Health and Social Care: State Pension

Lord Prior of Brampton Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what is their response to the suggestion by the Chief Executive of NHS England that they should look at all the options for adequately funding health and social care, including revisiting the guaranteed annual increases in the state pension until 2020.

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

My Lords, the Government are committed to both a state pension system that ensures financial security in retirement, and a sustainable health and social care system. We are increasing funding for the NHS by £10 billion a year in real terms to fully fund the NHS’s plan. Alongside this, local authorities have been given access to up to £3.5 billion extra a year by the end of the Parliament with the social care precept and additional investment.

[Lord Hunt of Kings Heath (Lab)]

I am grateful to the noble Lord. He mentioned billions of pounds, but he will know that the analysis by the King’s Fund shows that over the five years of this Parliament the real-terms growth rate for the NHS is actually less than in the last Parliament, and social care will see a continuation of the cuts. Research published today shows that 25 other countries spend more of their share of GDP than we do on health; we have fewer doctors and nurses and less equipment and access to new drugs than many comparable countries. The NHS is facing a huge crisis. When are Ministers going to tackle this and get a grip?

[Lord Prior of Brampton]

My Lords, the NHS produced its five-year forward view 18 months ago, which called for additional spending in real terms from the Government over the five-year period of £8 billion. The Government have met that in full and are front-loading that investment, as the noble Lord knows, spending £3.8 billion in the forthcoming year. So the Government are fully supporting the NHS’s plan.

[Baroness Brinton (LD)]

My Lords, there are two issues here. One is the short-term funding issue, and the noble Lord, Lord Hunt, is absolutely right to say that there is a crisis. Simon Stevens’s reference was about much more than just the pension; there are intergenerational fairness issues and a whole string of other things. My honourable friend in another place, Norman Lamb, suggested that there should be a cross-party commission to look at these issues, which cannot be resolved overnight. Is there progress on the Government accepting the principle of this cross-party commission and, if so, when might an announcement be made?

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[Lord Prior of Brampton]

The Government believe that we have a plan—it is the NHS’s plan, which we fully support—and that to set up an alternative commission or other kind of look at the future would be a distraction at this time.

[Lord Cormack (Con)]

My Lords, it is over 70 years since Beveridge and almost 70 years since the foundation of the National Health Service. In the debate brilliantly introduced by my noble friend Lord Fowler last week, there were many calls for a commission or an inquiry from all parts of the House—from the Cross Benches and all the political parties. Cannot my noble friend give us some hope that he has a chink of an open mind?

[Lord Prior of Brampton]

My Lords, I am afraid that I cannot today give my noble friend that chink or that hope, because we are supporting the NHS’s plan, which was developed and produced by the NHS. We believe that it would be wrong to set up an alternative at this stage.

[Lord Lansley (Con)]

My Lords, would my noble friend agree that, while the Government are fully funding the NHS five-year forward view, which is very welcome, the sustainability of NHS funding depends on the sustainability of social care services as well? Before establishing any other commissions, would not it be advisable for the Government to make progress on implementing the Dilnot commission’s recommendations? In that respect, will the Government specifically consider enabling that to proceed by removing the exemption on one’s principal personal residence when calculating the means test for domiciliary social care?

[Lord Prior of Brampton]

My Lords, as my noble friend knows, the Government accepted the findings of the Dilnot review but felt that now was not the right time to introduce them, given the financial pressures on local government. We are committed to introducing the Dilnot reforms by the end of this Parliament.

[Lord Brooke of Alverthorpe (Lab)]

Is not the plan inadequate? Many noble Lords come with requests for quite justifiable changes to health services and the Minister very generously and kindly kicks them back because of inadequate resources to meet those demands. Surely it is the case that in looking at the plan we need to look at the longer term and not just the short term in five years.

[Lord Prior of Brampton]

The NHS plan is for the whole five-year period—the lifetime of this Parliament. It was signed up to by all the arm’s-length bodies within the NHS. The Government support that plan and are front-loading the financing to support the plan as well, so we believe that the plan is achievable.

[Lord Fowler (Con)]

Is not the key point exactly the one that has just been made? We are talking not about the five-year plan but about the years that come after that and how you get a National Health Service which can be financed over the long term. Surely that is what we should also be looking at, apart from the Government’s own plan.

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[Lord Prior of Brampton]

I know my noble friend feels very strongly that we should have a royal commission to look at the long-term affordability and funding of the NHS. That is not the Government’s view.

[The Lord Bishop of St Albans]

My Lords, in last week’s NHS debate, which very helpfully explored a number of areas, a number of noble Lords referred to the independent American research pointing out that among the—I think—11 most developed countries, our health service came out right at the top, except in the area of prevention. The worry that many of us have is that a lot of the money is being front-loaded on to the NHS, which is responding to immediate needs, but that the long-term need for a cross-party agreement on how we get much better at preventing illness and having health programmes is lacking. Can we yet again press the Minister to see how we can get some sort of cross-party agreement on this proactive approach?

[Lord Prior of Brampton]

The right reverend Prelate is right to remind the House of the report by the Commonwealth Fund which indicated that the National Health Service is the most efficient and overall the best healthcare system in the world. He also referred to prevention. The childhood obesity prevention strategy is due to be announced by the Government in the next couple of months. We have made huge progress on reducing smoking and in other areas of prevention, but I agree with the right reverend Prelate that prevention is a critical part of our long-term approach to healthcare.

[Baroness Walmsley (LD)]

My Lords, the Minister talks about the support for the five-year forward view, but is he aware that more than 80% of finance leads within the health service do not believe that the five-year forward view can achieve the savings that it says it can? It just cannot be done without extra resources. Surely, particularly with the state of affairs in social care, where the Government’s extra money is being back-loaded, not front-loaded, we need to take an overall holistic look at health and social care and how much we should be spending as a country and how we are prepared to raise that money fairly.

[Lord Prior of Brampton]

My Lords, I think that the same question is being asked in slightly different terms by many different noble Lords. I cannot really add to what I said before. We are supporting the NHS’s plan. By the end of this Parliament we will be putting another £3.5 billion into social care through the social care precept and an extra £1.5 billion into the better care fund. We believe that we have a plan for social care and healthcare over the course of this Parliament.

NHS: Preventive Medicine

Lord Prior of Brampton Excerpts

Wednesday 20th January 2016 Lords Chamber

[Baroness Rawlings]

To ask Her Majesty’s Government how they intend further to incorporate preventive medicine into the National Health Service.

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

My Lords, the NHS five-year forward view set out a shared vision for the future of the NHS. It includes the long-standing aspiration for the NHS to focus as much on prevention and promoting wellness as managing poor health, working in partnership with local public health services through health and well-being boards.

[Baroness Rawlings (Con)]

My Lords, I thank the Minister for his positive reply. I never thought that I would quote in your Lordships’ House the leader of the Opposition in the other place. He asked the Prime Minister at Prime Minister’s Questions recently whether he had,

“forgotten the simple maxim that prevention is cheaper and better than cure”.—[Official Report, Commons, 16/12/15; col. 1545.]

I commend the National Health Service for shifting its policy from sickness and cure to wellness and prevention. Would the Minister, through the National Health Service, encourage private health insurance organisations to do likewise, thus evading certain serious sicknesses and not adding to the National Health Service’s overstretched budget?

[Lord Prior of Brampton]

My Lords, there is clearly a direct legal contractual relationship between a private insurance company and an individual. The NHS cannot interfere directly with that contract. There is no similar legal relationship between the NHS and the citizen, although there is clearly a social and moral contract between the two. As part of that contract the state agrees to provide free, high-quality healthcare. It is only right that the individual should accept personal responsibility for their health and well-being, and that of their family.

[Lord Rooker (Lab)]

Can I make a suggestion to the Minister? If the Government want to take preventive medicine seriously, they should invite Sir Nicholas Wald, Professor of preventive medicine at the Wolfson Institute, to come and talk about his lifetime’s work on things such as the polypill, and, indeed, his leadership in1990 of the Medical Research Council’s work on preventing spina bifida and neural tube defects in babies by the use of folic acid in flour.

[Lord Prior of Brampton]

I thank the noble Lord for raising this issue today. We discussed it yesterday and the Government will give him a full response to the issue of fortifying bread with folic acid in the very near future.

[Baroness Finlay of Llandaff (CB)]

Does the Minister recognise in his answer that people should be responsible for their own health and the health of their families that there is a responsibility on the NHS to ensure that there is adequate support before, during and after bereavement of children? The preventive effect on mental health problems later in life is very clearly shown. Those who are unsupported do less well in the whole life course in mental health, and in social and educational outcomes.

