Pregnancy: Neural Tube Defects

Lord Prior of Brampton Excerpts

Monday 21st December 2015 Lords Chamber

[Lord Rooker]

To ask Her Majesty’s Government whether they have any proposals to minimise the risk of neural tube defective pregnancy in women of reproductive age.

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

My Lords, the Government are looking at all aspects of preconception health. This includes the uptake of folic acid, which can reduce the risks of neural tube defects. Women are advised to take a supplement of 400 micrograms of folic acid from several weeks before conception until the 12th week of pregnancy. This information is available on the NHS Choices website.

[Lord Rooker (Lab)]

My Lords, is the Minister aware that on four occasions his predecessor told the House that the Government were awaiting information on blood folate levels? It was published nine months ago yesterday and we have had no statement whatever about it. Has the Minister had the chance to look at the scientific paper published last week showing that, if the UK had adopted white bread flour fortification at the same time as the United States of America, there would have been 2,000 fewer neural tube defect-affected pregnancies in the UK? There is now a spina bifida epidemic in Europe, which there is not in the 80 countries that fortify flour with folic acid. Surely it is time for action.

[Lord Prior of Brampton]

My Lords, I pay tribute to the noble Lord for the extraordinary work that he has done in this field and for giving this very important and tragic issue a greater degree of public awareness. My honourable friend in the other House, Jane Ellison, the Minister for Public Health, is considering her response to the report that the noble Lord referred to and to the report by the SACN, the committee on nutrition, published on 20 October. I expect that she will come to a decision early in the new year.

[Baroness Walmsley (LD)]

My Lords, given the importance for the health of the foetus of folic acid being taken by women before they are pregnant, will the Minister work with his colleagues in the Department for Education to ensure that all young women—and young men—know the importance of taking folic acid long before they even think of becoming pregnant?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. When you know you are pregnant, it is too late to start taking folic acid, and that is the fundamental reason why the noble Lord, Lord Rooker, is pushing for fortifying flour with folic acid. However, she is absolutely right that education is fundamental to this as well.

[Baroness Hayman (CB)]

My Lords, is the Minister aware that the best tribute that he could pay to the noble Lord, Lord Rooker, and his campaign would be to make an early and positive decision on the fortification of white flour in this country? How long are the Government going to go on not taking any notice of either the scientific evidence or the evidence in practice from 78 other countries? I remember the definitive trial proving the benefit of folic acid in pregnancy in 1991. We have seen that advice alone does not work. When will the Government take action?

[Lord Prior of Brampton]

My Lords, as I said in my response to the noble Lord, Lord Rooker, this matter is being actively considered by the Minister for Public Health, and she expects to come to a decision very early in the new year.

[Baroness Gardner of Parkes (Con)]

My Lords, we have unanimous feeling here. I was going to quote the statement made on a previous occasion by the noble Lord opposite that, really, we in this House are pretty well unanimously in favour of this and cannot see anything wrong with it, and yet the action has not followed.

[Lord Prior of Brampton]

My Lords, when my noble friend says that this House is almost unanimously agreed she may well be right. However, the decision on this matter has to be taken in the other House. As I said, my honourable friend Jane Ellison, the Minister for Public Health, is going to come to a decision very quickly.

[Lord Turnberg (Lab)]

My Lords, we seem to have been for ever on this particular question. There is an irrational fear that somehow it is dangerous to fortify flour, and this has held up people in some way or other. But scientifically that does not bear fruit. It is clear from all the experience around the world of many years of fortifying flour with folic acid that it does work. We should be doing it here now.

[Lord Prior of Brampton]

My Lords, I am certainly not going to argue on clinical grounds with the noble Lord, who knows far more about this than I do. However, the issues are not purely clinical; they are to do with the mass medication of the whole population to reach a very small minority of women of child-bearing age. There are also some administrative issues to do with making sure that people do not take too much folic acid, as some cereals have folic acid added to them. However, I understand exactly what the noble Lord is saying, and can only repeat that the Minister for Public Health is reviewing this now.

[Lord Blunkett (Lab)]

Can I surprise the Minister and not necessarily upset my noble friend Lord Rooker, but put down a word of caution? I agree with what the Minister has just said about having great caution when we involve ourselves in any mass medication—I have a history of being awkward on these issues, including mass medication through the water supply. I have no doubt whatsoever that this is an effective way of tackling the problem, but I have every concern that it is a slippery slope that we go down with great care.

[Lord Prior of Brampton]

My Lords, I think they were helpful and wise words from the noble Lord, Lord Blunkett. This is a difficult issue, and it is not as black and white as is sometimes portrayed. As I said, my honourable friend in the other House is taking all these matters into consideration.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I must inform the House that I am president of the Fluoridation Society. Therefore, although I always welcome my noble friend Lord Blunkett’s interventions, perhaps I welcome this one not quite as much as usual. I have great respect for the Minister’s colleague, the Minister for Public Health, and know that she is committed to public health. But she has had the evidence from the research, which caused the Government to delay a decision, for nine months. Is it not a fact that she cannot get agreement inside government, and that the Government have decided not to go ahead? Is not it time for them to be straight on this?

