Health and Care Bill

Lord Prior of Brampton Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Prior of Brampton (Non-Afl)]

My Lords, I should first refer to my declaration of interest—in particular, that I am currently chairman of NHS England. Looking down at the noble Lord, Lord Stevens, and also seeing the noble Lord, Lord Adebowale, and the noble Baroness, Lady Harding, I could almost believe we were back at a board meeting at NHS England. I will give the House an idea of the kind of chief executive the noble Lord, Lord Stevens, was. At the beginning of a board meeting he would tell us what he thought, and then, to avoid any unpleasantness, at the end of the meeting he would tell us what we thought, so we all went away perfectly happily. It was a very good arrangement. It is wonderful to see him here in this House, and he will make a huge contribution, I am sure, in the years to come.

The phrase “another NHS reorganisation” is designed to send a chill through the sturdiest of hearts of all of us who have worked in the NHS for many years, so why do I actually think that the Bill is the right thing at this time? First, there is a pragmatic reason: it has very wide support from within the NHS; it goes with the grain of NHS culture; it is a Bill to be delivered bottom-up. Secondly, there is another pragmatic reason: it is already happening on the ground. NHS England and NHS Improvement already operate as one organisation, and locally integrated care systems have been and are being created. Thirdly, this is not some new-fangled ideological concept dreamt up by an ambitious Secretary of State. The process towards integration was launched some seven years ago by my former colleague and noble friend Lord Stevens. Then, it was called the five-year forward view. The underlying philosophy of the Bill has been road-tested in numerous places across England for seven years.

Fourthly, the fundamental basis of the Bill is, I think, unanswerable. I quote something verbatim from the NHS Five Year Forward View written seven years ago which is still true today:

“The traditional divide between primary care, community services, and hospitals—largely unaltered since the birth of the NHS—is increasingly a barrier to the personalised and coordinated health services patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three.”


Finally and fifthly, the ICS structure will enable the NHS more effectively to deliver population health and, in particular, to address the growing and unacceptable levels of health inequality that disfigure our society.

For all those reasons, I support the Bill. I hope, however, that the Government will recognise that the improved accountability and transparency that resulted from the purchaser-provider split, the productivity gains that came from the incentives built into payment by results, and the innovation value driven by competition should still be kept as drivers of improvement and change within the ICS structure. I also hope—this will not be popular on all sides of the House, although it used to be popular on the other side—that this Government will publicly recognise the very important contribution that the private sector can make to delivering high-value care. I hope these issues will be debated fully in Committee.

The Bill, in whatever shape it finally takes, will not on its own mend a healthcare system that is extremely fragile, as many healthcare systems are in the developed world. Most health systems in the developed world are not, in reality, health systems; they are late-stage sickness and emergency care systems. By using digital technologies and predictive AI, by incorporating genomics, by focusing on population health, out-of-hospital care and self-care, and by investing in precision, personalised public health, we have a chance of changing what has now become an outdated model.

There are four particular issues I will leave with the Minister. The first is the workforce. I commend the amendment put forward by Jeremy Hunt in the other House. Long-term workforce planning is essential to the future of the NHS. The second is mental health. We have made huge progress but we are not there yet; there is no real parity of esteem in the provision of services and funding for mental health. Thirdly, I would like to see the ICBs committed to achieving net-zero carbon emissions, which the NHS as a whole is now committed to. Finally, on social care, I thought the contribution by the noble Lord, Lord Kerr, was pertinent. He is absolutely right: we are at the beginning of reforming social care, not the end.

Academic Health Science Centres

Lord Prior of Brampton Excerpts

Tuesday 2nd July 2019 Grand Committee

[Lord Prior of Brampton (Non-Afl)]

My Lords, I should first declare an interest as chairman of NHS England and a non-executive director of Genomics England. I support the noble Lord, Lord Butler, especially and all the arguments other noble Lords have made.

I will begin by taking noble Lords’ minds back to 1980, when two Senators in the US, Senator Bayh and Senator Dole, passed the Bayh-Dole legislation, which forced universities receiving money for federal research to commercialise their IP. Until that day the IP had sat in the ivory towers of the universities and had not been exploited. From 1980 on we saw this extraordinary growth in Silicon Valley and, latterly, Boston as universities were forced to commercialise their intellectual property.

We have been much slower in the UK. Until recently, universities, particularly Oxford and Cambridge, were ivory towers. That has changed and the AHSCs are part of that change. We have developed an ecosystem in the UK that is both hard to replicate elsewhere and extensive. Whether it is the BRCs, the HSCs, the AHSNs, the Crick or the LMB, we have an extraordinary and competitive life sciences ecosystem. It is becoming even more competitive as we see the convergence of biology with data, statistics, computer sciences and artificial intelligence. That puts the UK in a very strong position.

Money comes into this. I have done the Minister’s job and I was involved at BEIS with the industrial strategy. Our problem is that our ambition is so low. Our ambition was to get up to the OECD average for research spending in five years—2.4% of GNP, at a time when the Germans were already at more than 3%. We have to argue for £5 million for a new LICRE digital application across London. We have to argue for £20 million or £15 million for a new dataset for people with polygenic risk scores, for example. We are fiddling while the rest of the world—China and the US—is putting huge resources into this. When I was working on the industrial strategy, I looked at countries as diverse as Singapore, Israel, Ireland and Switzerland, where there was active government involvement in research and industrial strategy. America is always seen as the land of small government, but the NIH is a massive funder of life sciences research.

I do not know how we can change the mindset of the Treasury and the British Government. The only good thing that might come out of Brexit, which I think is a universally bad thing, is that it will provide us with a big shot in the arm. Whether we put in the money through AHSCs or through other vehicles in our ecosystem—UKRI, the MRC, the BBSRC—I do not care, as long as we get more money into fundamental, basic research and support the translational research for the BRCs, the NIHR and the AHSCs. I am fully in alignment with the redesignations of AHSCs. Whether more money comes in through them or other parts of the ecosystem, we have a huge opportunity in life sciences. I know that the Minister supports that, too.

Health Service Medical Supplies (Costs) Bill

Lord Prior of Brampton Excerpts

2nd reading (Hansard): House of Lords
Wednesday 21st December 2016 Lords Chamber

Moved by

[Lord Prior of Brampton]

That the Bill be now read a second time.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, this is a short and focused Bill, which is vital not only for the NHS but for patients. The Bill’s provisions have received robust debate and scrutiny in the other place, but also, I am pleased to report, broad support for their aims, objectives and measures from all sides of the House.

NHS spending on medicines is second only to staffing costs. The Health and Social Care Information Centre estimated that the NHS in England spent more than £15.2 billion on medicines in 2015-16—a rise of nearly 20% since 2010-11. With advances in science and our ageing population, these costs can only continue to grow. This is true across the world.

Of course, medicines are a vital part of patient care in the NHS, both in hospitals and the community. Thanks to the research and development efforts of the life sciences industry—an industry which contributes £56 billion and tens of thousands of jobs to the UK economy every year—our understanding of diseases and the best way to treat them has improved dramatically over the past 20 years. I have got to know many businesses in the life sciences industry over the past six months. They include some of the finest companies in the world—from Japan, the USA, Europe, Israel and other countries, as well as the UK. My message to them is clear: “You are part of the solution, not part of the problem. Your new innovative products can both provide better care and help the NHS deliver care at an affordable, sustainable cost”.

We recognise that we have a diffusion problem in the NHS—diffusion more than innovation. I would characterise this as a treacle problem. For a whole host of reasons—not just financial, by any means—we in the NHS are slow at uptake. This problem has been addressed in the Accelerated Access Review, chaired by Sir Hugh Taylor and Professor Sir John Bell, and it will be a key part of our life science strategy as we move forward. Our ambition is for the UK to be the best place in the world for life sciences: for research, development, innovation and manufacture and for use by our patients. Nothing in the Bill stands in the way of that. I would argue that the structure of the NHS—the biggest single-payer health system in the world—our access to patient outcome data and our exceptional discovery and translational research base should mean that we are well placed to have our cake and eat it, with new innovative medicines and devices at an affordable cost. To pursue that rather weak culinary metaphor, the treacle can become the icing on the cake.

The purpose of the Bill is to clarify and modernise provisions to control the cost of health service medicines and to ensure that necessary sales and purchase information can be appropriately collected and disclosed. These provisions will align the statutory and voluntary cost-control mechanisms currently in existence, allow the Government to control the cost of excessively priced unbranded generic medicines and ensure that we have comprehensive and accurate data with which to reimburse people who dispense medicines. Taken together, these measures will secure better value for money for the NHS from its spend on medicines.