[Lord Prior of Brampton]

My Lords, clearly, the state has a huge role to play in prevention; I was certainly not questioning that for one moment. I was just saying that I believe that individuals and families have responsibilities as well.

[Baroness Tyler of Enfield (LD)]

My Lords, given that £1 in every £5 of healthcare costs is associated with conditions that could be prevented, what assessment have the Government made of the likely cost savings on NHS spending of using more preventive medicine?

[Lord Prior of Brampton]

My Lords, if the noble Baroness reads the Five Year Forward View, she will see that prevention is a very critical part of that. But, of course, prevention goes much wider than healthcare in the NHS; it goes to employment, housing, education and a whole range of other things. Having a strong and vibrant economy with high levels of employment is vital.

[Lord Howarth of Newport (Lab)]

My Lords, in their preventive strategy what will the Government do to attend to the social determinants of ill health, including inequality, deprivation in early childhood and deteriorating public services?

[Lord Prior of Brampton]

My Lords, it is a very serious issue that over 40 years, and probably for longer, the difference between the life expectancy of the rich and the poor has always remained at about 10 years: and for healthy living it is more like 25 years. I think it is fully understood from Sir Michael Marmot’s report and thereafter that the social determinants are more important in closing that gap than anything we can do in healthcare directly, so what the noble Lord says is absolutely true.

[Baroness Greengross (CB)]

In the 2015 report Opportunity Knocks: Designing Solutions for an Ageing Society, the University of Cambridge Engineering Design Centre, the ILC-UK and the IET highlighted the vital role of good design and technology in supporting preventive medicine, particularly, but not exclusively, for older people. The OBR warned us last year that without technological innovation over the next decade, health spending in 2063 might be 5% of GDP higher than currently projected. Do Her Majesty’s Government agree that we must invest in technology to save money by facilitating the preferred solution of sustaining independent living, particularly among older people and those subject to the revolving door syndrome? Will the Government support this and invest in it?

[Lord Prior of Brampton]

My Lords, good design is very much part of any long-term strategy towards improving the lives of our citizens, so it is a hugely important part of our longer-term strategy.

[Baroness Wheeler (Lab)]

My Lords, we know that smoking is by far the biggest cause of death in the UK and research shows that two-thirds of smokers want to quit, yet the recent ASH survey has shown that the cuts in public health funding and in council budgets have led to 40% of local authorities having to cut stop smoking services. Last year these were used by more than 450,000 people. They are three times more likely to quit if they get the vital support of these services. How can it make sense to cut services when for every £1 spent on cessation services, £10 is saved in future NHS and health gains?

[Lord Prior of Brampton]

Successive Governments have had a huge impact on reducing smoking levels, which are now down to 18%—the lowest they have ever been.

[Lord Forsyth of Drumlean (Con)]

My Lords, would this not be a suitable subject to be considered by a royal commission on the health service, which my noble friend Lord Fowler has advocated and for which he has considerable support in all parts of the House?

[Lord Prior of Brampton]

My Lords, the issue to which my noble friend refers was fairly fully discussed in a debate in this House initiated by the noble Lord, Lord Crisp, only some two months ago. If Members of this House wish to discuss it further, they are, of course, very welcome to do so. However, I am not sure that a royal commission is necessarily the right way to proceed.

Health: Cancer

Lord Prior of Brampton Excerpts

Wednesday 20th January 2016 Lords Chamber

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

My Lords, I join everybody else in thanking the noble Baroness, Lady Walmsley, for bringing this very important debate to the House. It really is a shame that we have only an hour. So much has been said that I cannot do it all justice. The noble Baroness kindly gave me a hint of what she might say this evening, so I hope that I will cover that in my main speech. I would like to come back to her on the two-week target. Maybe I could write to her on that.

My noble friend Lord Colwyn raised the importance of the dental profession, which again is all part of the common theme of early diagnosis. The importance of clinical trials was raised by the noble Lord, Lord Wood, particularly in relation to teenagers and children. They are clearly very important. I would like to come back to the noble Lord, Lord Sharkey, about his comment that CCGs were putting in incentives to GPs for not referring suspected cases of cancer. Perhaps I might investigate and come back to him on that important issue.

The noble Lord, Lord Freyberg, mentioned powerfully the power of transparency. The example he gave which stuck with me was that of prostate cancer and the differing rates of incontinence as a result of that. I think that it was in Hamburg that the results were particularly good. In answer to the noble Lord, Lord Hunt, I have already agreed to meet the noble Lord, Lord Freyberg. Transparency about survival rates will not solve all the issues but could be very powerful.

Both my noble friend Lady Hodgson and the noble Lord, Lord Hunt, raised the issue of screening for elderly people. I will write to them on that issue, as I cannot give them an answer this evening. The noble Baroness, Lady Masham, raised the issue of proton beam therapy. Again, I will write a progress report to her on that. As she knows, we are proceeding with two centres, one in Manchester and one at UCLH in London. I believe that both of them have started and are on target, but I will revert to her on that if I can.

My noble friend Lady Redfern asked whether we could look at increasing public awareness and referred to the Be Clear on Cancer campaign. That is important. The noble Lord, Lord Aberdare, raised the issue of pancreatic cancer. I was not aware that the survival rate after a year was 5%. That is terribly low, and I would like to research that more. The noble Lord, Lord Hunt, raised lots of important questions, but in answer to a particularly important one, NHS England has, as I understand it, accepted the recommendations of the Harpal Kumar report and will be implementing them over the next four years.

I hope that I will answer most of the questions in my speech. It is worth noting that we have made huge progress over the last 15 years, even though the kernel of the debate this evening is that we have got a lot further to go to catch up with our European neighbours. Activity has increased dramatically. In the last five years, 645,000 more patients with suspected cancers were seen, an increase of 71%. Almost 40,000 more patients were treated for cancer, an increase of 17%.

The proportion of cancers diagnosed as a result of emergency presentation—an issue raised by a number of noble Lords—has decreased significantly. At the same time, the proportion of cancers diagnosed through urgent GP referral following a suspicion of cancer has increased. In 2006, almost 25% of all cancers were diagnosed as an emergency. In 2013, this figure had fallen to 20%, or one in five. That is a considerable reduction, but there is still a long way to go. To help diagnose cancer earlier, we have invested over £22 million in our Be Clear on Cancer campaigns and we continue to expand and modernise our cancer screening programmes. Nationally, 37% of radiotherapy treatments are now being delivered with more precise intensity-modulated radiation therapy—IMRT—ahead of the 24% target.

Since October 2010, the Cancer Drugs Fund has helped more than 84,000 cancer patients in England, and £1 billion has now been made available to support that fund. We are committed to the fund, although we are out for consultation at the moment as to how we should progress it forward for next year. It is worth noting that in this current year some £340 million has been spent in that fund. Some of these new cancer drugs are extremely expensive.

We know that cancer survival in England has historically lagged behind the best-performing countries in Europe and the world, but none of these international comparisons of cancer include patients more recently diagnosed than 2009. As a result, we should be careful about using these comparisons as a measure of the current performance of the system, although they can be useful as a long-term benchmark. Although we will have improved considerably since that time, I suspect that other countries will also have improved, so the question is whether that gap has closed. Although our survival rates are at a record high and continue to improve, as shown by the new figures published by the ONS in November, we know that we must do better. The gap between England and the better-performing countries is narrowing for some cancers, but for others it remains.

That is why, in January last year, NHS England announced a new Independent Cancer Taskforce to develop a five-year strategy for cancer. A report was published in July 2015, which I think was well received by most interested parties. It recommends improvements across the cancer pathway with the aim of improving survival rates. I thank Sir Harpal Kumar and his colleagues for that report.

In terms of delivery, NHS England has recently appointed Cally Palmer, whom some of you will know, as she is also chief executive of the Royal Marsden, as the NHS National Cancer Director. She will lead on implementation, as well as new cancer vanguards to redesign care and patient experience. She is currently setting up a new Cancer Transformation Board to lead the rollout of the recommendations of the new strategy, and a Cancer Advisory Group, chaired by Sir Harpal Kumar, will oversee and scrutinise its work. I hope that that will go some way to addressing the concerns of the noble Lord, Lord Hunt, about the networks that used to be there. We hope that they will put in place something similar, if not the same.

Although this is a five-year strategy and an implementation plan is being developed, good progress has already been made on many of the key recommendations. The task force recognised the importance of early and faster diagnosis to improve outcomes and experience. It is essential that we make sure that cancer is diagnosed as early as possible, so we will adopt the task force’s ambitious new waiting times target for the NHS. From 2020, patients will be given a definitive cancer diagnosis or the all-clear within 28 days of being referred by a GP. This will mean that the period of uncertainty will be as short as possible.