[Lord Prior of Brampton]

My Lords, I do not think that what the noble Lord has said is entirely correct. My honourable friend Jane Ellison received a letter from the SACN, the committee on nutrition, on 20 October that indicated that many more women were below the foliate level than had previously been thought. That evidence is quite new and came in at the end of October. That is what she is now considering.

[Lord Patel (CB)]

My Lords, the Minister has said that he is against mass medication. Do we really think that this is mass medication? We are talking about adding to flour micro amounts of nutrition that is lacking, to give a choice to people: if they intend to get pregnant, they eat bread made from that flour and not unfortified flour.

[Lord Prior of Brampton]

Just to correct the noble Lord. I did not say that I was against mass medication; I said that it was one of the things that should be considered. It is also worth saying that, even if there was mass medication, it probably would affect between 15% and 30% of women who have babies with neural tube defects and not all women.

Down’s Syndrome: Do Not Resuscitate Orders

Lord Prior of Brampton Excerpts

Tuesday 15th December 2015 Lords Chamber

[Lord Alton of Liverpool]

To ask Her Majesty’s Government what assessment they have made of East Kent Hospitals University NHS Trust’s decision to list Down’s syndrome as a reason to issue a Do Not Resuscitate order to a patient.

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

The department expects trusts to have local policies on resuscitation, based on expert professional guidance. Such guidance has been published jointly by the British Medical Association, the Resuscitation Council and the Royal College of Nursing. All resuscitation decisions must be tailored to the individual circumstances of the patient. For patients who lack capacity, the Mental Capacity Act requires a decision in their best interests, taking account of their known wishes, beliefs and values.

[Lord Alton of Liverpool (CB)]

My Lords, in considering Mencap’s estimate that 1,200 people with learning difficulties die needlessly in NHS care every year, will the Minister look at the inspiring work of the Blue Apple Theatre company, which includes actors with Down’s syndrome performing either “Hamlet” or their play “Living Without Fear”, which was staged in Mr Speaker’s House, and then consider how best we can counter a slide into eugenics, discrimination and non-resuscitation orders, as in the case of Andrew Waters, and look for ways to promote positive and life-affirming attitudes towards people with Down’s syndrome?

[Lord Prior of Brampton]

My Lords, perhaps I could address first the particular issue of Andrew Waters. The doctor who signed the DNR order was a junior doctor who made a mistake. It was a misjudgement, he apologised for that mistake, and he has learnt from it by using his experience to teach other doctors how to deal with similar issues. It is important to make that statement first—the reaction of that junior doctor was the right one, having made that mistake. The noble Lord mentioned the Blue Apple Theatre company. He was kind enough to send me a copy of some of the work that it does, which illustrates that people with Down’s syndrome can have a very full, useful, good and happy life, and their lives should be valued just as highly as the life of any other person.

[Baroness Walmsley (LD)]

My Lords, does the Minister know how widespread such discrimination is against people with learning difficulties? What reassurance can he give to parents such as those I met recently in the House of Commons Dining Room, who were terrified to allow their disabled son to go into hospital because they knew they were going to be put under pressure to sign a DNR notice? They were also afraid that, even if they refused but were not at his bedside 24 hours a day, it would happen anyway.

[Lord Prior of Brampton]

My Lords, the noble Baroness has just made a truly shocking statement. If indeed this practice was systemic and widespread, it would be a matter of huge concern and I think all of us in this House would be appalled by it. I have no evidence that this is a systemic problem, but it is absolutely the case that this group of very vulnerable people have been let down not just by doctors and clinicians but actually by all of us—the whole of society, for ever. The report produced three weeks ago called Building the Right Support recognised that we have let down this group for decades, and I hope that over the next five years we can start to make amends.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, in his original Answer the Minister referred to the Mental Capacity Act, which is widely admired as legislation that is on the whole benign. However, he will be aware that a Select Committee of your Lordships’ House met last year and produced a report that pointed out that the implementation of the Act is not always as effective as it should be, which has a lot to do with the way health professionals understand their duty under the Act in situations such as this. What progress is being made in improving the training of health professionals under the Act?

[Lord Prior of Brampton]

My Lords, the noble Baroness will be aware that the noble Baroness, Lady Finlay, has become chairman of the National Mental Capacity Forum, which was established in September. She will be looking at all these issues and reporting back in March next year. I entirely agree with the noble Baroness, Lady McIntosh, that the principles in the Act are generally accepted as being the right ones, but their application has not been as consistent as we would like.

[The Lord Bishop of Peterborough]

My Lords, from these Benches we affirm that those with Down’s syndrome and other learning disabilities and handicaps are fully human and fully made in the image of God. We believe that the chief mark of a civilised society is the way it cares for the most vulnerable. Can the Government, through the Minister, indicate what they can do to change the culture, training and attitudes within the NHS—and perhaps within society more widely—to make sure that mistakes such as the one made by this junior doctor are not made again?

[Lord Prior of Brampton]

My Lords, the right reverend Prelate makes a number of very important points. This is a society issue as much as a medical issue. Before coming into the Chamber today I discussed with the noble Baroness, Lady Hollins, the importance of teaching students at medical school how to value people with learning difficulties, and the important role that people with learning disabilities might play by going to medical schools and directly telling medical students about their lives and concerns.