The first element of the Bill relates to controls on the cost of branded medicines. For many years, the Government have had both statutory and voluntary arrangements in place with the pharmaceutical industry to limit the overall cost of medicines to the NHS. Companies can choose to join either the voluntary scheme or the statutory scheme. The current voluntary scheme is the 2014 pharmaceutical price regulation scheme, known as the PPRS. The objectives of the 2014 PPRS include keeping the branded health service medicines bill within affordable limits, while supporting the availability and use of effective and innovative medicines. For industry, the PPRS provides companies with the certainty and backing they need to flourish in the UK and in global markets. The current PPRS operates by requiring participating companies to make a payment to the Department of Health of a percentage of their NHS sales revenue when total sales exceed an agreed amount. So far, the PPRS has resulted in £1.45 billion of payments, all of which have been reinvested into the health service for the benefit of patients.

For those companies not in the PPRS, the Government operate a statutory scheme, which—until the current PPRS—was broadly financially aligned with previous voluntary schemes. The current statutory scheme is based on a cut to the published list price of products, rather than a payment mechanism on company sales. The difference between the two schemes has led to some companies making commercial decisions to divest products from the PPRS to the statutory scheme. This pricing misalignment of the two schemes makes no sense.

Last year, the Government consulted on options to reform the statutory medicines pricing scheme by introducing a payment mechanism broadly similar to that which exists in the PPRS. Our intentions were to put in place both a voluntary and a statutory scheme which were broadly comparable in the savings they achieve. Companies have freedom to decide which scheme to join and may move from one to the other, depending on the other benefits they offer, but it is the Government’s position that the savings to the NHS offered by each scheme should be broadly the same. In response, while NHS respondents supported our position, the pharmaceutical industry queried whether the Government had the powers to introduce a statutory payment scheme.

The Bill will clarify the existing provisions in the National Health Service Act 2006 to put beyond doubt that the Government can introduce a payment mechanism in the statutory scheme. The Bill would also amend the NHS Act 2006 so that the existing provisions for enforcement action would apply to the new powers. Payments due under either a future voluntary or statutory scheme would be recoverable through the courts, if necessary.

The powers to control the cost of medicines proposed in the Bill are a modest addition to the powers already provided for in the 2006 Act to control the price of, and profit associated with, medicines used by the health service. However, these additions are necessary to ensure that government has the scope and flexibility to respond to changes in the commercial environment. The intended application of the powers will be set out in regulations, on which we intend to consult as soon as we are able to do so. The Government have already published illustrative regulations to demonstrate how the powers will be exercised in a fair and proportionate way.

I would also like to reassure noble Lords and those companies in the statutory scheme that we will consult further on the implementation of a payment mechanism in the statutory scheme, including the level of the payment mechanism, before any regulations come into force. We estimate that 17 companies will be affected by the introduction of a payment mechanism, with the 166 companies that are currently members of the PPRS not affected. Small companies will continue to be exempt from payments. Our proposals will save the health services across the UK an estimated £90 million per annum.

I now turn to the second key element of this Bill, which amends the National Health Service Act 2006 to strengthen the Government’s powers to set prices of medicines where companies charge unreasonably high prices for unbranded generic medicines. We rely on competition in the market to keep the prices of these drugs down. This generally works well and has, in combination with high levels of generic prescribing, led to very significant savings. However, we are aware of some instances where there is no competition to keep prices down and companies have raised their prices to what look like unreasonable and unjustifiable levels. This was also highlighted by the Times earlier this year.

We cannot allow this practice to continue unchallenged. My department has been working closely with the Competition and Markets Authority to alert it to any cases where there may be market abuse and to provide evidence to support this. Earlier this month, the Competition and Markets Authority issued its highest fine ever of £90 million against Pfizer and Flynn Pharma after finding that each broke competition law by charging excessive and unfair prices for anti-epilepsy drugs in the UK, and only last week the CMA issued a statement of objections alleging that Actavis UK has breached UK and EU competition law by charging excessive and unfair prices in relation to the supply of hydrocortisone in the UK. Those CMA findings are provisional, and no conclusion should be drawn at this stage that there has in fact been any breach of competition law. We also know that Concordia International, one of the companies that featured in the Times investigation, is under investigation by the CMA. It announced this itself.

We also need to be able tackle this practice within our own framework for controlling the cost of medicines. While the Government’s existing powers allow us to control the price of any health service medicine, the current powers do not allow controls to be placed when companies are members of the voluntary PPRS scheme. Today, most companies have a mixed portfolio of branded medicines and unbranded generic medicines, and therefore we are currently unable to act. I have to stress that this is not a widespread practice in the industry. This Bill amends the National Health Service Act 2006 to allow the Government to control prices of these medicines, even when the manufacturer is a member of the voluntary PPRS scheme. We intend to use the power where there is no competition in the market and companies are charging the NHS an unreasonably high price. We will engage with the industry representative body, which is also keen to address this practice, on how we will exercise this power.

The final element of the Bill will strengthen the Government’s powers to collect information on the costs of medicines, medical supplies and other related products from across the supply chain from factory gate to those who supply medicines to patients. We currently collect information on the sale and purchases of medicines from various parts of the supply chain under a range of different arrangements and for a range of specific purposes. Some of these arrangements are voluntary while others are statutory.

The Bill will streamline and expand the existing information requirements in the National Health Service Act 2006. The Bill will enable the Government to make regulations requiring all those involved in the manufacture, distribution or supply of health service medicines, medical supplies or other related products to record, keep and provide at request information on sales and purchases. The requirement to provide this information would be for defined purposes: reimbursement of community pharmacies and GPs; determining whether value-for-money is being achieved from the supply chain or products; and controlling the cost of medicines. This will put the current voluntary arrangements for data provision with manufacturers and wholesalers of unbranded generic medicines and manufactured specials on a statutory footing.

Because the arrangements are voluntary, they do not cover all products and companies, limiting the robustness of the reimbursement mechanism. The information power would also enable the Government to obtain information from across the supply chain to assure themselves that the supply chain is delivering value for money, something that we cannot do with our existing, fragmented data. The new power will provide insight into where profit is made and how much. This is important because, although the Government are generally not the buyer of these products, they pay for all products used in the health service.

The 2006 Act already provides powers for government to control the prices of medical supplies. We are not using those powers at the moment, nor do we currently see any reason to start using them, but we want to keep open the possibility, and in the Bill we are updating the powers in line with those for medicines. The term medical supplies, as defined in the 2006 Act, is capable of covering a wide range of medical supplies from bandages to MRI scanners. Many of these products are bought following competitive tendering, and a scheme that controls prices would therefore not bring any benefits.

I also reassure the House about the application of this information power to the medical technology industry. Over 99% of the companies supplying medical technologies to the NHS are SMEs. We have no interest in placing large additional burdens on these companies. The 2006 Act also already requires suppliers of medical technologies to provide information on almost any aspect of their business. We are not putting any new requirements on them but merely streamlining existing requirements.

I thank the devolved Administrations for their constructive input and engagement with my department with respect to the Bill provisions. The Bill reflects the agreement between the Government and the devolved Administrations that information from wholesalers and manufacturers will be collected by the Government for the whole of the UK and shared with the devolved Administrations, while information from pharmacies and GP practices will be collected by each nation. This avoids the burden created by each country collecting the same information.

The Bill will ensure there is a more level playing field between our medicine pricing schemes, while ensuring the decisions made by the Government are based on more accurate and robust information about medicine costs. I believe this legislation will establish a framework that is fairer for industry, pharmacies and the NHS, while also being fairer for patients and taxpayers. I beg to move.

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, I thank the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, for their kind comments about me. I have very much enjoyed this role for the past 18 months. Going over to BEIS, which is the rather horrible acronym we have, I will still have a keen interest in many of the issues that lie behind the debate we have had today. I welcome my noble friend Lord O’Shaughnessy, who is sitting behind me, to his role.

I think my noble friend Lord Lansley, or maybe the noble Lord, Lord Warner, said that in another place this was called a technical Bill. At one level it is, because the issues are quite difficult and technical, but there is substance in it as well. It is not a technical Bill in that sense of the word.

I will start by addressing the wider issues around life sciences and access. We are all agreed that access to new drugs and devices for the NHS is a huge issue. We are falling behind. I do not think there is any doubt about that. That is what lay behind the Accelerated Access Review; that is why we had it. The work led by Sir Hugh Taylor and Professor Sir John Bell absolutely nailed that in its report. I assure the House that the principles behind the Accelerated Access Review will be incorporated into our strategy for life sciences that we are developing over the next few months with industry.

We have to reconcile access and affordability. That is the issue behind the NICE and NHS England consultation: if the impact is more than £20 million per annum—that is our suggestion—it has to be looked at. There will always be a tension between access and affordability. As I said in my opening speech, that circle can often be squared because many such new developments, particularly in medical devices, will save costs. A lot of the work that has been done around digital health, adult hospital healthcare, health analytics, machine learning and the like has the potential to help us solve the productivity problem which has bedevilled not just our own health system but every health system in the world.

