8, page 11, line 13, after second “section” insert “(other than enforcement decisions falling within subsection (5A))”

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Moved by

[Lord O'Shaughnessy]

28: Clause 9, page 11, line 33, after “Section” insert “(Remuneration for persons providing special medicinal products: England) and”

Residential Care

Lord O'Shaughnessy Excerpts

Monday 6th February 2017 Lords Chamber

[Baroness McIntosh of Pickering]

To ask Her Majesty’s Government what estimate they have made of the number of residential care home beds that were available in (1) 2005, and (2) 2015.

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

My Lords, I am informed by the Care Quality Commission that, as of 31 March 2015, there were 464,110 nursing and residential care home places in England. According to the annual reports of the Commission for Social Care Inspection, the predecessor to the CQC, the equivalent figure as of 31 March 2005 was 451,288.

[Baroness McIntosh of Pickering (Con)]

My Lords, I thank the Minister for that Answer, but will he ensure that the number of care home places remains at a sufficiently high level to enable people to be discharged from hospital when it is deemed safe to do so? If there is currently a shortage of care home beds in, for example, rural counties such as North Yorkshire, will his department work very closely with local authorities up and down the country to ensure that people can leave hospital and go to a care home when that is appropriate?

[Lord O'Shaughnessy]

I thank my noble friend for making a very important point. Clearly, the capacity in the care home sector is important for ensuring that there is a proper flow of patients out of hospitals and into a more appropriate setting. In regard to the county that she was talking about, North Yorkshire, I think the overall number of beds has been broadly flat over the period in question, but there has been an increase in domiciliary and supported accommodation, which is increasingly the way that care is being structured across the country.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister agree that where there is a shortage of residential or, indeed, nursing home care beds, the onus on care falls on the families? Will he take this opportunity to update his honourable friend in the other place, the Minister for Health, who last week exhorted the nation to care for its elderly relatives? He apparently forgot that there are 6.5 million people who already do so at great personal cost to themselves.

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight the work that carers do. There is now, of course, a national carers strategy to support those who are supporting their families, often in very difficult circumstances. The point that my honourable friend in the other place was trying to make was that there is an important role for families to continue doing so—in the way that parents care for children, children should do the same for their parents in return.

[Baroness Brinton (LD)]

My Lords, it is absolutely evident that the care homes are facing an existential problem. Their costs have increased by 30% in the last year with the introduction of the national living wage, and their profits have significantly reduced. Some 1,500 homes have closed over the last six years. There is a major problem going on, and it is not good enough to exhort local councils to pick up the gap when their funding has been severely curtailed, which is also not helping care homes. When will the Government get a grip of this very serious crisis?

[Lord O'Shaughnessy]

I am pleased that this Government have introduced the national living wage, which is supported, I believe, across this House and the other place. The noble Baroness is quite right that there is an impact on social care home providers, many of the staff of which are paid at that level. The truth is that there is a cost pressure, of course, in the social care sector—that is one of the reasons that the precept is rising quicker than it would have done otherwise—and the better care fund has been created to support more care provision in the appropriate setting that people want to have it in.

[The Lord Bishop of St Albans]

My Lords, with applications for nursing degrees having gone down by 10,000 and with planned immigration restrictions being imposed, what are Her Majesty’s Government doing to ensure that we have not only sufficient beds but the caring and nursing staff to look after those who are using the beds?

[Lord O'Shaughnessy]

The number of workers in the social care sector has increased by about 165,000 over the last five years: there is an increased demand because we have a growing population. I think that we are going to have another opportunity to talk about the impact on nursing degrees tomorrow, so I do not want to spoil the party. As for the impact of the European Union, of course, a significant section of the workforce comes from the European Union but we are increasing the number of nursing training places and there is also now a nursing apprenticeship scheme which is providing 1,000 places for people who want to enter the profession by that route.

[Baroness Greengross (CB)]

My Lords, does the Minister agree that people in acute hospitals would not need to be there if there was somewhere they could go very soon after being admitted to hospital, such as rehabilitation centres? Many countries have small, nurse-led rehab centres; many of our smaller hospitals which are being closed down could be used in this way. People could go there as soon as they can out of the acute hospital sector. If we did that, we could solve some of the problems and we would have the right sort of care for a lot of frail people who are at the moment accused of blocking hospitals—they do, but it is not their fault.

[Lord O'Shaughnessy]

The noble Baroness raises an incredibly important point. Patients end up in hospitals for a variety of reasons and it is not always the best setting for them. The kind of care she describes is important; it might be rehab centres or cottage hospitals. Indeed, what we are seeing through the sustainability and transformation plans are ideas for intermediate care and step-down care that provide exactly the sorts of things she is talking about.

[Lord Lansley (Con)]

Does my noble friend recognise that when care users go into a residential care home their own home is very often included in the means test, even if subject to deferred payment? However, if they receive their care at home, their own home is exempted. This both reduces the resources available to support care and also creates a disincentive to go into care homes for people for whom it might be the best result. Does my noble friend recognise this as an issue we should look at?

[Lord O'Shaughnessy]

The most important thing when providing care is that it is in a setting that people want and feel comfortable with. There is, of course, a trend towards more domiciliary and supported housing for precisely that reason.

[Baroness Wheeler (Lab)]

My Lords, what is the Minister’s view of Disability United’s recent FOI finding on NHS continuing care that a large number of CCGs are saying they will not support the care of chronically ill people in their homes if it is cheaper for them to be in residential care? How does this sit with the reality of the state of the residential care industry, with bed shortages in many areas so that patients cannot be transferred from hospital, and with the Government’s aim of giving chronically and terminally ill people choice about where they want to be cared for, particularly at the end of life?

[Lord O'Shaughnessy]

The noble Baroness makes a very good point. There is clearly a need for additional capacity, because there is a much greater population. The number of people aged over 85 has increased by about 25% in the last five years and that will increase at a similar rate over the next five years, so more capacity is needed both at hospital level, in residential and nursing homes, and at a domiciliary level too.

[Lord Cashman (Lab)]

My Lords, there are worrying trends of discrimination suffered by people in vulnerable groups, people with HIV, those who are ageing and others. Therefore, will the Minister work with care providers to ensure that such discrimination, ignorance and stigma are absolutely outwith the provision of such services?

[Lord O'Shaughnessy]

I completely concur with the noble Lord’s point. He is right, of course: there should be no such discrimination on those grounds or any other. I will certainly investigate that and see if there is anything worrying going on and write to him.