[Baroness Hollins (CB)]

The assumption that pregnant women who are expecting a baby with Down’s syndrome will abort that child affects public and medical attitudes. As one woman with Down’s syndrome put it when speaking at a conference on prenatal diagnosis, “You want to kill us”, which is a hard perspective for an adult with Down’s syndrome to hear. I am grateful to the Minister for picking up the point that medical nursing students need to learn from people with learning disabilities, so that their attitudes change. That familiarity with and being comfortable with people with learning disabilities will change things. Will the noble Lord commit to asking the General Medical Council, the Nursing and Midwifery Council and the Medical Schools Council to make this a priority and to teach not just knowledge and skills but practical attitudes to people with learning disabilities?

[Lord Prior of Brampton]

My Lords, the noble Baroness makes a profound point—that medical education and training is not just about passing exams and the technicalities of medicine but about attitudes and how you work and deal with people, particularly people such as those who suffer from learning difficulties. I will certainly do what I can to encourage medical schools and nursing schools to adopt the noble Baroness’s suggestion.

Southern Health NHS Foundation Trust

Lord Prior of Brampton Excerpts

Thursday 10th December 2015 Lords Chamber

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

My Lords, I shall now repeat as a Statement the Answer to an Urgent Question given in another place by my right honourable friend the Secretary of State for Health on the report into the investigation into deaths at Southern Health NHS Foundation Trust.

“Mr Speaker, the whole House will be profoundly shocked by this morning’s allegations of a failure to investigate more than 1,000 unexpected deaths by Southern Health NHS Foundation Trust. Following the tragic death of 18 year-old Connor Sparrowhawk at Southern Heath NHS Foundation Trust’s short-term assessment and treatment unit in Oxfordshire in July 2013, NHS England commissioned a report from audit providers Mazars into unexpected deaths between April 2011 and March 2015.

The draft report, submitted to NHS England in September, found a lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths of mental health and learning disability service users. Of 1,454 deaths reported, only 272 were investigated as critical incidents, and only 195 of those were reported as serious incidents requiring investigation. The report found there had been no effective systematic management and oversight of the reporting of deaths and the investigations that followed.

Prior to publication or, indeed, showing the report to me, NHS England rightly asked the trust for its comments. It accepted failures in its reporting and investigations into unexpected deaths but challenged the methodology, in particular pointing out that a number of the deaths were outpatients for whom it was not the primary care provider. However, NHS England has assured me that the report will be published before Christmas, and it is our intention to accept the vast majority, if not all, of the recommendations it makes.

Our hearts go out to the families of those affected. More than anything, they want to know that the NHS learns from tragedies such as what happened to Connor Sparrowhawk, and that is something we patently fail to do on too many occasions at the moment. Nor should we pretend that this is as a result of the wrong culture at just one NHS trust. There is an urgent need to improve the investigation and learning from the estimated 200 avoidable deaths that we have every week across the system.

I will give the House more details about the report and its recommendations when I have had a chance to read the final version and understand its recommendations, but I can tell the House about three important steps that will help to create the change in culture we need. First, it is totally and utterly unacceptable that only 1% of the unexpected deaths of patients with learning disabilities were investigated, so from next June we will publish independently assured Ofsted-style ratings of the quality of care offered to people with learning disabilities for all 209 CCG areas. This will ensure that we shine a spotlight on the variations in care, allowing rapid action to be taken when standards fall short.

Secondly, NHS England has commissioned the University of Bristol to undertake an independent study of mortality rates of people with learning disabilities.

Thirdly, I have committed to the House previously that next year we will publish the number of avoidable deaths by NHS trust. Professor Sir Bruce Keogh has worked hard to develop a methodology to do this and will write to medical directors at all trusts in the next week explaining how it works and asking them to supply estimated figures that can be published in the spring. Central to this will be instilling a no-blame reporting culture across the NHS where people are rewarded, not penalised, for speaking openly and transparently about mistakes.

Finally, I pay tribute to Connor’s mother, Sara Ryan, who has campaigned tirelessly to get to the bottom of these issues. Her determination to make sure the right lessons are learnt from Connor’s unexpected and wholly preventable tragic death is an inspiration to us all. Today, I would like to offer her and all other families affected by similar tragedies a heartfelt apology on behalf of the Government and the NHS”.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, our hearts go out to the family of Connor Sparrowhawk and all the other families who have struggled so hard to get investigations of the unexpected deaths of their loved ones. On many occasions they have struggled to find the financial support required to make that investigation. That is quite wrong. In this particular hospital’s case, the percentage of unexpected deaths that was investigated is pretty scandalous. In fact, across the board, only 1% of unexpected deaths of those with learning disabilities are investigated.

I very much welcome the Minister’s saying that a light will be shone on this, but will the investigation bear in mind the possibility that it should not be the hospital trust itself that decides which of its unexpected deaths should be investigated? Police forces no longer investigate themselves—that is done by another police force. Should that not be the case with hospitals too? My second question is about timeliness. The report is not the first indication we have had of problems with this trust. The coroners have complained on numerous occasions, and over a long period, about the timeliness and quality of the reports received by them on cases that were investigated. Surely this indicates that there have been problems with the administration, the collection of evidence and the systems of this trust. Why was that not picked up earlier?