I think it is pretty much universally agreed that we need to take more powers around isolated cases of huge price increases for certain generic medicines where there is no competition. I think there is no question about that and we are all as at one.

The purpose of putting a payment mechanism into the statutory scheme, which is in the first part of the Bill, is only to align the two schemes. I assure the noble Lord, Lord Hunt, that we are not doing away with the voluntary scheme—on the contrary. It is just that we want to avoid the temptation, to which my noble friend Lord Lansley alluded, for companies, quite legitimately, to arbitrage between the two schemes. Historically, the two schemes have been broadly aligned from a financial point of view. It was only when the payment scheme was introduced into the voluntary scheme in 2014 that the two schemes became unaligned. The department’s view at the time was that we had the powers under existing legislation to put a payment scheme into the statutory scheme. It was only when, as part of the consultation, the industry queried whether we had that power that the department decided that we should introduce the power, which we are doing through this Bill, to put the two schemes roughly on a par. That is not to say that there will not be other benefits in the voluntary scheme which will still be very attractive to industry. I hope that that is the case and that we will be able to build on the voluntary scheme.

It is also worth mentioning that we will become much more sophisticated over time in the way that we price medicines. As a relative layman and objective viewer, it seems to me extraordinary that we have not already developed outcomes-based pricing for many of these drugs. When a drug is going to have an effect on 60% of the people who use it, why would we want to pay for the other 40%? Given that we in the UK are a single system and have access to data in a way that many other, more disaggregated systems do not, we are in a very strong position to have well-informed, data-rich, outcome-based pricing. The hep C drug is a classic case of our being able to move towards more annuity-based pricing. If we cannot afford the up-front cost of some medicines all in one go but can spread the cost of them over a number of years, that would seem an eminently sensible reimbursement process. I think we will see some much more sophisticated pricing arrangements coming into the mix as we move forward. That is the purpose of aligning those two schemes.

The aspect of the Bill about which the noble Lord, Lord Warner, and others have expressed the most concern is the information requirements and powers to extract information, particularly from small companies supplying medical devices. The noble Lord asked what the cut-off was for an SME. It is sales of £5 million, which omits quite a few supplies into the NHS from companies below that level. Again, the purpose of this part of the Bill is to ensure that we get our reimbursement rates right, particularly for integrated wholesale pharmacies. There is a feeling that some of the very big wholesalers—I will not name any names—make pretty hefty margins on some of these products. We need to know what price they buy at so that we can try to manage those margins and be sure that the NHS gets a reasonable deal.

Many of the issues raised are quite detailed and I am delighted to leave them to my successor to address in Committee. However, the last thing in the world we want to do is to build a bureaucratic edifice here, or to gold-plate regulations, information requirements and the like. I assure noble Lords that we are absolutely open to all ideas and suggestions on how we can reduce the regulatory and bureaucratic requirement on companies that supply the NHS.

The noble Lord, Lord Warner, heard that certain companies look to go overseas to less bureaucratic and regulated systems. I think that that is down to not so much the regulation as the uptake issues. I am sure the noble Lord and others have met, as I have, many small companies that tear their hair out about trying to supply to the NHS. They find it easier to supply the US, Australian or other world markets than our own. That is not to do with the information requirements that already exist or will exist under the Bill. It is still the case that the NHS is a very treacly organisation. It is hard to get your product into it. Even when it has been approved by NICE, it is difficult to get it diffused throughout the NHS.

Not many noble Lords participated in the debate but, as always in this House, the quality of contributions has been extremely high. I thank all those who contributed and ask the House to give the Bill a Second Reading.

Bill read a second time and committed to a Grand Committee.

Consumer Rights (Enforcement and Amendments) Order 2016

Lord Prior of Brampton Excerpts

Tuesday 20th December 2016 Lords Chamber

Moved by

[Lord Prior of Brampton]

That the draft Order laid before the House on 17 November be approved.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, the Consumer Rights Act came into force last year. It simplified UK consumer law and it empowers consumers, improves consumer choice and drives competition. The Act provides clear rights for consumers when buying goods, services and digital content. It also provides clear remedies for consumers so they know what they are entitled to when things go wrong and can take action where needed. The Act also provides enforcers, such as trading standards officers, with a set of updated powers, to aid them in investigating potential breaches of consumer law while ensuring businesses have relevant rights of appeal.

The Consumer Rights (Enforcement and Amendments) Order 2016 before us today makes a number of small but essential amendments to Schedule 5 to the Consumer Rights Act 2015. It adds a number of pieces of legislation to the list of legislation in the Act so that enforcers, such as trading standards, can access the updated investigatory powers contained in that schedule. The order will ensure that a comprehensive range of powers are available to enforce the Tobacco and Related Products Regulations 2016, which harmonise trading rules on how tobacco products are manufactured, produced and presented, and the Standardised Packaging of Tobacco Products Regulations 2015, which require cigarettes and roll-your-own tobacco to be packaged in a standard colour with a standard typeface.

Noble Lords will recall that a number of tobacco companies have challenged the standardised packaging legislation in the courts. I am pleased to say that the Government have won on every ground raised, not only in the High Court but also more recently in the Court of Appeal. It will be important, then, that trading standards have wide-ranging enforcement powers to ensure that this legislation now has the maximum impact on discouraging children from taking up smoking and helping smokers to quit.

Lastly, the order also makes consequential amendments to two pieces of legislation so that the investigatory and enforcement powers contained in Schedule 5 are referred to. The legislation affected by the order is the London Local Authorities Act 2007, which tackles rogue traders by requiring mail forwarding businesses in London to register with their local authority, and the Weights and Measures (Northern Ireland) Order 1981, which regulates the quantity of goods and weighing and measuring equipment used by traders. The Government consider that this order provides for the application of the most modern suite of enforcement powers to these pieces of legislation and, importantly, will allow trading standards to play their full part in enforcing the new tobacco legislation introduced by this Government, and in turn continue to drive smoking rates down in this country. I beg to move.

[Viscount Ridley (Con)]

My Lords, in relation to the tobacco and related products directive, my noble friend mentioned several times the aim of driving down smoking in this country. We are now in a situation in which there are many varieties of tobacco products available to people, many of which do not involve smoking. Could he bear in mind that good intentions in regulation often lead to unintended consequences? Would he ask his officials to brief him on Yale University’s recent research, demonstrating how increases in regulation of e-cigarettes are pushing up smoking rates among young people?

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the noble Lord for his comprehensive analysis of the order before us this afternoon. I declare my interest as president of the Royal Society for Public Health.

We have made great strides in this country in reducing smoking. I am particularly proud of the last Labour Government’s measure in relation to the ban on smoking in public places—and, indeed, of my own amendment in the last Parliament, which the Lords passed, to ban smoking in cars when children are present.

Although the number of smokers in this country has halved since 1974, currently one in five adults still smoke. Enforcing the regulations and legislation relating to the sale, packaging and marketing of tobacco is, therefore, important. In that regard, I want to ask the Minister about progress on the enforcement of the Tobacco and Related Products Regulations 2016 and the Standardised Packaging of Tobacco Products Regulations 2015. Can the Minister confirm that enforcement officers have already had a number of options available to enforce these regulations? Secondly, how much enforcement activity has there been? Thirdly, how good does he assess compliance to be?

I want to pick up the point made by the noble Viscount, Lord Ridley, on e-cigarettes. The noble Lord, Lord Prior, will recall that e-cigarettes were embraced within the tobacco regulations. I want to ask him about the recent alarmist and, I believe, misleading report of the US Surgeon General, on the use of electronic cigarettes by young people, in which he urges greater restrictions on access to vaping products. Would the Minister go so far as to agree with me that it was a pretty shoddy piece of work, which does not seem to be evidence based? Does he agree that it focused on risk to teenagers without looking at potential benefits to adult smokers; that while the science is detailed in the body of the report, the headlines and marketing material are not appropriately caveated; that the report does not put vaping risks into context with smoking or other risks; and that the Surgeon General proposed restrictive policies on e-cigarettes for the supposed benefits to young people without considering the likely harmful consequences for adult vapers or smokers? He also appears to be treating vaping products as just another form of tobacco, which of course is absolutely wrong.

Will the Minister say that the Government will not go down the route that the US Surgeon General has taken? Will he confirm that vaping has been outstandingly successful in helping adult smokers to stop smoking? Will he also confirm that there is no evidence of vaping in the UK being a gateway to smoking for young people? Has he also noticed that, in reality, in the US the most recent data on youth smoking, published, just after the Surgeon General’s report, actually contradicts the alarmist nature of that report, since it shows that vaping is in decline? That point was made by the noble Viscount.