We are backing this with an expected investment of up to £300 million a year by 2020, along with a national training programme for an additional 200 staff with the skills and expertise to carry out endoscopy tests by 2018. This is an area of shortage at the moment. We have also confirmed a commitment from NHS England to implement the Independent Cancer Taskforce’s recommendations on molecular diagnostics. This will mean that about 25,000 additional people a year will have their cancers genetically tested to identify the most effective treatments. I noted the comments of the noble Baroness, Lady Masham, about fairness in access to molecular diagnostic tests.

To monitor the impact of the new strategy, we are also introducing two new outcome metrics: the proportion of cancers diagnosed at stages 1 and 2 and the proportion of cancers diagnosed through an emergency route. These will be published quarterly at CCG level from May 2016. From April 2016, the new cancer dashboard will enable every CCG to see its data and benchmark itself against other CCGs and England as a whole. It will measure progress with a focus on incidence, survival rates, patient experience and quality of life for patients.

In conclusion, I congratulate your Lordships’ House on the quality of this debate. Some fascinating issues have been raised. The personal experience of many noble Lords has been particularly illuminating. I hope that I have been able to set out our commitment to delivering the Independent Cancer Taskforce’s new strategy, the good progress that has already been made, and NHS England’s robust plans to turn the recommendations into reality.

If the NHS is successful in implementing its initiatives and ambitions, an additional 30,000 patients a year will survive cancer for 10 years or more by 2020, 11,000 through early diagnosis. There will also be a closing of the gap in survival rates between England and the best countries in the world, which is something that we all want to see.

We have some progress to report. It is never enough. It will take time to build up both the diagnosis and treatment resources so that we can close that gap with other European countries completely, but with Sir Harpal Kumar’s task force report, we have a very clear way to do that.

[Lord Aberdare]

My Lords, before the noble Lord sits down, I hope that I did not misspeak, but the figure I cited of 5% for pancreatic survival was for five years, not one. I apologise if I misled the Minister.

Health: Red Cell Folate

Lord Prior of Brampton Excerpts

Tuesday 19th January 2016 Lords Chamber

[Lord Rooker]

To ask Her Majesty’s Government, further to the remarks by Lord Prior of Brampton on 21 December 2015 (HL Deb, col 2308), whether the letter from the Scientific Advisory Committee on Nutrition gave any indication of how many women aged 16 to 49 in the United Kingdom met the recommendations from the World Health Organisation regarding red cell folate concentration.

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

The advisory committee’s letter indicates that 14.5% of UK women of childbearing age met the new threshold for red cell folate concentration that has been recommended by the World Health Organization since April 2015. Ministers are reviewing the contents of the letter carefully. They plan to come forward with their response to the committee’s latest advice in due course.

[Lord Rooker (Lab)]

I thank the Minister for that Answer but he has just told the House that 85% of women of childbearing age in the United Kingdom failed to meet a major World Health Organization target. The letter says that UK levels are the same as those in the United States of America before fortification with folic acid. Following fortification, US women are now above the World Health Organization target, there have been fewer avoidable abortions, there have been fewer babies with a serious lifelong disability, and the USA is saving half a billion dollars in healthcare costs. The same story is repeated from Canada to South Africa and from Chile to Australia. Worryingly, the same letter says that blood folate levels have gone down so low, it looks like there has been a 25% increase in terminations in England and Wales in the past few years as a result of the current policy of advice only rather than fortification. I say to the Minister: none of the figures in that letter was new. They were known on 20 March last year. The House recesses on 23 March this year. Will we have a decision before we recess?

[Lord Prior of Brampton]

My Lords, the letter that the noble Lord refers to was received on 20 October last year, so we have had it for a little over three months. It is very important to make the point that it is not that the red cell folate levels of British women have gone down but that the threshold used by the WHO has gone up, from 340 nanomoles per litre to 906 nanomoles per litre. Nevertheless, the noble Lord makes a very strong point. He has made it before, in December. There is a lot of medical and scientific evidence on his side of the argument. There are other arguments that the Government are taking into account.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that, as I was told this morning by three neural disease specialists, the danger of overmedication with folic acid by fortification is absolutely minuscule—you cannot measure it? In addition, they suggested to me that it is vital that we reduce the number of babies with neural tube defects because, due to our success in the past in reducing the numbers, the specialists and services for such babies are very thin on the ground. We really need to do something about this now.

[Lord Prior of Brampton]

My Lords, the danger of overmedication with folic acid is small, I accept that. It is not non-existent but it is small. Just so that the House knows the numbers, the number of babies aborted because of neural tube defects is about 400 a year; the number who are born with neural tube defects, alive or not alive, is about 60 a year. It is a very serious issue and one that the Government are taking extremely seriously, but we have to weigh that against the other issues of medicating the entire population.

[Baroness Hayman (CB)]

My Lords, some of us have long memories that go back to 1991, when the MRC study into this issue had to be stopped early because the results were so overwhelmingly in favour of folic supplementation. The lead researcher on that study was Sir Nicholas Wald. More than 80 countries have taken very seriously those results and have taken on board fortification of white flour. In 2015 Sir Nicholas published a paper about the lost opportunity in the UK. Is it not a matter of profound regret, verging on shame, that in this country, where the initial research was done, we are now being told that there will be a decision “in due course”? If I remember correctly, the last time the Minister spoke about this, he said that it would be very early in the new year.

[Lord Prior of Brampton]

My Lords, I think we are still quite early in the new year. I do not go back to 1991 but the noble Baroness is right: for many years now there has been a large body of scientific opinion in favour of increasing the uptake of folic acid. There is no dispute about that—I do not think there is much science to dispute. The issue is one of balancing the scientific and medical arguments with issues around choice and whether or not it is right to medicate the entire population for the benefit of a fairly small part of it.

[Lord Hughes of Woodside (Lab)]

My Lords, when the Minister says that other views have been taken into account, will he lay to rest today and for ever the idea that the Government will be swayed by those who say, spuriously and nonsensically, that this is mass medication?

[Lord Prior of Brampton]

The proposal is that bread should be fortified with folic acid. The point of doing it through bread is that most people eat bread and that it would reach the widest number of people. It would be fortifying a product that most people eat; that is the purpose of it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is the Minister really saying that adding a very small amount to flour is mass medication; is that not overdoing it? I say to him, as I said on 21 December: can Ministers not come to a decision, yes or no? I get the sense that it is no, because he is putting much more stress on the issue of mass medication now than he has ever done on previous questions. I also go back to the answers that his noble friend Earl Howe gave over the last two or three years. Can the Minister not make that decision? The last thing we need would be to refer it yet again to another expert committee for yet more research, when it is quite clear that it would be effective and safe.

[Lord Prior of Brampton]

My Lords, I can only repeat what I said: we are in the process of making a decision and that decision will be made shortly.

National Health Service: In-Patients with Learning Disabilities

Lord Prior of Brampton Excerpts

Monday 18th January 2016 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what is their estimate of the number of avoidable deaths of National Health Service inpatients with learning disabilities since 2011.

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

My Lords, this Government are committed to reducing the level of avoidable deaths. The learning disabilities mortality review, commencing this year, is piloting local reviews of premature deaths of people with learning disabilities. The Care Quality Commission will also be undertaking a wider review into the investigation of deaths in a sample of acute, mental health and community trusts.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister for his Answer. He is clearly aware of the recent reports which have shown that there have been many avoidable deaths of people with learning disabilities within the care of the National Health Service. Indeed, some estimates have put it at more than 1,000 deaths per year. He is aware that Sir Bruce Keogh, medical director of NHS England, has very recently written to NHS and foundation trusts asking them to carry out a self-assessment of avoidable deaths. Given that the NHS seems to have a real problem with providing decent care generally to people with learning disabilities, how confident can we be that this self-assessment will actually identify people with learning disabilities who have suffered avoidable deaths within its care?

[Lord Prior of Brampton]

My Lords, this is a very important question. The fact that so many people with learning difficulties die much younger than people without them is of concern to everybody in this House. The review being conducted by Sir Bruce Keogh, to which the noble Lord referred, is a self-assessment tool. It is due to report quickly—by April—so is a short-term attempt to get the bottom of this. It is not a long-term effort, which would be much more comprehensive. We have two forms of looking at avoidable or excess deaths. One is the standardised system, which is a statistical basis for looking at the number of excess deaths. The other looks at avoidable deaths and is done by looking comprehensively at a wide sample of case reviews to give us a much more accurate picture of what is really happening.