[Lord Prior of Brampton]

My Lords, the noble Lord, Lord Hunt, gave two very important figures: 1% of these incidents involving people with learning difficulties were investigated and 0.3% involved people with learning difficulties who are older. We have not got it right in this country when it comes to people with learning difficulties. We have not fully learnt the lessons of Winterbourne View. However, NHS England has now published this new strategy for people with learning difficulties and mental health problems. We will hold it to account for delivering that. I think that represents a step change in trying to get as many of these people out of hospital settings—“from hospital to home” is the line in the report—which is so important. That is the fundamental issue that we should not lose sight of.

NHS England received the report in September. It has not yet been published because it had to give the trust a chance to comment on it, and the methodology has to be fully sorted before it is published. However, Jane Cummings has given a commitment to the Secretary of State that the report will be published before Christmas. So does NHS England have a grip? I think it does.

On the question of an independent investigation, which the noble Baroness, Lady Walmsley, raised, the trust has to be the first line in this. It is up to the trust to have the right culture within it so that these incidents come to the surface. We now have a much more empowered CQC providing independent inspection, and of course the Secretary of State has agreed to set up an independent investigation branch, on the recommendation of the PASC, which will be operable from March.

[Lord Cormack (Con)]

Will my noble friend institute an emergency review, through the CQC or wherever, to try to establish that this is an isolated incident and that there are not more horrors waiting to be discovered?

[Lord Prior of Brampton]

My Lords, I certainly cannot give a guarantee that this is an isolated incident. Often in the past we have taken these awful events when they happen and tried to say that they are isolated. The fact is that there are many trusts that the CQC has characterised as requiring improvement, so I cannot give my noble friend an assurance that this is an isolated incident. However, I can reassure him that our inspection procedures are much more robust than they used to be.

[Lord Campbell-Savours (Lab)]

My Lords, we have had repeated references to unexpected deaths, but no details. What are the causes of these unexpected deaths?

[Lord Prior of Brampton]

Avoidable deaths are estimated at some 10,000 a year. “Unavoidable deaths” is the phrase that I think I used, which are estimated at some 10,000 a year. That is not out of line with what is found in other countries, such as America and Germany. However, it should not be accepted, which is why the Secretary of State has asked Bruce Keogh to produce these new statistics for every trust, starting from next spring.

[Lord Patel (CB)]

The Minister might want to look at those figures again, and correct them with a letter if necessary, regarding avoidable and unavoidable deaths. Turning to my question, on a daily basis now we get at least two items of bad news relating to the NHS, mental health, public health or other issues in social care. Is it not time to look at the whole organisation of the NHS, including funding and so on, through an independent commission? Why would the Government not do that? The Opposition might not support it but it would take politicians out of it and we might end up with a better service.

[Lord Prior of Brampton]

The noble Lord makes an interesting point. We have a much more transparent system than we used to. Surely it is better that we know about what is going wrong within the NHS rather than that we cover it up as it was in the past.

[Lord Mawhinney (Con)]

My Lords, after all the investigations, inquiries and reviews relating to the terrible events at Mid Staffordshire NHS Foundation Trust, your Lordships’ House was told that no one was to blame. Is it the Minister’s initial instinct that after these shocking new facts have been analysed, reviewed, examined and so on, the House will again be told that no one was to blame?

[Lord Prior of Brampton]

My Lords, I do not think anyone was told that no one was to blame as a result of the investigation into Mid Staffs. There were failures at all levels within the NHS with the regulation, the professions and the management of that particular trust. I believe that transparency is the right way to deal with the systemic problems that we have in many of our hospitals.

[Lord Harris of Haringey (Lab)]

My Lords, if you are to achieve transparency, is it not the case that, first of all, as the noble Baroness, Lady Walmsley, has suggested, there should be an independent element in deciding whether a particular death is going to be investigated at all, and, secondly, there must be some independence in the nature of that investigation? Too often those investigations are too close to the establishments concerned. Does there not also need to be some oversight of those independent investigations so that general conclusions of a systemic failure can be picked up, acted upon and brought to his attention as a Minister?

[Lord Prior of Brampton]

My right honourable friend the Secretary of State for Health is committed to having a blame-free, independent investigation service looking at incidents of this magnitude in the NHS. That is why, on the recommendation of the PASC, he set up the investigations branch which will be up and running in March.

Residential Care: Cost Cap

Lord Prior of Brampton Excerpts

Thursday 10th December 2015 Lords Chamber

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

My Lords, I am slightly relieved—the noble Lord, Lord Hunt, said he had 10 questions but he got to only six, I think.

I thank the noble Baroness, Lady Wheeler, very much, as other noble Lords have done this evening, for securing this important debate. I think we will be having this debate fairly regularly over the course of this Parliament, and we should, because lots of ideas come out of these debates, which I can assure noble Lords are taken very seriously. I shall pick out a few points at the beginning.

Many noble Lords, including the noble Baroness, Lady Wheeler, mentioned Four Seasons, about which there has been publicity. I cannot comment on that particular case, but the CQC’s market oversight function means that it is looking at the finances of all these large care providers very closely and if it has a concern it will liaise confidentially with local authorities.