The relevance of raising this in your Lordships’ House today is that the risk is that the kind of alarmist headlines that we heard in our own media in relation to that report might dissuade smokers from switching from smoking to vaping. There are concerns that a large and increasing number of smokers incorrectly believe that vaping is as harmful as smoking, and there is a real danger that smokers may decide not to switch to safer alternatives, such as e-cigarettes, and are potentially missing out on what I can describe only as a very useful smoking cessation aid. Will the Minister reiterate that evidence to date on e-cigarettes indicates that they present a safer alternative to smoking and, for many—for thousands and thousands of people—are a useful cessation tool?

[Lord Prior of Brampton]

My Lords, two questions have been raised. The first related to the existing powers of trading officers, how much enforcement has been going on and how good our compliance is. I hope that the noble Lord will be happy if I write to him with the details as I do not have the figures at my fingertips. We have already had two quite long debates in this House on vaping. I entirely take on board the point made by my noble friend Lord Ridley—namely, that the road to hell is paved with good intentions, and sometimes good intentions have unintended consequences. I have not read the work carried out at Yale University to which he referred, but I will certainly ask my officials to have a look at it. I am very happy to meet him subsequently to discuss its findings.

On the more general point raised by the noble Lord, Lord Hunt, I absolutely reiterate that all the evidence, whether from Public Health England or the Royal College of Physicians, indicates that vaping is much better for you than smoking cigarettes. Of that there is absolutely no doubt, so we should be unequivocal about it. On the other hand, I think the noble Lord will agree that better than vaping is not to vape or smoke cigarettes or anything else at all. Therefore, we certainly should not encourage young people to vape. I cannot comment on the science behind the US Surgeon General’s report, but I think that his concern was that the number of people taking up vaping has gone up by some 900% from 2011 to 2015, and that people may have been caught up in vaping who would not otherwise have smoked. If these people would otherwise have smoked, it is obviously much better that they should vape. However, if they would have done neither, it is much better to have done neither. I think that is the Surgeon General’s fundamental concern. Therefore, the policy in this country is to encourage vaping compared with smoking but not to publicise vaping to young people in the traditional way through risqué advertising and the like. That is probably not a bad balance to strike.

Consumers and businesses benefit from the Consumer Rights Act in all sectors. The Act was introduced to simplify, strengthen and modernise the law and consolidate enforcement powers. It is right that these powers are applied to the specified legislation without further delay and to provide legal certainty for enforcement authorities.

Motion agreed.

NHS: Community Pharmacies

Lord Prior of Brampton Excerpts

Tuesday 6th December 2016 Lords Chamber

[Baroness Cumberlege (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In so doing, I draw attention to my interests as declared in the register. Also, I am a vice-chairman of the All-Party Parliamentary Group on Pharmacy.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

The Government recognise the vital importance of community pharmacy. Our recent reforms will reward quality and embed and integrate pharmacies with primary care, improving the services offered to the public and making better use of pharmacists’ clinical skills.

[Baroness Cumberlege]

My Lords, I thank my noble friend for that Answer. We are at one in agreeing that community pharmacy has an important part to play in the nation’s health. Is my noble friend aware of the report carried out by PwC, which showed that community pharmacy contributes £3 billion net to the NHS, the public sector, patients and wider society? That is through just 12 additional services; it excludes the core work of dispensing medicines. Will my noble friend and his ministerial colleagues reconsider the swingeing 7.4% cut in the income of community pharmacies next year and instead invest in their services, which are accessible 24/7, enhance the public’s health, and prevent patients going to more expensive GPs and ultimately to hospital and A&E departments?

[Lord Prior of Brampton]

My Lords, I do not recognise the figure of 7.4%. The actual reduction is 4% next year and 3.4% the following year. I echo my noble friend’s comments and recognise the huge importance of community pharmacy. If we look forward 10 years, we will see a much greater role for community pharmacy within the NHS in supplying many of the services that are currently supplied by more conventional NHS services.

[Baroness Pitkeathley (Lab)]

My Lords, the Minister mentioned clinical skills. Does he agree that in rural areas in particular, community pharmacies play a role much wider than their clinical function in giving advice, information and sign-posting to patients and their families? Does he agree that that is a very important part of their function that should continue?

--- Later in debate ---

[Lord Prior of Brampton]

Yes, my Lords, I completely agree with that. It is worth saying that the pharmacy access scheme will ensure that pharmacies in rural areas or in the top 20% for deprivation will receive higher levels of income than pharmacies grouped together in urban areas.

[Lord Low of Dalston (CB)]

My Lords, whatever the precise scale of the cut, a cut is still a cut. Would the Minister not agree that, rather than cutting pharmacies’ budgets, the Government should be commissioning more services from pharmacies in order to relieve pressure on the hard-pressed NHS?

[Lord Prior of Brampton]

My Lords, the fact is that across the NHS we are looking to save £22 billion, and sadly, community pharmacy cannot be exempt from those necessary efficiency requirements. But I repeat that, over time, we will see more and more NHS services delivered by community pharmacies, whether it is a sore throat testing service or the treating of minor ailments.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in these rather strange times, can I take it that the noble Lord’s party no longer believes in competition? This policy is intended to reduce the number of community pharmacies in the high street. Why do the Government want to reduce patient choice when the profession clearly can help reduce demands on GPs and A&E services at a very pressurised time?

[Lord Prior of Brampton]

This party does believe in competition. But it also believes that the NHS’s supporting community pharmacies to a very large extent when 40% of them are in clusters of three or more within 10 minutes’ walk from each other, and paying an establishment fee to each of those pharmacies, is probably not a very good allocation of resources.

[Baroness Janke (LD)]

My Lords, have the Government yet published the cost-based evidence for the cuts to the community pharmacies budget, and what safeguards will they put in place to ensure that the most needy communities are not hit hardest by the cuts to the pharmacies budget?

[Lord Prior of Brampton]

The pharmacy access scheme is being set up to deliver exactly what the noble Baroness is asking for—that rural pharmacies and those in very deprived areas will receive greater payments than others. I am not quite sure what report she is referring to. I will have to look at her question afterwards and write to her.

[Baroness Gardner of Parkes (Con)]

My Lords, are not people more willing to go to pharmacies for immediate help with dental conditions in particular because otherwise, they have to pay to have someone look at their mouth, and instead they can go in and ask for some sort of treatment if they have a pain? The pharmacist can diagnose at a very early stage any form of oral cancer—and indeed other conditions—which would otherwise not be noticed until perhaps too late.

--- Later in debate ---

[Lord Prior of Brampton]

My noble friend has made a very good case in support of community pharmacies, which provide a fantastic service. My own local community pharmacy provides an extraordinary service for people living in the part of rural Norfolk where I come from. They have an important role in public health as well.

[Baroness Finlay of Llandaff (CB)]

Will the Government undertake to review the funding model for community pharmacies? If they are undertaking more diagnostic services and reviews and giving more advice, while also rationalising the medication people are on, they are effectively advising themselves out of a source of income when they are reimbursed with dispensing fees. If they are going to lose income, it is very difficult for them to advise people to come off a range of medication.

[Lord Prior of Brampton]

My Lords, we have just looked again at the community pharmacy funding model and have decided to go from a purely volume-based payment structure to one with much more quality embedded in it, and to remove the permanent establishment fee over time. At the same time, we are developing the pharmacy integration fund, so that in future pharmacies will provide some of the care currently provided by highly pressurised GPs and NHS 111 services.

Young People: Self-Harm

Lord Prior of Brampton Excerpts

Tuesday 6th December 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, the Government are aware of the appalling rise in self-harm in children and young people and the misery this reflects. The Government are also acutely aware that self-harm is a leading indicator of risk of suicide and recognise that much more needs to be done to address this issue.

[The Lord Bishop of St Albans]

I thank the Minister for his reply. The research from the World Health Organization shows that around 20% of British 15 year-olds report some sort of self-harm. In the past five years, research shows that hospital admissions associated with self-harm have gone up by nearly 93% among girls and 45% among boys. Having recently visited the outstanding charity selfharmUK, in Luton in my diocese, I have seen what effect a concerted and systematic approach to this problem can have on a very difficult issue, and we need something similar at a national level. Will Her Majesty’s Government commit to publishing guidelines for schools and colleges about preventing and responding to self-harm?

[Lord Prior of Brampton]

I think the right reverend Prelate has raised an incredibly important issue. Around 300,000 young people go to A&E every year through self-harm, after cutting or burning themselves very badly. The right reverend Prelate asked about advice and guidance. In 2004, NICE put out explicit guidance that all those people should receive, at the very least, a psychosocial assessment; today, only 53% of those people—young people in the main—receive such an assessment. That means that 100,000-plus people are going to A&E with this very nasty self-harm and are really being sent home with very little. That is quite an indictment of our system and the words that we have about parity of esteem. I entirely take on board exactly what the right reverend Prelate said. There is a lot more we can do, and perhaps in response to subsequent questions I shall try to say what we are doing.