[Baroness Hollins (CB)]

My Lords, as the noble Lord says, we know a great deal about why people with learning disabilities die sooner than they should. What has been missing so far is a mechanism for taking that learning forward into practice. Such feedback mechanisms, and the fact that their reviews are mandatory, are the strengths of the other confidential enquiries. Will the Minister explain why the new national learning disability mortality review has not been established on the same footing as, for example, the national child death review?

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, the noble Baroness is right. The national learning disability mortality review programme, which is being hosted by Bristol University, does not have the mandatory basis that other reviews have had. I am not sure why it was not set up on the same basis. It is being funded by NHS England, although it has the support of a wide range of different organisations. I will look into that aspect of the review and write to the noble Baroness.

[Baroness Browning (Con)]

Does my noble friend agree that the failure in hospitals to assess the capacity of people with learning disabilities and those on the autistic spectrum is one of the great weaknesses in providing accurate and timely intervention for people who are in hospital and who have a learning disability? Will he make a particular case for assessing the ability of staff to accurately define capacity? Will he also take another look to see that hospital passports for people with learning disabilities and autism are a mandatory requirement, not just an option, for all inpatients?

[Lord Prior of Brampton]

My noble friend makes a number of very good points. I will draw them to the attention of Mike Richards, the chief inspector for acute care in England, who is about to embark on a thematic review of avoidable deaths. He will look in particular at those with learning difficulties and I am sure that he will take into account the words of my noble friend.

[Lord Rennard (LD)]

My Lords, does the Minister accept that something is seriously wrong when two-thirds of the unexplained deaths of these highly vulnerable people with learning difficulties who die in NHS hospitals in England are not properly investigated? Does he accept that this is a much more serious scandal than that based upon some highly dubious statistics used by the Secretary of State for Health to talk about unexplained deaths in hospitals at weekends?

[Lord Prior of Brampton]

I tried to explain the difference between avoidable deaths and excess deaths earlier in my answers, without trying to make any political point about it. There is an important distinction to be made, and I hope that I made it. I agree with the noble Lord that this is a very serious issue, and the Government are approaching it in a very serious way.

[Lord McColl of Dulwich (Con)]

My Lords, is the Minister aware that clinicians meet regularly to discuss all their complications, and that these meetings are extremely valuable and relevant? Have politicians considered the possibility that they might meet every week to discuss their mistakes?

[Lord Prior of Brampton]

My Lords, I am sure that it would be a very long meeting. My noble friend is right that mortality and morbidity meetings are extremely important in hospitals. It would seem that practice is very variable across hospital trusts and I know that part of what Sir Bruce Keogh, the medical director of the NHS, is doing is trying to develop, along with Monitor and the CQC, a governance structure around mortality that all hospitals can learn from.

[Lord Crisp (CB)]

My Lords, the new learning disability strategy, Building the Right Support, proposes that people with learning disabilities should get their mental health treatment from mainstream mental health services—which as noble Lords will know are already under considerable strain. Can the Minister let us know what assessment the Government have made of the likely impact that this will have on mental health services and how they envisage that the financial and other implications will be managed?

[Lord Prior of Brampton]

The noble Lord refers to the paper Building the Right Support, which I think he will be very supportive of. It is designed to treat and look after many more people with learning difficulties outside institutional settings—in their own homes or in special purpose, much smaller homes. Where necessary, they will of course need to receive mental health services. I am not aware that we have done a particular impact study on that, but I will investigate it and write to the noble Lord.

General Dental Council (Fitness to Practise etc.) Order 2015

Lord Prior of Brampton Excerpts

Monday 18th January 2016 Grand Committee

Moved by

[Lord Prior of Brampton]

That the Grand Committee do consider the General Dental Council (Fitness to Practise etc.) Order 2015.

Relevant document: 11th Report from the Joint Committee on Statutory Instruments

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

My Lords, the Dentists Act 1984 established the General Dental Council and sets out its functions and processes. The GDC is responsible for regulating the dental workforce in all parts of the UK. It has powers and duties which include setting the standards of conduct, performance and behaviour that dentists and dental care professionals are expected to adhere to. In addition, it is responsible for investigating any complaints or concerns which suggest that a dental professional may have failed to meet those standards.

The Government are keen to ensure that the GDC has the appropriate framework in place so that it can carry out its statutory responsibilities effectively. At present, the legislation governing the early stages of an investigation into a dental professional’s fitness to practise does not provide sufficient flexibility to enable the GDC to carry out this function in the most effective and efficient way. Legislative change is needed to address this.

This order, made under Section 60 of the Health Act 1999, amends the Dentists Act 1984 to reform the investigation stages of the GDC’s fitness-to-practise procedures. The Department of Health has publicly consulted on the proposals contained in the order and the vast majority of respondents agreed that the measures should be introduced and would have a positive effect on the GDC’s fitness-to-practise procedures. Through this Section 60 order I propose to provide the GDC with the powers to make five key amendments to its processes.

First, the GDC will be provided with a rule-making power that will allow it to delegate the decision-making functions currently exercised by its investigating committee to case examiners. The GDC’s current framework requires that following the triage of a fitness-to-practise complaint about a dental professional, if that complaint falls within the GDC’s remit it must be considered by an investigating committee. This means a panel must be convened for every case that reaches this stage. By introducing case examiners, it is anticipated that there will be a swifter resolution of fitness-to-practise cases, as a full investigating committee will not need to be convened for every case and instead allegations will be considered by two case examiners. The faster resolution of cases will enhance public protection. It will also remove some of the stress from the procedure for all parties involved. In addition, greater consistency in decision-making should be achieved, because case examiners will deal with a higher volume of allegations than the investigating committee, as the committee is convened from a large pool of individuals.

I realise that the fact that case examiners will be employees of the GDC may be a cause of anxiety for some. It is important to remember that they will not be making findings of fact in respect of whether a registrant’s fitness to practise is impaired. They will make the decision as to whether a case needs to proceed to the adjudication stage and be considered by a practice committee.

Additionally, the GDC, in its rules and guidance, will provide that the case examiners must make decisions based on documentary evidence which will be supplied to them in the same manner as is currently the case for the investigating committee. The case examiners will not be involved in evidence-gathering. There will also be one lay and one registrant case examiner, from the same part of the register as the individual whose case is being considered, considering an allegation, which will provide another safeguard in the process ensuring fairness.

I am also aware that interested parties will be keen that case examiners are recruited, trained and supported in the right way. I have been assured by the GDC that case examiners will receive comprehensive and robust training. The GDC is developing a robust system of review and appraisal that will monitor and support performance and ensure appropriate decision-making. The quality of the case examiners’ decisions will be underpinned by ongoing training and detailed guidance. The GDC will also introduce mechanisms for auditing decisions on a routine basis and will apply the lessons learnt from the audits to the guidance material.

Secondly, provision will be made to allow both the case examiners and the investigating committee, in certain cases, to address concerns about a registrant’s practice by agreeing appropriate undertakings with that registrant. This will be instead of referring them to a practice committee.

Undertakings will be applied, where appropriate, at the end of the investigation stage of the fitness-to-practise process. The introduction of this change will mean that some cases that are currently referred to a practice committee may not need to be. This would be in instances where it is determined that the agreement of undertakings would lead to the resolution of a case in a way that is sufficient to protect patients and the public. For example, if a case involved an allegation that a registrant’s health was affecting their fitness to practise, it may be possible to agree undertakings that would address any risks posed to the public and to the registrant themselves as a result of this health condition. This would also avoid the anxiety, time and cost incurred by referring the case for a full hearing. Rules will provide that a registrant must not be invited to comply with undertakings if there is a realistic prospect that if the allegation were referred to a practice committee, the registrant’s name would be erased from the register.

Thirdly, the GDC will be provided with the power to make rules to provide, first, for a review of a decision that an allegation should not be referred to the case examiners or to the investigating committee, and, secondly, for a review of a decision that an allegation should not be referred to a practice committee. However, this will not be an unfettered power. Through rules, the GDC will provide that a review can be undertaken by the registrar if it is considered that the original decision was materially flawed or if new information has come to light which may have altered that decision and a review is in the public interest. Such a review can occur only within two years of the original decision to close the case. Allowing the review in these circumstances adds a further safeguard to the system. Providing the GDC with the power to take suitable action will improve public protection and maintain public confidence in dental regulation.