The noble Baroness, Lady Wheeler, also talked about the spending round. I think it is worth saying, despite the apocalyptic comments from the noble Lord, Lord Hunt, that this was very much welcomed by Simon Stevens, chief executive of NHS England, who felt that it was a good settlement. Although the King’s Fund, the Nuffield Trust and others have been quoted, on balance, most independent commentators feel that this was a better settlement than we had a right to expect.

My noble friend Lord Lansley made an important contribution and reminded us of the importance of the Care Act. He thanked Paul Burstow, as did other noble Lords, for his important role in that Act. He talked about integration and personal budgets, which are a very important aspect of the future strategy. Noble Lords have asked about the future strategy. Personal budgets and integration will be very important parts of any future strategy. He also mentioned the Dilnot situation. I will come back to Dilnot, if I may, a little later.

The noble Baroness, Lady Brinton, talked with passion about the care her mother had received over 10 years. This is important, and others have mentioned it as well. In her mother’s case it was a combination of domiciliary care, residential care, respite care and NHS hospital care. When it works, it works incredibly well and we need to be careful in talking about the undoubted problems in this industry, which we all know of. Many providers of residential healthcare and many staff who work in that industry do a fantastically good job. The noble Baroness referred to the better care fund, which is a big stake in the ground and is bringing together funds from the health sector and from social care. Pooling those funds is the right way forward.

The noble Lord, Lord Turnberg, talked about the dependency of the healthcare sector on social care and vice versa, and how looking at the two in isolation made no sense at all. He asked about our response to David Dalton’s report on the development of chains and more integrated care. I can tell him that three of the vanguards are proceeding very much along the lines described in David Dalton’s report. I would refer also to the devolution that is happening in Manchester, where there are some serious comings together, not just within healthcare but between healthcare and social care. Devolution, again, will be a big part of any strategy as we go forward.

The noble Lord, Lord Filkin, had a number of concerns—in particular about the future supply of a skilled workforce. I believe that the national living wage and the care certificate that came out of the Cavendish report will both be helpful in improving the opportunities for staff in the sector. He referred to the hidden misery in social care, which other noble Lords have also mentioned, and I think that it is true that the NHS, because of its greater exposure and the love that the people of this country have for it, gets the lion’s share of available resources going into health and social care, which is something that we need to be conscious of. It is certainly something of which Simon Stevens is particularly conscious.

The right reverend Prelate the Bishop of Bristol importantly reminded us that statistics are all very well but these statistics are all individual people. He said that he looked out over Winterbourne View, where there was appalling care. Of course, that was not a result of lack of resources but the result of a rotten culture in that organisation. He also talked about family disintegration. He said that residential care is sometimes regarded as a place of last resort, whereas, as we know, much residential care, far from being a place of last resort can be a wonderful place for people to spend the end of their lives.

My noble friend Lady Redfern talked about the reality of the Care Act in north Lincolnshire and filled us all with some hope that it can be made to work and that the community can come together. She talked about the five community well-being hubs in north Lincolnshire and the better care fund being used to bring together social care and healthcare, and the importance of partnership working, including housing, which other noble Lords have mentioned.

Earlier this week, an interesting speech was given by Duncan Selbie, the chief executive of Public Health England, who said that when it comes to health the NHS touches just the top of the pyramid, but, actually, health comes from employment, education, a prosperous economy and, of course, good housing. The noble Lord, Lord Lipsey, raised with me separately his views on how we might be able to reallocate some of the money currently going through CHC, which is something officials are looking at. I can assure him that it has not been lost and we are looking at it. The noble Lord is very concerned about the postponement of Dilnot. I will come back to that subject in a minute. He also mentioned “Alive, Alive Oh!”—Diana Athill’s story of when she went into residential care, and how that is sometimes a remedy for loneliness and lack of support. Of course, good homes where there are good levels of activity and high levels of comfort can be wonderful places to live.

I think the noble Baroness, Lady Pitkeathley, said that she had been working, or involved, in the care industry for 40 years, and had been in this House for 18 years. She reminded us that, looking back on what those local authority homes were like 30 or 40 years ago, many of them were terrible. The split between commissioning, or purchasing, and provision has undoubtedly been a very good thing, in the main, and things are a lot better than they used to be. The noble Baroness also reminded us that for the 18 years she has been in this House we have been talking about integration—yet in her view we are still waiting for it. I respond to that by saying that the five-year forward view is a big step towards greater integration between health and social care.

The noble Lord, Lord Warner, raised a number of important issues. I shall have to pick out some of those and write to him later. In particular he talked about the fragility of the big providers and the problems in care homes. One of the things that the CQC market oversight does is to try to identify early some of the problems that may arise, such as those that arose at Southern Cross in the past. He also said that it is one thing to identify a financial issue ahead of time, but the question is: is there the capacity in the industry to pick up the fallout from the collapse of a major provider? The noble Lord, Lord Sutherland, also raised that point.

The noble Lord, Lord Bhattacharyya, raised a number of points about the importance of the million unpaid carers. He also asked, importantly, whether we could be more imaginative about financial products—whether those be care ISAs or other savings and pension products—which could help to meet the undoubted need for more funding in this sector.