[Lord Watts (Lab)]

The Minister will know that the mental health service is in crisis. He says on a regular basis that the Government are putting more resources into the area of mental health for young people. He also knows that that money is not getting spent by the trusts. When is he going to sack the trusts, or sack the chief executives of the trusts, for failing to spend that money on vital services for young people?

[Lord Prior of Brampton]

Last year, the rate of spend by CCGs on mental health went up by 8.6%, compared to 3.7% across the board, so the money is starting to get through. The fact is, though, that there are nooks and crannies in our NHS—which we all love—where we have fundamentally let people down for many years. The issue of self-harm and the suicide risk that derives from self-harm is a very black hole at the heart of the NHS.

[Lord Alton of Liverpool (CB)]

My Lords, is not the ultimate tragedy for any parent the suicide of their child? Has the Minister seen or talked to ministerial colleagues about the suicide sites on the internet and the chat rooms that are often visited by young people who may be facing depression, mental illness or low levels of self-esteem, and the terrible tragedies that have occurred as a result of a visit to those sites? Is not there more that can be done by the Government to force those providers and servers to stop making such sites available on the internet?

[Lord Prior of Brampton]

Unquestionably, there is more that can be done. Some of those sites, certainly some of the pornographic sites, are being addressed in the Digital Economy Bill that is going through the House at the moment. But we are working with the national council and the Samaritans, which in turn are talking to people at Google and YouTube and the digital providers to see what we can do in this area. We have also commissioned a new prevalence study to look at cyberbullying and all those sorts of issues, which will, unfortunately, not produce its results until 2018. So we are very much apprised of this, but, frankly, there is always more that we can do.

[Lord Rennard (LD)]

My Lords, over half of all adults with mental health problems first had them diagnosed in childhood, yet fewer than half of those people diagnosed in childhood were treated appropriately at the time. Does not the Minister think that something is seriously wrong when, according to the Royal College of Psychiatrists, 25 clinical commissioning groups are spending less than £25 a year on child mental health issues and 10 CCGs are spending less than £10 a year?

[Lord Prior of Brampton]

My Lords, I think something is seriously wrong, and something has been seriously wrong since 1948. Mental health has been a Cinderella service, and children’s mental health has been, if anything, even worse. We are committed to spending an extra £1.4 billion; we are spending more money on mental health liaison services in A&E departments; and we are putting in 56 new beds in CAMHS units to prevent the out-of-area treatments or what have you. But we have a huge way to go, frankly.

[Baroness Massey of Darwen (Lab)]

My Lords, is the Minister aware of a new report by the Children’s Society on adolescent neglect, which suggests that parental and societal failure to admit to the needs of adolescents and address those needs is having a detrimental effect on adolescent health, especially mental health? Does the Minister agree that it is the case that parental and societal neglect is vitally important and should be addressed? Does he have any comments on how to address it?

[Lord Prior of Brampton]

There is no question about it that parents and society are a critical part of any way to tackling childhood mental health problems. There is no doubt about that. We have just published a work for parents on how to deal with the issue of self-harm, for example, when it is your own child. It is a hugely complex area, frankly. Social media are a big part of this and family break-ups are a big part. I am not a psychiatrist, but when you are going through a period of huge emotional turbulence, cutting yourself or inflicting physical pain on yourself gives you some form of control. It is too complicated and too difficult for me to answer that question as well as I would like to.

[Lord Laming (CB)]

My Lords, the House will know exactly where the Minister stands on this, and I am sure that the House is very grateful to him for that position. Would he accept that this House will do everything that it can to support him in getting the message across that self-harm, particularly in a young person, is a sign of desperation and a sign to be taken that help is needed instantly—and that help needs to be substantial and speedy? We should never be relaxed about self-harm, in any circumstances.

[Lord Prior of Brampton]

I completely agree with the noble Lord. That makes it even more shocking that we do not provide these poor, miserable people, who are suffering horrendously, with even a counselling session. How much is a counselling session—fifty quid; a hundred quid? Maybe it is a series of them and it costs £500: we do not even do that for over 100,000 young people every year.

HIV Diagnosis: Clinical Guidance

Lord Prior of Brampton Excerpts

Thursday 1st December 2016 Lords Chamber

[Baroness Gould of Potternewton]

To ask Her Majesty’s Government, in the light of the forthcoming review of testing guidelines in 2017, what steps they are taking to ensure new national clinical guidance is adopted by the National Health Service and local authorities to reach people in the United Kingdom still living with undiagnosed HIV.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, we welcome the new HIV testing guidelines from NICE, which are particularly timely on World AIDS Day. Early diagnosis of HIV through increased testing carries huge benefits. Progress is being made and in 2015 the rate of undiagnosed HIV fell to 13% from 25% in 2010. We will keep working with partners to use the guidelines to encourage people to get tested and fight the stigma associated with HIV.

[Baroness Gould of Potternewton (Lab)]

I thank the Minister for his reply. Can he elaborate a little on the Government’s plans for promoting the guidelines to raise awareness—which I hope they will do—and monitoring the use of the guidelines to reduce the 17% rate of undiagnosed HIV and the continuing levels of HIV? The responsibility of government is absolute in making sure that the guidelines are adopted. On the same basis, can the Minister indicate what support or otherwise the Government are giving to ensuring that PrEP is made available to all those who might be at risk of HIV transmission?

[Lord Prior of Brampton]

My Lords, the undiagnosed rate of HIV is not 17%, as the noble Baroness said. That was in 2014. It is 13% now. So there is an improvement here and the trend is in the right direction. We have a whole range of programmes to try to improve the rates of testing, including self-sampling, and 1.1 million people attended GUM clinics last year. There is the HIV Prevention Innovation Fund and all the work being done by the Terrence Higgins Trust. There is a Question on PrEP later. Perhaps I could deal with it then.

[Baroness Gould of Potternewton]

My Lords, I must declare that I was on the innovation panel for Public Health England.

[Lord Black of Brentwood (Con)]

My Lords, all those living with HIV, particularly those diagnosed late, require significant levels of care for both their physical and mental health. Does my noble friend agree that specialist doctors and nurses in the NHS provide exceptional care for those living with the virus, and join me in paying particular tribute to the work of pioneering centres, such as the Ian Charleson Day Centre at London’s Royal Free Hospital, which have made a real difference to the lives of thousands of patients?

[Lord Prior of Brampton]

My Lords, I am very happy to do that. It is extraordinary how healthcare has changed a fatal disease into a chronic disease in just 20 years. I have a quote from the PHE report that was produced today, from a white lady who has HIV. She says:

“Just a few words from someone who has been living with HIV for nearly 20 years: it’s not that bad and there are times when you forget you have HIV. Eventually, even when you remember you’re positive, it’s no longer an issue”.

That is an illustration of just how far we have come in 20 years.

[Baroness Masham of Ilton (CB)]

My Lords, does the Minister agree that it is very dangerous to go around without knowing your HIV status? Will he organise some more publicity, particularly for women, because men seem to have more help than women?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. Early diagnosis is absolutely critical. We have made huge progress. The WHO guidelines aim for 90% of people with HIV to be diagnosed. We are at 87%. Sweden is the only country in the world that has hit the 90% target. I point to the It Starts With Me programme, which is based around individual responsibility and is co-ordinated by the Terrence Higgins Trust, which is making great progress.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I very much welcome the initiatives taken by the Government in this area but does the Minister accept that the NHS itself could do more, particularly in accident and emergency departments and in primary care? Would he be prepared to convene a meeting with NHS England to discuss how the NHS could be persuaded to be much more proactive in relation to testing?

[Lord Prior of Brampton]

My Lords, I am very happy to arrange a meeting of that kind. We are expecting an announcement very soon on the PrEP issue and it may be worthwhile having that meeting after that announcement.

[Baroness Walmsley (LD)]

My Lords, a high percentage of people living outside London compared to those in it are unaware of their HIV infection. It is 24% compared to 12% in London. Are the Government doing anything in the regions to replicate the good practice that we are beginning to see in London, so that that situation disappears?

[Lord Prior of Brampton]

My Lords, I think more is done in London simply because there is a greater incidence of HIV there. I was not aware of the difference between those two figures—the 12% and 24% which the noble Baroness referred to. I should like to look into that point and write to her.

[Baroness Berridge (Con)]

My Lords, one of the largest groups within the population who have got this disease through heterosexual transmission is the British black African community—men and women. There are 30,000 cases there. As of last year, estimated undiagnosed cases were increasing within this population. Can my noble friend the Minister please outline what initiatives are specifically aimed at raising awareness and avoiding the late presentation prevalent among that community? In particular, as many in that community are members of faith institutions, what is being done to engage them in raising awareness?