This order will also introduce a power to enable the investigating committee and the case examiners to review their determination to issue a warning. A registrant will be able to request such a review within two years of the original decision to issue the warning. At present, there is no mechanism through which a registrant who is issued with a warning can appeal this decision with the GDC. Instead, the only route of appeal open to them is to apply for judicial review. This can be costly for both the registrant and the GDC and stressful for the registrant. Warnings can remain on an individual’s record for a number of years, for as long as the warning has been issued, and accessed by patients and employers. Providing individuals with a route of appeal that does not require application for a judicial review is a fairer and more proportionate approach.

Finally, provision will be made to ensure registrants can be referred to an interim orders committee at any time during the fitness-to-practise process. Currently, the legislation is ambiguous around when a case can be referred to an interim orders committee at certain points in the process. This amendment will remove any ambiguity and maintain public protection and confidence throughout the entire fitness-to-practise process. It will provide a higher level of patient protection, ensuring that those who are potentially unsafe to practise can have their registration suitably restricted while inquiries and investigations are made. In addition to enhancing patient safety and improving the fitness-to-practise processes for a registrant and all parties concerned, it has been identified that making these amendments will create approximately £2.5 million of efficiency savings per annum over the next 10 years.

In summary, these proposals to reform and modernise the GDC’s fitness-to-practise processes will make the system more efficient and effective, benefiting patients, practitioners and the health service. They will result in improved public protection and an increase in public confidence in the GDC. I commend the order to the Committee.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, thank the Minister for his careful explanation of the order. I welcome the opportunity to debate it as well as the performance of the General Dental Council.

This is one of a number of Section 60 orders that the Minister has brought before your Lordships’ House in the absence of a Bill following up the Law Commission’s work. Will the Minister be able to update the Committee on exactly where we stand with the Government’s intention with regard to whether they see that any part of the Law Commission’s work will lead to legislation in the future? On the order itself, its terms seem unexceptional, although I would like to raise a few points with the noble Lord. The real question before us is whether the General Dental Council is a fit and proper organisation, capable of implementing the changes.

I shall start, however, with the order and will come on to the issues with the GDC and the various reports that have been published about its poor performance over the past four years. On the order, first, I refer to paragraph 8.4 of the Explanatory Memorandum, which refers to a number of organisations which have commented. The British Dental Association is not listed there. I have received a briefing from the British Dental Association, and I wondered whether it had submitted a response to the department. If it has, I am surprised that it is not listed in paragraph 8.4.

The other point I want to make about the order concerns the question raised by the noble Lord, Lord Colwyn, which is about the performance of the GDC. The BDA briefing that I have received states that while the GDC is,

“Britain’s most expensive healthcare regulator”,

it,

“is also the least efficient, most troubled and enjoys little confidence among”,

either dentists or the Professional Standards Authority. It states that the GDC failed to meet eight out of 24 of the PSA standards of good regulation in its 2014-15 performance review and, crucially, fully met only one of the 10 standards relating to fitness-to-practise processes, representing what the PSA describes as,

“a significant decline in its performance compared to the assessment of the year before”.

The BDA points out that, in comparison, last year, the GMC met every one of the 24 standards while charging its members less than half of the annual retention fee that the GDC charges.

I also pick up the point raised by the noble Lord, Lord Colwyn, about the importance of the independence of case examiners. This is a point that we have raised before on some of these Section 60 orders. It is crucial because of the problems that have arisen from the way the GDC has conducted cases in the past, as identified by the various inquiries. I very much support the noble Lord in emphasising that case examiners must be, and be seen to be, independent.

We then come to the real issue for me, which is GDC governance. The Minister will be aware that in February 2013, the Professional Standards Authority published a report following the resignation of the GDC’s chair, Alison Lockyer, in May 2011. The Department of Health had asked the PSA to investigate several concerns which the then chairman had raised in a letter she had written to the Secretary of State on her resignation.

The PSA’s findings were complex. It did not find that the GDC was failing, but it identified some general learning which could be gained from the experiences of the GDC. Following the PSA’s report into the allegations made by Lockyer, it wrote that new evidence had come to light about poor practice in the support and operation of the GDC’s investigation committee. In July 2013, a member of the investigation committee raised concerns under the GDC’s whistleblower policy that certain processes were compromising the independence of the investigating committee’s decision-making. The GDC also commissioned an independent review into the concerns of the whistleblower, which was published in 2014, but in April 2014 the PSA started its own investigation. This was published on 21 December 2015.

The PSA came to a number of conclusions and found several areas of improvement for the GDC. I will come to the main recommendation but I read this report with considerable disquiet. I do not think I have ever seen a report relating to a statutory regulator quite like it. It was published only a few weeks ago, before Christmas. Paragraph 2.1 of the summary states:

“The approach taken by the GDC to recruiting, training and supervising the Investigating Committee Secretaries is likely to have contributed to the development/continuance of objectionable practices”.

These are objectionable practices by the statutory professional body concerned with dentistry. It is a very long report of more than 300 pages but, to get the flavour of it, here are some of the objectionable practices listed that the PSA looked into. First, there are:

“Discussions about cases between Investigating Committee Secretaries and Investigating Committee Chairs prior to Investigating Committee meetings”.

Then, quite remarkably, there is,

“advance drafting of Investigating Committee decision documents/reasons by Investigating Committee Secretaries”.

There are irregularities around the,

“provision of legal advice by Investigating Committee Secretaries to the Investigating Committee during Investigating Committee meetings … Inappropriate interventions/undue influence by Investigating Committee Secretaries during Investigating Committee meetings”,

and,

“amendment of Investigating Committee decision documents after Investigating Committee meetings by Investigating Committee Secretaries without appropriate authorisation”.

There are other identified irregularities but I do not need to go into them; I have made the point. The PSA report goes through this in great detail and its overall recommendation is:

“The GDC’s Council, executive management team and the relevant committees should consider this report in full, both individually and collectively, in order to identify all the lessons that should be learnt in particular in relation to governance, accountability and management oversight, as well as the actions the GDC should take to address our recommendations”.

The point I want to make about this is that these matters now go back some years. It was 2011 when the then chairman first raised those issues. This report was started in 2014 and finished only a few weeks ago. It clearly found continuing improper practices—or at least those that would not accord with good practice. Reading between the lines, I see here a culture of utter complacency within the GDC. It looks as though the GDC has simply not accepted the core conclusions of the various reports written about its conduct and carried on with that complacent culture. It is also clear from reading between the lines of the report and the careful way it has been put together that the PSA lacks confidence in the performance of the GDC. Frankly, I would have expected the entire board of the GDC to resign in the light of that report just before Christmas. I understand that the chief executive has resigned but no one else on the board seems prepared to take responsibility for a culture that has clearly lasted over a good many years. That is not acceptable. Can there be any confidence that this organisation is fit for purpose?

I now understand the concerns that the profession has about the GDC. I had not realised until I went through this information just why there was so much angst within the profession. It is absolutely justified. I would be doubtful of putting any order through in relation to the GDC unless we were absolutely certain that it is able to carry out its job properly.

[Lord Prior of Brampton]

My Lords, a number of points have been raised. I will start with those raised by my noble friend Lord Colwyn. He said that independence is critical for the case examiners; I will address that issue first. It is important to remember that case examiners will not be making findings of fact in respect of whether a registrant’s fitness to practise is impaired. They will make the decision about whether a case needs to proceed to the adjudication stage and be considered by a practice committee.

Additionally, in its rules and guidance, the GDC will provide that the case examiners must make decisions based on documentary evidence, which will be supplied to them in the same manner as is currently the case for the investigating committee. The case examiners will not be involved in evidence-gathering. There will be one lay and one registrant case examiner considering an allegation. I accept, however, that they will be employees of the GDC. Nevertheless, our feeling is that sufficient safeguards are built into the way that case examiners will work.

The issue raised by my noble friend and expanded on by the noble Lord, Lord Hunt, is fundamental. If the GDC is not a fit organisation—if its governance and performance are not right—that is a much more profound worry than the details of the order before us today. Before I address this, I will deal with one other point that the noble Lord raised. He asked whether the BDA had submitted anything. It has; it was omitted in error and is now being attached.

Clearly, we are concerned about the performance of the GDC. The report from the PSA is indeed extremely worrying. As the noble Lord said, this has not happened just recently; it goes back many years. It is very important that the council takes responsibility for the proper running of its organisation. My colleague Ben Gummer is the Minister with direct responsibility for the GDC and he has a meeting coming up in the very near future to discuss the GDC’s performance in the light of the PSA report. It is not all bad news in that report. There are some signs that the GDC is working hard to improve. Nevertheless, as my noble friend and the noble Lord have both said, there is a lack of confidence in the GDC among the profession and that confidence must be rebuilt.