The noble Lord, Lord Bichard, who as chairman of SCIE has a profound knowledge of social care, also talked about integration. He said that a third of the places inspected by the CQC are deemed to require improvement. It is important that at least we know that fact. This has not suddenly happened. We know this now because of the CQC inspection regime, which, particularly in social care, has been very much welcomed by the industry. The noble Lord said that Martin Green was not someone who overstated his case. But I think that occasionally Martin Green has been known to overstate his case; he has certainly done so to me in the past. However, his words of warning about the local authority-funded residential care market, as distinct from the self-funded care market, are not to be dismissed.

The noble Baroness, Lady Dean, talked about Abbeyfield—a wonderful care group—and the joy she feels when she walks out of one of its homes. She also mentioned an investment in five new dementia care homes. May I write to her about the particular issue that she raised about funding supported housing? I cannot give her the answer today, but I will write to her after the debate. She also made the interesting point that since higher wages have been paid to staff, sickness absence and staff turnover have both come down. Low wages and high turnover of staff have dogged this industry for years, with all the knock-on effects on continuity of care and training, so there is quite an important message there.

The noble Lord, Lord Sutherland, referred to the usual suspects. This debate has been well attended by the usual suspects and a few others. I suspect that the band of usual suspects will grow, rather than diminish, over the next five years. He made an interesting point about the number of empty beds in the nursing home and care home sector at a time when there are so many delayed discharges or people who should not be in acute hospitals. It is overly simplistic to say that there are 10,000 empty beds in that sector so we could therefore have 10,000 patients out of hospitals who could go into those beds. The fact is that those beds are often not the right kind of bed. They do not have the right nursing care around them or they are in the wrong place. Nevertheless, there is plenty more scope for acute hospitals to work much more closely with the acute sector.

I will pick up the points made by the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, in my speech, but I will write to the noble Baroness on the nursing care issues in particular. I would rather do that.

First, why have we postponed Dilnot? I must say that it is a postponement. We will come back to Dilnot in this Parliament. To be completely frank with noble Lords, it was postponed because it was felt that it would be too expensive to implement it now and that it would put too much pressure on local authorities. One of the priorities of this Government is to reduce the budget deficit and start repaying the debt that has accumulated over the years. Noble Lords may not like that very much and might have a different view from that, although it was the view of the coalition Government. That is our view and that is why it has been postponed. It does not alter the fact that the Government believe that the Dilnot report was outstanding and we accept the vast majority of its recommendations. Indeed, our decision to delay those reforms was welcomed by many in the sector. The Local Government Association in particular and others welcomed our decision as a real example of the Government listening to their concerns about introducing significant reforms at a time of financial challenge for local authorities.

I think the noble Lord, Lord Hunt, said that we like to blame local authorities—he says it was not him; someone said it. On the contrary, part of the Government’s strategy is to devolve more power and responsibility to local authorities. By delaying, we allow local authorities time to focus on delivering the important reforms to care and support under the 2014 Act, which came into force on 1 April this year, putting in the necessary groundwork to implement the funding reforms as successfully as possible in 2020.

The grant funding of £146 million made available in 2015-16 to support implementation of the cap prior to delay will remain with local government. I assure noble Lords that the decision to delay implementation was not taken lightly. The recent spending review reaffirmed our commitment to implement these reforms in April 2020, making funding available in 2019-20 to help local authorities to prepare for implementation.

I turn now to quality and the workforce. Delivering the outcomes that people want and need would not be possible without a sustainable care home sector capable of delivering quality care. We are taking steps to support the sector to continuously improve in this area. Noble Lords will be aware of the Care Quality Commission’s new inspection regime and will know that we are investing £115 million this year to support the training and development of the care workforce, including a national programme of support for registered managers, who play such a vital role in ensuring the quality of care homes.

I have talked about the CQC’s market oversight role, which is an important new development, and at other times I have talked about the importance of the new vanguard programme. I refer in particular to the six enhanced health and care home vanguards, where we now see GPs doing ward rounds around care homes and a much more integrated model between healthcare and social care.

I will just say a little bit about the money. Noble Lords will know that the Government are giving local authorities access to £3.5 billion of new support for social care in 2019-20. From April 2016, councils will be able to introduce a new social care precept, allowing them to increase council tax by 2% above the existing threshold. This could raise nearly £2 billion a year for social care by 2019-20. A number of noble Lords, including the noble Lord, Lord Warner, asked about smoothing payments and we will have to address that issue. I must apologise that I do not have time to finish what I wanted to say because of all the issues that have been raised. I wonder if it would be acceptable if I wrote to all noble Lords who attended this debate with what else I wanted to say and just apologise that I am timed out.

Alcohol

Lord Prior of Brampton Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government whether they will review the responsibility deal for alcohol in the light of the Institute of Alcohol Studies’ report Dead on Arrival? Evaluating the Public Health Responsibility Deal for Alcohol.