[Lord Prior of Brampton]

The black African community, male and female, is a group especially vulnerable to HIV, as identified in the work done by NICE. It is a part of the population where special efforts must be made to increase early testing. The work done by the Terrence Higgins Trust in the MARPs programme has also identified that community as extremely important. I think we will see greater targeting of the about 13,000 people in the population who are living with undiagnosed HIV.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the Minister referred briefly in his opening Answer to the question of stigma. I do not know whether he will have heard some testimony from people living with AIDS on the “Today” programme this morning—probably not, as he may well have been working already. It showed that they were subjected to shocking levels of prejudice, most of which appears to come from ignorance. Can he expand a little on what the Government are doing to encourage the right kind of information, not just for people who have AIDS or might be vulnerable to getting it but to the wider population whose attitudes are, frankly, a little prehistoric in quite a lot of cases?

[Lord Prior of Brampton]

That is a very insightful question. If we look back over time it is a lot better than it was but, as the noble Baroness says, it is still far from good enough. The education programme needs to go beyond just the people who have AIDS to the wider population, to get a greater degree of understanding. Perhaps I could investigate that issue a little further and write to the noble Baroness.

Social Care

Lord Prior of Brampton Excerpts

Thursday 1st December 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I join everyone else in thanking the noble Baroness, Lady Pitkeathley, for introducing the debate, which is very important. It is not easy to respond to, to be honest. I acknowledge that there are great pressures on care providers. We saw queues in A&E on the news last night. There are delays in people getting discharged from hospital. In its recent report on adult social care, the CQC found that the market was approaching “a tipping point”. In addition, as has been mentioned, the Autumn Statement did not make any specific announcements on health and social care. So there is no question but that adult social care is under huge pressure. However, that does not mean that we should become so utterly depressed that we do not see that some good things are being done as well. Many councils have risen to the challenge of achieving significant savings while setting balanced budgets, keeping council tax low and maintaining satisfaction in services. The CQC notes that,

“despite increasingly challenging circumstances, much good care is being delivered”,

and there was encouraging evidence that improvements were taking place. Nearly two-thirds of users of social care services have said that they are satisfied or very satisfied.

It is not all bad—there are some bright lights out there. We all know that there are some wonderful care homes, domiciliary care agencies and social care workers. As the noble Baroness, Lady Wheeler, did, I empathised very much with the words of my noble friend Lady Cavendish, who talked about people being “only a carer”. I agree with the noble Lord, Lord Bichard, that in many ways it is the noblest profession, very much unsung. Over time, the care certificate and the living wage will be able to transform some of those roles and give them greater status, as well as providing them with greater pay. In response to my noble friend Lady Cavendish, I say that we are looking at a single data source for data provided by care homes and others who provide social care. Extending the care certificate to volunteers is an interesting idea.

The noble Lord, Lord Patel, raised the issue of Dilnot. It is still our intention to implement Dilnot at the end of this Parliament, as I said in a debate a week ago. It will be interesting to see the results from the noble Lord’s Select Committee. Its views on insurance will be interesting to read.

I want to spend most of my speech talking about the strategic issues that underline the word “integration”, which has dominated our discussions on the subject for many years; I think that the noble Baroness, Lady Pitkeathley, said that she wrote a book on this in 1978. We had case management in the 1980s, inter-agency working in the 1990s, and integrated care pathways in the 2000s. Successive Governments have tried to bridge the gap. With great blowing of trumpets in 2000, the NHS Plan talked about integrating health and social care. The better care fund, which came out of the coalition Government, was the first national, mandatory integration policy. This year, it has a mandated minimum spend of £3.9 billion. Interestingly, it looks as though it will be up to £6 billion through local authorities voluntarily pooling resources into it. There are some examples around the country—I could give details on Northumberland, North East Lincolnshire and Plymouth—of the better care fund resulting in a change. It is not the bureaucratic change referred to by the noble Lord, Lord Bichard, although that is always a risk if you pool resources. If you pool two enormous bureaucracies, you can end up with an even bigger mess than you started with, but there is evidence on the ground that the better care fund is achieving some results. Of course, the Care Act 2014 placed a statutory duty on local authorities to promote integration. So there is no lack of rhetoric on this matter.

These efforts have not been enough, however, and all Governments—the coalition Government, our Government, the previous Labour Government—have to accept that we have brought in other policy changes that have worked in completely the opposite direction. The creation of foundation trusts, brought in by the party of the noble Baroness, Lady Wheeler, the proliferation of CCGs, brought in by the coalition Government, and, of course, payment by results have all had the effect of making the system less joined up and more fragmented and have diverted resources away from community and primary care—exactly where we want them—into secondary care. Integration is still possible in our fragmented system, but it is incredibly difficult. In practice, it requires exceptional leadership, preferably based on long-standing, trusting relationships, which are rare in many parts of the country.

The Five Year Forward View explicitly recognises this. I shall quote from it because it is worth reminding ourselves of the strategy we are embarked upon:

“The NHS will take decisive steps to break the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally … The traditional divide between primary care, community services, and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three … Increasingly we need to manage systems – networks of care – not just organisations. Out-of-hospital care needs to become a much larger part of what the NHS does”.

I think most of us who have taken part in this debate would say amen to that.

Underpinning all this work on integration is the difficult question of relationships between organisations. As the King’s Fund said last November:

“NHS organisations need to move away from a ‘fortress mentality’”,

with individual organisations protecting their own interests at the expense of the system as a whole. This is the classic “tragedy of the commons” in which individual interest destroys collective and community interest. This separation is not just a legal separation, it is budgetary, it is financial, it is institutional and, most importantly and most difficult, it is cultural. These barriers will not melt away overnight, nor will they be transformed by us passing new legislation: politicians should take note of this.

How do we put this into practice? NHS England’s planning guidance for 2016 states that sustainability and transformation plans,

“will be place-based, multi-year plans built around the needs of local populations. STPs will help drive a genuine and sustainable transformation in health and care outcomes between 2016 and 2021. They will also help build and strengthen local relationships”.

Planning by individual institutions for a year in advance will increasingly be supplemented and replaced by planning by place for local populations for a number of years in advance. For too long, the NHS has emphasised an organisational separation and autonomy that does not make sense to staff, to patients or to the communities they serve. The Government recognise, as NHS England recognises, that the process of developing STPs has been easier in places where there are strong existing relationships. As Sir Bruce Keogh says, different areas are starting in different places and they will finish in different places at different times.

Jim Mackey, the chief executive of NHS Improvement, has said that the STPs are a process, not an event, and we expect local organisations to continue to work closely together to address local health and care needs, but the STPs are bringing together health and social care on the ground. They are not perfect and they will not solve this problem overnight, but they are starting to have an impact. Different organisations are sitting down together for the first time ever and thrashing out some very difficult long-standing problems.

The next theme I want to explore is devolution because that probably has the best chance of driving towards better and more integration across boundaries and more widely across the public sector. We recognise that this process will not be easy but the direction of travel is right. To paraphrase Nye Bevan, when a bedpan is dropped on a hospital floor in Salford, its noise should resonate in Manchester Town Hall, not Westminster. Devolution should be seen as more than a shift from central to local government. It should enable communities to be directly involved in designing responsive and personalised services. Devolution will make care more accountable to local people.

The first and probably the biggest of these devolution arrangements is Greater Manchester, which has already been referred to in the debate, with the Greater Manchester Health and Social Care Partnership now taking responsibility for implementing its five-year strategic plan. The chair, the noble Lord, Lord Smith, said only a month ago that,

“the progress we have made has been revolutionary for the region”.

That progress has been made possible by the unprecedented partnership shown by working with all 37 organisations involved. It works because Manchester has long-established and well-respected leadership.

NHS England has agreed that Greater Manchester’s partners should make their own decisions on how to spend their £450 million transformation fund, which covers more than 2 million people. The new governance structure has both strategic oversight for all matters relating to health and social care services and the accountability to make big, bold decisions that can truly deliver the levels of transformation we are seeking to achieve. We are looking for transformation as well as sustainability. The same is beginning to be true for Birmingham and Solihull STP, for example, which is another STP that is led by a director of social services. The foreword to the STP plan states:

“The STP is an iterative process, and this is the start of a longer transformation journey. It’s not a short term plan—this is for long-term, sustainable change over 5 years and beyond”.

So the STPs, for all the shortcomings that some of them have, are a step in the right direction towards bringing together health and social care at local level. Picking up the point made by the noble Lord, Lord Bichard, I believe that over the next few months we will see a much greater involvement of local users and local people in structuring those STP plans.