Perhaps I might bring to Ben Gummer’s attention the comments that have been made by my noble friend and the noble Lord and ask him to draw them to the attention of the GDC when he meets it in the near future. Clearly, he will wish to keep a very close eye on the performance of the GDC as we go forward. I do not think I can say much more today about that. I do not have the information with which to comprehensively address the issues that the noble Lord has raised. Is he content on that basis? If he would like to meet my honourable friend Ben Gummer, I can arrange for him to do that.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful. One of the problems is that this was scheduled very late and therefore I was able to look at the information only over the weekend. I suspect that I would have put a Motion down for a debate in the Chamber if I had had time to do that.

Secondly, I realise that this is quite a difficult situation. Clearly, the independence of the regulators of the health profession is very important and I have always been keen to protect it. The PSA has a crucial role and I think it does a great job. I pay tribute to the chairmanship of my noble friend Lady Pitkeathley, and Mr Harry Cayton, the chief executive. I think they have done a fantastic job, but it seems to me that there is a gap.

It is patently obvious when you look at it from the outside that the board should have read those reports, accepted its ultimate responsibility and stood down. I accept the invitation; I would be very glad to meet Mr Gummer. Of course, this will be debated tomorrow in the other place, and other Members may come back on that. This message clearly needs to go to the GDC council: that it is not good enough and the members should consider their position. I wonder whether it is right that the board carries on willy-nilly simply because the chief executive has stood down.

I am not someone who rushes to say that this, that or the other board should resign because something has gone wrong, but this has been a continuing problem. I accept that improvements have been made, but only a few weeks ago the PSA had to publish a report that continues to draw attention to what is, essentially, the culture of the organisation. Therefore, I very much hope that Ministers will take the appropriate action; that is all that they can do. Ultimately, I am surprised that the board of the GDC feels that it is able to carry on and I think there needs to be a change.

I am grateful to the Minister for the way that he has responded; clearly, he understands the issues that are being faced.

[Lord Prior of Brampton]

My Lords, perhaps we can leave it on the basis that I will organise for the noble Lord to meet Ben Gummer and perhaps ask Harry Cayton to come along, too, as he fundamentally authored the report, so that the noble Lord can express his concerns directly to them. On that basis, I beg to move.

Motion agreed.

National Health Service

Lord Prior of Brampton Excerpts

Thursday 14th January 2016 Lords Chamber

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

My Lords, first, I thank the noble Lord, Lord Turnberg, for bringing this debate, and I thank the 45 people who have contributed to it. That shows that the noble Lord has touched an important nerve. The future of the health service and of social care in this country is hugely important.

The noble Lord, Lord Turnberg, talked about his experience at Salford, where they have a fantastic hospital with a joined-up system. This shows that it can be done. Around the country, there are hospitals and healthcare systems that are doing it; they are doing a fantastic job by good standards. Of course, that requires great leadership, and leadership is not something that can be cloned; there just are not that number of great leaders in any system. However, in Salford, under David Dalton, they have a great leader.

The fact that it can be done lies behind the work that the noble Lord, Lord Carter, has done. Hospitals around the country are achieving great performance. However, the noble Lord, Lord Carter, has uncovered a huge amount of what he would call “unwarranted variation”; that could be unwarranted clinical variation, operating variation or any other kind of variation. That has to be addressed, and the noble Lord, Lord Carter, has given us a methodology for doing that. He, along with other noble Lords in this debate, points out that unless we can crack delayed discharges in hospitals and delayed transfers of care, many of our hospitals are going to struggle.

I also pay tribute to the noble Baroness, Lady Watkins. In her maiden speech she very properly reminded us of the importance of training and community-based services. Her mentor, the noble Lord, Lord Patel, who was watching as she gave her address, is no doubt watching me from India as I speak to the debate.

I want to mention two particular contributions. The first is the speech by the noble Lord, Lord Winston. The noble Lord, Lord Hunt, picked up on his point about academic medicine. That is a crucial issue and one that I cannot address head-on today, but perhaps we might have a meeting involving others, including Hugh Taylor, to talk about it further. The second is the contribution by the noble Lord, Lord Mitchell, about the contrast between his son, who is a junior doctor, working in England compared to working in New York. I thought that that was a very revealing contribution, if I may say so.

I want to preface all my remarks by paying tribute to not just junior doctors but to all those who work for the NHS and in social care. They do an extraordinary job and have a true vocation, and many noble Lords have experienced the benefit.

This is the third general debate that we have had on the NHS since the election. The first was introduced by the noble Lord, Patel, and the second by the noble Lord, Lord Crisp. In that debate, we talked very much about prevention. We could be here for many hours talking about prevention. The noble Lord, Lord Rea, talked about the importance of housing and employment, and there are so many other issues that we could talk about in the context of prevention. Therefore, I hope that noble Lords will excuse me if I do not address prevention as much as they might like me to.

I want to go back to June 1948 for a minute, and to Nye Bevan talking to the Royal College of Nursing. He said:

“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving—it must always appear inadequate”.

The noble Lord, Lord Desai, made the point that when you have a service that is free, demand will always exceed what we can provide. Nye Bevan saw that back in 1948, and it is important to hold on to that when we look at our funding situation at the moment.

We do have a plan: the NHS Plan. The NHS Five Year Forward View was produced by Simon Stevens of NHS England and supported by all the arm’s-length bodies. It is not the Prime Minister’s plan, it is not my plan and it is not the Secretary of State for Health’s plan. It is the NHS’s plan. It called for £8 billion of real investment over that five-year period, and the Government have given the NHS that amount of money: it is £16 billion in cash terms and £8 billion, or arguably £10 billion, in real terms. This is broadly what the NHS wanted.

The NHS is actually doing quite well. I will come back to some areas where it is not doing as well as we would like but, broadly speaking, it is doing quite well. The Commonwealth Fund said that it is first overall compared with other OECD countries, scoring highest on quality, access and efficiency and second on equity. In the recent Economist review looking at end-of-life care, we came out top. However, that is not perfect. The noble Lord, Lord Freyberg, pointed out that our cancer outcomes are not as good as they should be. The noble Lord, Lord Bradley, talked about mental health, and clearly we can do better there and in other areas too. There is too much variation in what we do. However, if we look at medical research, the quality of our education in most of our medical schools, medical publications and clinical outcomes, the NHS can still be regarded as a world-class health service.

Other noble Lords have already made the point that we do this at very low cost. In America, they spend 16% of GDP on healthcare; we spend around 8% and most of Europe spends around 10% or 11%. We do it at very low cost and we get very good results. On that basis, when people say that it is not affordable—an issue my noble friend Lord Fowler and others have raised in this debate—I say that it is affordable. We are doing it at 8% of GDP at the moment but we could choose to spend 10% or 11%: the country can afford good healthcare. I would argue that we are providing good healthcare at the current level of spending.

There is no evidence that a tax-funded system is any less efficient or effective than other systems of funding healthcare. Indeed, I would argue that, on the contrary, the NHS, for the reasons that I have given, is an efficient system. The OECD made a more neutral comment, saying that,

“no broad type of health care system performs systematically better than another in improving the population health status in a cost-effective manner”.

Therefore, I do not think there is an argument for questioning whether we can afford a good healthcare system in this country.

I turn to the various questions that were raised. Is it affordable? Yes, it is affordable, and we are demonstrating that. Is a tax-funded system viable? Yes, it is viable, and I will go further and say that there is evidence to suggest that it is more viable than any other way of funding a healthcare system. Do we have a viable plan in this country? Yes we do, and I will come to that in a minute. Do we need another plan or another commission? I do not think we do. It would be an enormous distraction at a time when we have a five-year forward view. At a time when the whole of the health service is committed to that view, there would be immense concern if we embarked on yet another review or commission of any kind. We would go through a two-year hiatus waiting for that report and would not be able to get on and deliver what we have at the moment.

What is that plan? It falls into two parts. First, can we make the existing system more efficient? The answer is: of course we can. We have some of the best hospitals, wards, clinics, laboratories and specialties in the world in the NHS. Our problem is that there is so much variation across the system—clinical variations, staffing variations, property utilisation variations, procurement variations, pharmacy and medicines utilisation variations and back office costs variations—all of which have been identified, as shown by the extremely important work done by the noble Lord, Lord Carter, assisted by clinicians such as Professors Tim Briggs and Tim Evans. They have given us an improvement methodology based on transparency which will deliver huge improvements over the next five years. A great deal of their work is mirrored on commissioning through the use of the Right Care programme and the Atlas of Variation that has been developed largely by Dartmouth in the USA.