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

My Lords, we are currently reviewing all aspects of the responsibility deal, including for alcohol. Partnership working continues to play an important role and the Government remain committed to its principles. We will continue to engage with the alcohol industry to encourage it to take action to reduce some of the harms caused by alcohol.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful to hear that the Government have decided to review the responsibility deal after its operation for the past five years. During that time, we have seen obesity grow; we have seen no increase in the activity undertaken by individuals; and we have seen more people presenting in hospital with alcohol problems. Will the Minister tell us whether he is sticking to the principles that guided the previous partnership, which was not, in fact, supported by the health industry? What will be the changes in the future to ensure that there is some real pace and real change taking place and that the mechanism of a voluntary approach is not used to delay?

[Lord Prior of Brampton]

My Lords, we have asked the London School of Hygiene and Tropical Medicine to review the impact of the responsibility deal, which it will do later in 2016. There have been, however, some benefits from it on alcohol, to which the noble Lord referred particularly. The number of units not sold as a result of it is 1.3 billion and the package labelling on alcohol products has improved substantially.

[Baroness Hollins (CB)]

My Lords, does the Minister agree that it would be better named the “irresponsibility deal” and that it is time for effective policies to be introduced, including a minimum unit price; zero tolerance for drinking and driving; and clear and unequivocal advice for pregnant women not to drink?

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[Lord Prior of Brampton]

My Lords, I think that is an incorrect labelling of the responsibility deal. It might not be perfect, but it has achieved some benefits, not just in relation to alcohol but in salt reduction and other areas. On drink and driving, the social argument has been won, and the number of deaths through drink and driving—although still far too high—has gone down from some 1,640 in 1979 to 240. So improvements are being made.

[Lord Garel-Jones (Con)]

My Lords, can the Minister confirm that alcohol continues to be regarded as a habit-forming, hallucinatory drug?

[Lord Prior of Brampton]

My Lords, I am not sure who considers alcohol to be habit-forming and hallucinatory—whether it is my noble friend or others. I think it depends very much on the quantities in which it is taken.

[Lord Rennard (LD)]

My Lords, does the Minister accept that the 1.3 billion unit reduction in alcohol consumption of which he spoke represents a reduction of only 2%, and that the alcohol industry itself cannot be relied on to assess objectively the scientific evidence that points strongly towards the need for things such as minimum unit pricing and for alcohol taxation to be proportionate to the alcohol content of drinks?

[Lord Prior of Brampton]

My Lords, as I say, an independent assessment of the responsibility deal will be done by the London School of Hygiene and Tropical Medicine. It is important that the assessment is independent and certainly is not undertaken by the industry or, indeed, by the Department of Health. It is worth noting that the consumption of alcohol seemed to peak in 2005 and has declined slightly since then. I am not in any way minimising the appalling damage that alcohol does to the lives of many people, but consumption is coming down slowly.

[Baroness Hayter of Kentish Town (Lab)]

My Lords, the BMA concluded that the Government’s alcohol policy had been weak and ineffective due to an overreliance on working with the alcohol industry. Does the Minister concur with the BMA’s judgment that the responsibility deal has pursued initiatives that are known to have little effect in reducing alcohol-related harm and that the responsibility deal should now be abandoned?

[Lord Prior of Brampton]

My Lords, I can only repeat that we will have an independent review of the responsibility deal, at which point we will have objective evidence on which to assess it. I agree entirely with the noble Baroness that the health world, including the BMA and many of the royal colleges, takes a very strong view about alcohol. Many doctors see the appalling impact that it has on individual lives day in and day out, so we take their views extremely seriously.

[Lord Lansley (Con)]

My Lords, can I tell my noble friend the Minister—

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[Lord Lansley]

Can I ask my noble friend the Minister if he agrees that the report from the Institute of Alcohol Studies is purely polemical in character and not a research report at all? Actually, its argument is based on a flawed proposition, which is that the pursuit of voluntary agreements through the responsibility deal prevented the pursuit by government of minimum unit pricing. Does my noble friend agree that from the very outset of the responsibility deal, it was made clear to the industry that its pricing of alcohol and indeed the Government’s attitude in terms of tax and pricing were no part of the responsibility deal, and that within government no discussion of minimum unit pricing was affected by the fact of the responsibility deal?

[Lord Prior of Brampton]

I am happy to be told that by my noble friend and I can only agree with him.

[Lord Patel (CB)]

My Lords, as it is Christmas, does the Minister think that the Parliamentary Estate should be alcohol-free, as it is smoke-free?

[Lord Prior of Brampton]

My Lords, I think that we would be setting an excellent example if we did that.

[Lord West of Spithead (Lab)]

My Lords, does the Minister not agree that alcohol has been a fundamental part of western civilisation for millennia, and that in moderation it is actually quite pleasant?

[Lord Prior of Brampton]

My Lords, I agree entirely with that. Pubs, clubs and restaurants are a vital part of a happy and cohesive society, so I am very happy to agree with those sentiments.

[Lord Wallace of Tankerness (LD)]

My Lords, do the Government have any intention of evaluating the reduction in the drink-drive blood alcohol limit in Scotland?

[Lord Prior of Brampton]

In Scotland the permitted number of milligrams of alcohol per 100 millilitres of blood was reduced from 80 to 50, and we will be following that change with great interest. If it results in a significant reduction in the number of deaths on the road, I am sure that we will wish to take it on board.