There are two important preconditions for the success of this programme. First, too often social care is seen as the poor relation or simply as a means by which we can reduce demand on the NHS. This is to hugely undervalue and undermine the contribution that those working in the service make to the well-being of users, and the importance of social care services in their own right. Any approach to integration that fails to recognise this and instead seeks to draw in social care services just as a means to reduce NHS demand cannot be right. So when we consider how best to bring health and care services together, it is important that local areas fully appreciate the role of social care and the spectrum of services it provides. It would be wholly wrong to see social care solely as a means to reduce A&E admissions or delayed transfers of care from hospital.

Secondly, we need to be careful not to fall into the trap of thinking that better health can be secured just through integrating health and social care services, when in reality the factors that contribute to a person’s health are much more complex and wide-ranging than those within the scope of health and social care alone. The Marmot review and many other commentators since have been clear that health inequalities arise from a complex interaction of many factors—housing, income, education, deprivation, social isolation and disability—all of which are strongly affected by a person’s economic and social status and well-being. Plans to integrate services around people’s needs should consider the wider determinants of poor population health and factor them in.

The five-year forward view sets out a non-partisan strategy for what needs to be done to ensure NHS sustainability and drive improvements in the health and social care system. The STPs are putting that plan into practice. I accept, as I did at the beginning of my speech, that this is taking place against a very tough financial background. Some will argue that it makes it more difficult; I would argue that change will happen only if organisations are forced to change in order to survive. Change is necessary to meet the needs of today’s population in a way that delivers care that is both better and affordable.

I have not given up hope at all on this. The short term does look bleak and I acknowledge the huge pressures on social care—but, for the first time, we have a strategy that is actually being put into practice. It will not deliver all that we need to do in the space of two or three years, or even within the length of the five-year forward view, but if we can show that it works in some parts of the country, we have a much stronger hand to go back to the Treasury and say, “We need some more money to finance these STPs”. But we have to show that it can work at some pace and to some scale.

HIV: Barriers to Treatment

Lord Prior of Brampton Excerpts

Thursday 1st December 2016 Lords Chamber

[Lord Cashman]

To ask Her Majesty’s Government what assessment they have made of barriers to accessing treatment to prevent the spread of HIV; and what steps they are taking to address those.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, HIV treatment in itself is preventive. HIV positive people are now being given early access to HIV drugs, resulting in an undetectable viral load, which makes it very unlikely that the virus will be passed on to others. To ensure that we continue to make progress in preventing HIV, NHS England and Public Health England will say more about their further plans for a new programme in the next couple of days.

[Lord Cashman (Lab)]

I thank the Minister for his response and indeed for his commitment on this issue. However, there has been much prevarication and procrastination over who is responsible for providing access to PrEP, a drug that is known to prevent transmission of HIV. More people are at risk than ever before, so will the Government explain how they are working with NHS England and Gilead, the supplier of PrEP, to take the lead on this issue? If the price of PrEP does not decrease, how and when will the Government ensure that those at significant risk from HIV will have access to it?

[Lord Prior of Brampton]

My Lords, negotiations have been going on between NHS England, Gilead and others, and we expect a positive outcome in the very near future—in the next few days. I cannot comment on the details at this time, but as soon as we have that information, I will ensure that it is placed in the Library of the House of Lords immediately.

[Lord Paddick (LD)]

My Lords, I declare an interest as a former participant in the PROUD project and as someone whose former partner was HIV positive. The reasons why some men do not use condoms are many and complex. Why will the Government not fund PrEP when it has proved so effective in preventing HIV? Would the Minister not agree that having PrEP on the NHS would potentially save the NHS money?

[Lord Prior of Brampton]

My Lords, one of the purposes of the Act promoted by my noble friend Lord Lansley was to remove the Secretary of State, and indeed politicians, from these very difficult clinical decisions. That decision will be made by NHS England, and we expect a positive decision to be made in the very near future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, Ministers cannot evade their responsibility for the NHS in the end. NHS England is not a clinical body; it is a quango wholly owned by and wholly responsible to government. The decisions it has made have been purely about money, and it is continually endorsing crude rationing of services and the restriction of drugs. In the current agreement with the drug companies, the Minister’s Government have received nearly £2.5 billion back in rebates from those companies. Why on earth has his department allowed the Treasury effectively to ambush that money, instead of it being spent, as it should have been, on innovative new drugs for NHS patients?

[Lord Prior of Brampton]

My Lords, I think the noble Lord will agree that there is a clinically driven process, through the specialised commissioning groups and the clinical priorities group within NHS England, that attempts to look at all these drugs in an objective, clinical way. Surely it is better that these decisions on priorities should be made by clinicians acting in that way than by politicians, who are subject to all the pressures of which we are all only too well aware. Of course affordability is an issue in assessing whether a new drug should be commissioned; it always has been and always will be. The £2 billion, which the noble Lord has mentioned before and which I think comes from the PPRS, is taken into account when setting the overall budget for NHS England.

[Lord Black of Brentwood (Con)]

My Lords, one of the significant barriers to effective HIV treatment is that it is often present with a co-infection such as hepatitis. What steps are the Government taking to identify, diagnose and treat people who are co-infected with HIV and hepatitis C, the most deadly form of the infection?

[Lord Prior of Brampton]

My Lords, I am afraid I cannot answer that question, or at least I could answer it in only a very inadequate way. I would like to reflect on it and write to my noble friend as soon as I can.

[Baroness Tonge (Non-Afl)]

My Lords, what progress is being made in the development of a vaccine against AIDS?

[Lord Prior of Brampton]

I do not like to have two questions on the trot that I cannot answer, but I do not know the answer to the noble Baroness’s question. I shall have to research it and write to her.

[Baroness Hussein-Ece (LD)]

My Lords, what steps are being taken to ensure that prisoners have access to treatment, testing and care while in prison? They are more likely to be drug users, more susceptible and more likely to be from communities that do not get themselves tested, even when they are in good health. Could the Minister say something about prison health?

[Lord Prior of Brampton]

There is a particular problem in prisons, as the noble Baroness refers to. There is a higher incidence of HIV in prisons, for all the reasons that she has alluded to. The NICE guidance and the PHE resources report that came out today echo her point. We have to reinforce and redouble our efforts in prisons to identify HIV earlier through better testing.

[Baroness Masham of Ilton (CB)]

My Lords, does the Minister agree that the HIV virus is a very difficult virus, and that this is one of the problems of getting a vaccine?

--- Later in debate ---

[Lord Prior of Brampton]

I thank the noble Baroness for coming to my rescue on that. It is very difficult, as she knows, because the HIV virus is complex. What is remarkable is the extraordinary advances that have been made in treating HIV over the last 20 years; that has been a real triumph of the pharmaceutical industry. I will still write to the noble Baroness, Lady Tonge, about vaccines.

[Baroness Gould of Potternewton (Lab)]

My Lords, I was not going to refer to vaccines but to something else, but a report on the radio this morning said that South Africa believes it has developed a vaccine that will prevent HIV. Maybe we could find out more about that in due course.

I wanted to ask the Minister about barriers, of which there seem to be two. My noble friend has raised one—stigma—and I got the impression that the Minister felt it was perhaps not as serious as it used to be. It is very serious; there are still many examples, particularly of women, who will not go to a clinic, thus creating a barrier, because of the stigma that is attached. The other barrier that is equally important is that local authorities that fund testing are having huge difficulty in raising the funds to do so. Maybe we should be looking at whether there is a positive way in which the Government can help with resources to local government.

[Lord Prior of Brampton]

Frankly, this is an area where government can never do enough. We should take some comfort from the fact that the level of undiagnosed HIV is consistently coming down; it is now down to 13%, and we are within touching distance of the WHO’s 90% level. So we are making progress, but I accept what the noble Baroness says. On stigma, I am sure there is much more that we can do.

Health and Social Care

Lord Prior of Brampton Excerpts

Thursday 24th November 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, when the noble Lord, Lord Turnberg, said that this has been a depressing debate, he was not exaggerating. The noble Lord, Lord Warner, referred to “A Streetcar Named Desire”. Frankly, I feel more like Hamlet:

“To be, or not to be”.

It has been a very thought-provoking debate and I thank the noble Baroness, Lady Finlay, for raising this hugely important issue. If there has been some deviation from the subject on the Order Paper, that is perhaps understandable, given how important the issue is. In thanking the noble Baroness, I echo the remarks of the noble Lord, Lord Wigley, about the work she has done in palliative care in Wales. I know she has had a huge impact on healthcare in Wales. Indeed, that has extended to Norfolk because she has been to Norfolk a few times as well and I know that that is hugely appreciated.

Before I get into the meat of the subject, I will pick up the point about people who work in social care. The noble Baroness said that the turnover rate of people who work in social care is 37%, which is a pretty shocking figure. You cannot run a business if you have a staff turnover of one in three; you certainly cannot deliver good-quality care. I see my noble friend Lady Cavendish sitting in the corner. The Cavendish report that she produced four years ago, which introduced the care certificate for people working in social care, has had a huge impact. I think there was a worry at the time that it was another piece of bureaucracy but it has had a big impact. Of course, the move to the living wage will have a big impact as well. I agree with the right reverend Prelate the Bishop of Ely and others that social care workers are a hugely undervalued part of our workforce. They do extraordinary work and I record the strength of feeling we all have in this House for the work they do.