The second part of our plan concerns the new models of care—an issue raised by the noble Lord, Lord Turnberg—and we have already seen these operating effectively in Salford.

This is a move from institutions to systems. We are now trying to develop a place-based care, a population-based care. Although there were many benefits from foundation trusts—I believe wholly in the principle of earned autonomy—one of their unintended consequences is that they have created a fortress mentality in some parts of the country. The King’s Fund has used the analogy of the tragedy of the commons, where everyone is looking after their own interests rather than the interests of the wider system. It has also left patients having to navigate a complex, unjoined-up series of different organisations. We will see over the next four or five years the emergence of new systems of care, including PACS and MCPs, and the Accountable Care Organisation, ACO, will become increasingly familiar to us.

We will also see different outcome-based payment systems and incentives as we move to integrate with social care. There will be many cynics and sceptics because some people, as the noble Lord, Lord Turnberg, said, have seen all this before. We have been talking about integrated care for 20 odd years. I think it is different this time—but I would say that, wouldn’t I?

We have to ask why change is so difficult in healthcare—and not only in the NHS. Why has there been such dramatic change in car manufacturing and retailing across the world, when healthcare systems have proven much more difficult to change? Interestingly, in the 2000 NHS plan, echoed in the five-year forward view, were two comments: that we have a 1940s system delivering care to a 2016 population with entirely different needs to the population of 1948; and that healthcare has been slow to move, not only in the NHS but around the world. Changing that system will be difficult but very important.

Why am I optimistic about it? First, we have a narrative. The five-year forward view gives the whole service a very powerful narrative around which it can combine and work together. Secondly, the architecture of the system is not perfect—I know that the noble Lord, Lord Lansley, is sitting behind me—but it is serviceable. We do not need another top-down reorganisation. We can work with the bodies created through the last reorganisations, and NHS England is now building resources and a team of people who can truly deliver on its plan. The new purpose of the NHS is based around improvement and learning rather than regulation, which is important, and the independent CQC.

There are two other reasons for optimism. Transparency will be a much better improvement mechanism than targets, regulation, competition and the command and control structures that we have had in the past. The financial crisis we have gone through has made hospitals look more radically at how they can change their models of care. Finally, we have not spoken in the debate today about the huge impact that technology will bring in empowering patients to look after themselves and take greater personal responsibility, as other noble Lords have mentioned.

I have to conclude. I thank the noble Lord, Lord Turnberg, for introducing this fascinating debate, which has raised important issues. I look forward to reading it in the cold light of day over the weekend.

Sugar Tax

Lord Prior of Brampton Excerpts

Wednesday 13th January 2016 Lords Chamber

[Lord Clinton-Davis]

To ask Her Majesty’s Government what plans they have to impose a sugar tax on fizzy drinks.

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

My Lords, we will be launching our childhood obesity strategy soon. It will look at everything, including sugar, that contributes to a child becoming overweight and obese. It will also set out what more can be done by all sides.

[Lord Clinton-Davis (Lab)]

If we had a league of government U-turns, this one would surely head the list. Not so long ago, the Prime Minister said that a sugar tax was not worth while. Now, urged on by experts and MPs of all parties, he says that it is not a bad idea. What should we now do? My view is that we should follow the example of Mexico. Why wait for many months when the evidence is very clear? Why do the Government not act immediately?

[Lord Prior of Brampton]

My Lords, I think the Prime Minister’s position is that he will want to think long and hard before imposing a tax that would fall by and large on those least able to afford it. On the other hand, the Prime Minister and the Secretary of State for Health recognise that obesity is a scourge in this country, affecting young people in particular, and will want to implement a comprehensive range of measures to tackle it.

[Baroness Hollins (CB)]

My Lords—

--- Later in debate ---

[Baroness Hollins]

My Lords, what assessment have Her Majesty’s Government made of evidence provided by the BMA—I should declare an interest here as chair of the BMA’s Board of Science—Public Health England and others on the anticipated positive impact of implementing a sugar tax? Does the Minister agree that we need a range of regulatory and educational measures to reduce the intake of added sugars, particularly among children and young people, but also adults with learning disabilities who are vulnerable to some of the same market pressures?

[Lord Prior of Brampton]

My Lords, the Government have taken into account a range of evidence from Public Health England, the McKinsey institute, the SACN and others in coming to their strategy. The noble Baroness is absolutely right that the response will need to take into account issues such as reformulation, portion size, availability and a whole range of other issues that affect sugar intake.

[Lord Ribeiro]

My Lords, while the sugar tax for fizzy drinks is a regressive tax, the very people it would target stand to benefit from such a tax because, leaving aside obesity, which is a long-term problem, dental caries are a short-term problem. There is no doubt that sugary drinks are causing a massive amount of dental caries, the cost of which falls on the NHS, as these unfortunate children have to have dental extractions which will affect their well-being and quality of life for years to come.

[Lord Prior of Brampton]

My Lords, reduction of sugar is a critical part of the Government’s obesity strategy. It has been made clear by the reports of Public Health England, the McKinsey institute and others that there is no silver bullet. It is not just a question of passing a tax and getting the results that you wish to have. If a tax were to come in, it would be part of a whole range of other measures.

[Lord Rennard (LD)]

My Lords, does the Minister accept that the introduction of a modest sugary drinks tax should be a win-win policy in that, if it works, people would be deterred from consuming those drinks, switch to alternatives and lead healthier lifestyles, and, if it does not work, it would raise money much needed by the NHS to deal with the problems of the obesity and diabetes epidemics?

[Lord Prior of Brampton]

My Lords, as I said earlier, the Prime Minister and the Secretary of State for Health are thinking long and hard about what should be part of the obesity strategy. I am not sure that the noble Lord is right when he says that a modest tax would have much of an impact; it would have to be a significant tax to have a major impact on the consumption of sugary drinks.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister agree that the campaign against tobacco and cigarettes has been particularly effective? It has been applied across all sectors of the economy with no differentiation between any particular sectors. He mentions that, this time round, we have to be concerned about how sugar might impact on particular parts of the community but, surely, we should make our approach similar to what we did with cigarettes and tobacco and we should apply it right across the board so that we all gain from the change.

[Lord Prior of Brampton]

My Lords, I think that the noble Lord is right; indeed, the Prime Minister has called this the new smoking. Obesity is as important to public health as smoking has been in the past. We have to build a much stronger case among the public at large before we can start to introduce the full range of tax and other measures that we have had for cigarettes and alcohol.

[Baroness Walmsley (LD)]

My Lords, has the Minister tried the Sugar Smart app on his mobile phone, which can be found on the Change4Life website? I tried the app this morning—it is very clever; it reads a barcode and tells you how much sugar is in a product. Unfortunately, however, I tried it on five sugary products and it did not have any of them in its database. Has this very good idea been under resourced?

[Lord Prior of Brampton]

My Lords, fortunately I, too, tried the Sugar Smart app this morning. Interestingly, 600,000 people have downloaded that app and the PHE Change4Life programme has had considerable success in raising awareness of the amount of sugar that you consume when you buy a product in the supermarket.

Children: Obesity

Lord Prior of Brampton Excerpts

Tuesday 12th January 2016 Lords Chamber

[Baroness Benjamin]

To ask Her Majesty’s Government what steps they are taking to ensure that children, especially girls, grow up fit and healthy, in the light of the recent report on the dangers of obesity in women in adult life.

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

My Lords, tackling obesity and creating a fit and healthy society, particularly in girls and boys, is one of our major priorities. As we have previously said, we will be publishing our comprehensive childhood obesity strategy in the new year, and we will be doing so shortly.

[Baroness Benjamin (LD)]

I thank the Minister for that Answer. As he said, childhood obesity has become the biggest public health challenge in the UK, with nearly a third of our 10 year-olds overweight. High sugar consumption means tooth decay and is the most common cause of hospital admissions among five to nine year-olds. Half of seven year-olds have less than an hour of daily exercise, and we all know that obesity and inactivity lead to major adult health problems. Shockingly, 29% of UK children are overweight as mothers risk having overweight children. What are the Government doing to address the educational and environmental factors that are causing this obesity crisis? Will they start by urgently introducing a mandatory sugar reduction target applicable to all firms in the food and drink industry?

[Lord Prior of Brampton]

My Lords, we all recognise, as does the Prime Minister, that obesity is a scourge in this country that affects many thousands of young people. Some 2.1 billion people worldwide are overweight or obese, so it is a huge global problem that requires a comprehensive strategic response. I hope that our obesity strategy will be announced in the very near future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in developing this strategy, is his department talking to the Department for Education? He will understand that this is a particular issue at primary school level. There is evidence that the incessant determination of the Government to test primary school children at every age at every moment is squeezing the curriculum of playtime and physical activity. I hope that his department will talk to the Department for Education to turn this around.