There are three big issues running through this debate. First, there should be no doubt that the healthcare system, social care and the NHS depend on people from all over the world—from Asia, Africa and the Caribbean as well as Europe. It will always be so and we are hugely in their debt. The Health Service Journal held its awards yesterday and Alastair McLellan, the editor, said:

“The NHS has always relied on people from around the world to help it deliver for its patients and even accounting for planned welcome increases in home grown staff, it always will”.

I echo those words and would add people who work in social care. We owe a huge debt to all those people. They play a vital role.

The second theme is this: like most people who contributed to this debate, I voted to stay in the EU and I have not changed my mind about that. I voted to stay in the EU and I would like to have stayed in the EU. As was mentioned by the noble Lord, Lord Lipsey, sometimes it is as if we in this House are preparing a dossier on why the British people got it wrong. It is about time that we listened to what the British people said. They voted to leave the European Union. It does us no credit as a House to keep on moaning about why we have left. We have left. Let us make most of it.

[Noble Lords]

We have not left.

[Lord Prior of Brampton]

We have voted to leave the European Union. We now have to make the most of it. We can make the most of it and we can make a success of it. We can use Brexit as a catalyst for change. Even though most people, like me, wanted to stay in the EU, none of us felt that the EU was perfect. Most of us felt that it was a deeply flawed institution. Now that we will be outside the European Union there are huge opportunities that we can take.

The third theme is immigration. Immigration has been hugely beneficial for our country, not least for the NHS but for our country as a whole, and we should celebrate that. But that does not mean to say that uncontrolled, high levels of immigration cannot do damage to our country. The tone of the debate, both in the US around the election and here around Brexit, was often deeply shocking, deeply unhelpful and, as many others have mentioned, deeply deplored.

However, let us not pretend for one minute that all the difficulties around immigration in this country stem from those two debates. No one can say that the “Black Lives Matter” campaign in the US suddenly started when Donald Trump became President-elect. No one can say that the problems which people from BME backgrounds have with the criminal justice system, or have in the NHS, suddenly stemmed from Brexit. Many of these issues are much more profound, much deeper and much more fundamental than that. Controlled levels of immigration can undoubtedly enrich this country materially and culturally, but uncontrolled immigration runs the risk of damaging both those things. Those were the three big issues that ran through this debate.

I turn to the scale of the issue that confronts us. There are 57,000 colleagues from EU member states working in the NHS and about 90,000 working in the social care system. As we heard from my noble friend Lord Colwyn, there are 7,000 dentists from the EU. We know that the proportion of overseas and EU staff is much higher in some parts of the country, especially London. We also know that there is a huge impact on our life sciences industry—I took note in particular of the comments of the noble Lord, Lord Bilimoria, on this—from EU nationals and people from other parts of the world. The collaborative work we do across the EU in life sciences is extremely important. Cancer Research UK says that between 30% and 40% of all its research is done in collaboration with EU nationals. As we put together our strategy for the life sciences, as part of the industrial strategy, I assure the noble Lord that access to the world’s best talent will be absolutely centre-stage and critical.

There should be absolutely no doubt that the UK benefits from immigration, but reducing net migration is compatible with continuing to attract hard-working and skilled people who come here to study and to work. The immigration system will always have a role to play in supporting growth and meeting the needs of UK businesses. People from overseas fill vital gaps in our labour market in social care, nursing, medicine and science.

The Prime Minister has been absolutely clear that she wants to protect the status of EU nationals already living here—incidentally, this was also the view of her predecessor, David Cameron—and that the only circumstances in which it would not be possible is if British citizens’ rights in European member states were not protected in return. Some degree of reciprocity does not seem unreasonable. Personally, I regard the chances of that happening as being so remote as to be almost inconceivable. My right honourable colleague the Secretary of State for Exiting the EU, David Davis, also made this clear when he said:

“We will always welcome those with the skills, the drive and the expertise to make our nation better still. If we are to win in the global marketplace, we must win the global battle for talent. Britain has always been one of the most tolerant and welcoming places on the face of the earth. It must and it will remain so”.

[Lord Bilimoria]

Can the Minister explain this one fact? We have had uncontrolled immigration from the European Union, and we have heard from all quarters in this debate that the NHS and the care sector are highly dependent on those people. We have more than 3 million people from the EU living and working here, yet we have the lowest level of unemployment and the highest level of employment in living memory. How would we have managed without these people? If people voted to leave because of the burden of immigrants on the public sector, we have just proved in this debate that without those immigrants they would not have the public sector.

[Lord Prior of Brampton]

I repeat what I said earlier: the contribution made by people coming into this country from the EU and elsewhere has been enormous. It was clear in the Statement yesterday that one of the great fundamental problems we face in this country is low levels of productivity. If we are to afford the kind of social care system and health system that we want, we have got to increase levels of productivity. It has been too easy for us in this country to rely upon people coming from overseas rather than training our own people.

I strongly believe that that is why we must focus on areas such as life sciences, for example, where we have huge strength in research and high levels of productivity. That is the only way that we are going to be able to afford to have the kind of health and social care system that we need. I agree with David Davis. The Conservative Party is unashamedly internationalist, outward-looking and global in its outlook. There is no place for jingoistic, xenophobic or little England views in our party. On the contrary, we look out to the world, a world that includes Europe, but is not defined by Europe. Noble Lords deplored the xenophobia that appears to have increased since Brexit, and I entirely share their views. There can never be any excuse for that kind of attitude.

We recognise that we cannot continue to rely on people from overseas to maintain the level of staff that is required within our health and care system, nor is it right to do so. If we are honest with ourselves, we knew this before Brexit. We must become more self-sufficient. Indeed, this is consistent with our commitment to the World Health Organization’s priorities on human resources for health. It cannot be morally right for a rich country such as the UK to recruit skilled doctors, nurses and other workers from countries whose need is so much greater than ours, so we will take a range of actions to increase the supply of domestically trained staff and to increase efficiency through better use of technology and skill-mix solutions.

In respect of the NHS, we have already increased the number of key professional groups being trained. For example, since 2013 the number of nurse training commissions has increased year on year by some 15%, and we expect to have 40,000 more nurses by 2020 than we had in 2015. We are committed to ensuring that there will be 5,000 more doctors working in general practice by 2020. From September 2018, the Government will fund up to 1,500 additional undergraduate student places through medical schools in England each year. This is in addition to the 6,000 medical school places currently available in England. That is a very significant increase. It is 1,500 places each year on a five-year course, so that is an extra 7,500 doctors coming through the system. The recent reforms to the funding of training for nurses and allied health professionals will further increase supply by removing restrictions on the number of training places, so that universities are enabled to deliver up to 10,000 additional nursing, midwifery and allied health training places over the course of this Parliament.

Nevertheless, it is important to recognise that it takes time to train skilled health and care professionals, and therefore we have introduced initiatives to improve retention and to encourage trained staff to return to practice. We are also working to increase the efficiency with which we use our existing staff and to improve productivity by changing the skill mix through the introduction of new roles, such as physician associates and nursing associates. This will ensure that highly trained professional staff are properly supported and more productive. We will also see over the next five years a huge increase in the use of digital technology to enable more people to be looked after outside hospital settings.

We all recognise that social care is a vital service for many older and disabled people. The Department of Health is working with Skills for Care, employers and Health Education England to support activity to recruit and, importantly, retain our caring and skilled workers who work in social care. In many ways, these people are the unsung heroes of the health and social care system, delivering very personal care to very vulnerable people at very low salary levels. Since 2010, we have seen more than 340,000 new apprentices into the workplace in the care sector, which is more than any other sector. So we are taking action to increase our home-trained workforce in medicine, nursing and social care.

I do not want anyone in this House to think for one minute that we underestimate the challenges that Brexit presents to the health and social care system, but I think it also presents huge opportunities. It behoves us in this House just occasionally to look on the slightly more optimistic side, and not to be quite as depressing as we sometimes are.

[Lord Warner]

Before the Minister sits down, could he address the issue of reciprocity, which some of us raised? There is no incentive for the EU to give guarantees on reciprocity, so why should it move on this area at this point? We stand to lose because those people will actually leave unless they are given guarantees. If we are going to wait to reassure these people until there is reciprocity, we are bound to lose that argument. Why can we not move on this issue before reciprocity?

[Lord Prior of Brampton]

My Lords, we have not even triggered Article 50 at this point. It would be pretty strange for us to start taking unilateral action until at least the article had been triggered and negotiations had begun.