[Lord Prior of Brampton]

My Lords, we have got to have a collective response to the obesity problem across many government departments, as the all-party parliamentary group made clear in its paper. Education is a critical part of that. The noble Lord will know that in the spending review the Government committed to continue the PE and sports premium in primary schools because we recognise that physical exercise and playtime at all levels in schools, but particularly in the early years, are vitally important.

[Baroness Heyhoe Flint (Con)]

My Lords, I recommend to my noble friend that sport may be the panacea for many of the problems mentioned by the noble Baroness, Lady Benjamin. A new strategy for sport which targets young primary school children has just been issued, but does my noble friend agree that this dreadful problem needs a cross-departmental approach involving health, environment and transport, including cycling and walking? We should not spread the butter too thin as far is sport is concerned—or perhaps I should say the low-fat spread in this instance.

[Lord Prior of Brampton]

My Lords, my noble friend is right that we have to involve all departments. For example, she mentioned the environment. There is plenty of evidence to suggest that urban and educational environments can be designed so that children spend more time walking. The development of cycleways in London is another example of how we can design our environment to improve the level of physical exercise that we take.

[Baroness Walmsley (LD)]

My Lords—

[Baroness Finlay of Llandaff (CB)]

Can the Minister outline what is being done specifically in relation to women in pregnancy, given that excessive weight gained in pregnancy, which is often linked to the phrase “eating for two”, is very difficult to lose afterwards, particularly if women do not breastfeed? Moreover, postnatal depression can itself be a cause of excessive eating after delivery of the baby, causing the maintenance or even aggravation of obesity. That requires specific services to target these women.

[Lord Prior of Brampton]

The noble Baroness will know that the report of the Chief Medical Officer which came out two or three weeks ago laid particular stress on the importance of women who are pregnant because of the impact of obesity not just on themselves but on their children as well. Advice is available through NHS Choices, Start4Life and Healthy Start; we have various schemes that are focused on pregnant women. I am sure that we can do more, and perhaps when the government strategy on obesity is announced in the near future, it will address that issue as well.

[Baroness Walmsley]

My Lords—

[Lord Winston (Lab)]

My Lords, given that homo sapiens is a species that is programmed to eat carbohydrate and fat, what estimate have the Government made of how much childhood obesity is due to epigenetic factors rather than simply eating sugar and carbohydrate later on in life? Might this not be programming earlier in the generation perhaps as the result of previous generations’ environment? This is an essential point in understanding obesity.

[Lord Prior of Brampton]

The noble Lord makes an interesting point to which I cannot give an answer from the Dispatch Box. It is clear that epigenetic factors are important. It is not just about behaviour: rather, it is also the genes that we have inherited from our forebears and the fact that we have entirely different nutrition and an entirely different way of life today from that of 70,000 years ago. Would it be all right if I write to the noble Lord and explain that more fully?

Four Seasons Group

Lord Prior of Brampton Excerpts

Monday 11th January 2016 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government, in the event of the financial collapse of the Four Seasons Group, what contingency plans are in place to provide alternative accommodation, care and support to ensure the safety and well-being of over 20,000 residents currently residing in Four Seasons homes.

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

My Lords, managing provider failure in the adult social care market is a local responsibility. I cannot comment on the finances of individual providers. However, the Care Quality Commission has financial oversight of the larger providers and would supply local authorities with early warning if one of the businesses were to fail and its regulated activities to cease, allowing time for local contingency plans to be implemented. The Department of Health would co-ordinate any appropriate national response.

[Baroness Wheeler (Lab)]

I thank the Minister for his response but it is disappointing that he cannot be more reassuring on government contingency plans for the fallout that would result from the collapse of major and small providers in the care industry. The problem goes wider than Four Seasons, given the rising costs of care, the postponement of the care cap and the inability of cash-starved local authorities to increase fees to meet rising costs and demands. The Southern Cross collapse affected 31,000 frail and elderly residents, who had to be found alternative care. Surely the Minister recognises that and the fact that there needs to be a wider government strategy to ensure the financial sustainability of the sector and to deal with the huge scale of closures that will happen unless the funding problems are addressed.

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, the collapse of Southern Cross in 2011 was the main reason that the previous Government gave the CQC market oversight responsibilities, which will give early warning of any failure of a large provider. It is worth noting that the LGA believes that at least 95% of all local authorities have contingency plans ready to be implemented.

[Baroness Greengross (CB)]

My Lords, the former Health Minister, Norman Lamb, called for a cross-party commission to review future funding for health and care services in this country. Does the Minister not agree that we have to start talking, honestly and openly, about what standards of health and care older people can expect now and in the future? Having a commission to look in depth at this and to come up with strong recommendations seems—to me, at any rate—a rather good idea. Does the Minister agree, and will he comment on whether such a commission might be established?

[Lord Prior of Brampton]

My Lords, the idea of having a commission has been discussed a number of times in this House, and there will be a long debate on this matter on Thursday. In the spending review the Government are enabling local authorities to increase their precept by 2% and they are increasing the contribution to the better care fund by £1.5 billion, which will see a real increase in the resources available for adult social care.

[Lord Lansley (Con)]

My Lords, does my noble friend agree that in circumstances of provider failure one of the most important things is for residents to be maintained in their existing homes? In fact, that was achieved in the overwhelming majority of cases following the Southern Cross collapse. It is often possible to separate the going-concern basis of individual homes from the commercial situation of the provider as a whole.

[Lord Prior of Brampton]

I fully agree. Our interest is in the residents in the homes. The CQC’s oversight regime is not intended to prop up a provider—that is an entirely different matter. My noble friend is absolutely right that when Southern Cross went into insolvency, very few homes—in fact, I do not think that any homes—closed as a direct result at the time; most of them carried on as going concerns.

[Baroness Brinton (LD)]

My Lords, is the Minister working with the Department of Health, the CQC and BIS to ensure that the new financial instrument, whereby an individual can invest in a single room in a care home for a guaranteed rent, protects the user of that room as much as it provides any yield for the investor? Evidence in the student sector has shown very mixed results. Students can move on elsewhere, but elderly care residents have nowhere else to go and their protection, and indeed the trading viability of a care home, could be affected if investors had to move out quickly.

[Lord Prior of Brampton]

My Lords, I could not see where the question was coming from. I am not fully briefed on the financial instrument that my noble friend—I am sorry; the noble Baroness—referred to. I will have to research it and get back to her.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister agree that Four Seasons, which is the subject of the Question from my noble friend on the Front Bench, is only one of the groups facing financial crisis? It is estimated that by 2020 there will be a funding gap of £3 billion for the residential care sector, and 15 social care groups warned the Chancellor of this before the Autumn Statement. Have the Government any long-term plan for funding and improving social care or are they committed to short-term solutions and to saying that it is a matter just for local authorities?

[Lord Prior of Brampton]

My Lords, clearly, it is a matter principally for local authorities. However, the Government are making available in the spending review another £1.5 billion for the better care fund and allowing local authorities to raise a special precept of 2%. The oversight provisions of the CQC cover 45 providers, which cover some 20% of the market. It is intended that that will give early warning to local authorities of any likely collapse.

[Baroness Barker (LD)]

My Lords, can the Minister confirm that anyone who has their care package funded by a local authority is entitled to alternative provision? Anyone who is a self-funder under the law is entitled only to advice. Are the Government taking steps with local authorities to ensure that older people and their families are aware exactly what their entitlement would be in the event that their care home were to close?

[Lord Prior of Brampton]

My Lords, it is up to local authorities to have contingency plans in place in the event of the closure of a home in their area. As I said earlier, the Local Government Association has indicated that at least 95% of local authorities have contingency plans in place.

[Lord Sutherland of Houndwood (CB)]

My Lords, the problems of care home residents through the demise of Southern Cross was dealt with very significantly by the rest of the care home sector; a condition of that happening was that it was in “robust condition”. Can the Minister reassure us that the care home sector is currently in equally robust condition?

[Lord Prior of Brampton]

My Lords, it is true, as the noble Lord says, that the fallout from the collapse of Southern Cross was that the industry took on most of the homes currently owned or operated by Southern Cross. I think that if a large provider went into insolvency, many of those homes would be taken over by the industry. The important thing is that the industry has confidence in its long-term future. As I said earlier, I believe that the commitment to increasing the better care fund and allowing local authorities to have a 2% precept for social care will provide that level of long-term confidence.