Health: Liver Disease

Lord Prior of Brampton Excerpts

Wednesday 9th December 2015 Lords Chamber

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

Since the publication of the report of the Lancet commission, the Government have continued to address the incidence of liver disease through a number of measures which focus on both the prevention of liver disease, and improved care for those with liver disease. Public Health England has a programme of public health action to tackle liver disease and is working with key stakeholders, including the Lancet commission, to produce a framework for liver disease next year.

[Baroness Finlay of Llandaff (CB)]

As we enter the festive binge drinking season, do the Government recognise that 28% of deaths in 16 to 24 year-old males are alcohol-related and that 85% to 90% of the cost of in-patient liver disease is due to alcohol? By raising the floor cost of alcohol by 10%, we may be able to reproduce the Canadian evidence of a 30% fall in deaths attributable to alcohol. Do the Government also recognise that we have a responsibility to the next generation because in pregnant women hepatitis, obesity and alcohol are each risk factors, each compounding the other? If we implement a six-in-one vaccine programme for hepatitis B in neonates, we may prevent the next generation suffering from hepatitis B as well as decrease the incidence of foetal alcohol syndrome by tackling alcohol abuse in pregnancy.

[Lord Prior of Brampton]

My Lords, there was quite a lot in that question. Some 6,000 babies suffer from foetal alcohol syndrome and it is a shocking and appalling by-product of alcohol. Canada has increased the floor price of alcohol and I understand it has seen some reduction in alcohol-driven disease as a result of that. We are watching what happens in Canada carefully. Of course, Scotland is considering a similar move although it is awaiting the outcome of a court case in the European Union. I gather that Wales will possibly follow suit if that court case goes accordingly. We will watch what happens in those other countries, study it and then make up our minds accordingly.

[Lord Walton of Detchant (CB)]

My Lords, my former medical colleagues in Newcastle upon Tyne, including several distinguished hepatologists are gravely concerned by the increasing incidence of alcohol- induced liver disease in young people. The problem is that in Newcastle—in the centre of the city and on the quayside—many organisations sell what are called, “cheap shots” with a very high alcohol content. Surely the time has come, yet again for the Government to give urgent consideration to the introduction of a statutory minimum price per unit of alcohol.

[Lord Prior of Brampton]

My Lords, there are strong arguments for minimum unit pricing. However, other consequences might flow from minimum unit pricing to do with illicit alcohol sales and the fact that the cost of that would fall very heavily on those least able to afford it. As I said earlier, it will continue to be kept under consideration by this Government and we will study with great interest what happens in other countries which are introducing minimum unit pricing.

[Lord Anderson of Swansea (Lab)]

My Lords, given the statistics just given to the House by the noble Baroness and the scale of profits of the drinks industry, are the Government content with the amount of financial help given by the drinks industry to the victims, as suggested by the noble Baroness?

[Lord Prior of Brampton]

My Lords, as part of the responsibility deal, a financial contribution was made by some of the alcohol companies. I accept that it was a small contribution. I shall have to take this under advisement as I am not sure how much the industry does contribute to the victims of alcohol disease. I agree with the noble Lord’s premise that the damage done to many people through excessive alcohol consumption is a cause of great concern.

[Lord Ribeiro (Con)]

My Lords, does my noble friend agree with recommendation 3 in the report, which requires the establishment of liver units in district general hospitals, acting in a hub-and-spoke network with specialist hospitals? This is important to provide access to people, particularly in the north-west, where, sadly, there is very little access to specialist hepatology units.

[Lord Prior of Brampton]

My Lords, the recommendations in the report about a hub-and-spoke approach, to which my noble friend refers, with district general hospitals having some hepatology services but being linked into a specialist centre are absolutely right. It is the right model; I have no doubt about that. We have established 22 operational networks for hepatitis C treatment, which are all linked into specialist treatment centres. We believe that that may be a model for the future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the issue of specialist centres, has the Minister actually read the Lancet report, which points out that the north-west has the highest incidence of liver disease, yet does not have a transplant centre? In view of the very good outcomes from the transplant centres, are the Government making sure that the north-west gets such a centre?

[Lord Prior of Brampton]

I have read the Lancet report and I noted this rather unusual omission in the north-west. I do not understand why the north-west does not have a specialist liver facility. It is something that I will follow up and find out. I will write to the noble Lord if I can.

[Baroness Walmsley (LD)]

My Lords, the Lancet said that the majority of people with obesity have non-alcohol related fatty liver disease. Does the Minister agree that we need restaurants and takeaways to publish the calorie, fat, sugar and salt content of their dishes? Some of the best do it, but not many do. Will he also consider further restrictions on the advertising of high-calorie junk food to children?

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[Lord Prior of Brampton]

My Lords, I understand that that is precisely one of the issues that the responsibility deal has studied and addressed.

[Baroness Masham of Ilton (CB)]

My Lords—

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[Baroness Masham of Ilton]

My Lords, thank you. Is the Minister aware that the UK is the worst country in Europe for liver disease? Is he not rather worried about cutting funds for public health?

[Lord Prior of Brampton]

My Lords, we clearly have a major problem with liver disease—I think that we can all agree on that. The report by the Lancet commission has some very useful recommendations that we must take seriously. It is true that other countries in Europe have had more success in tackling this. I cite France as a case in point. We will take on board the number of recommendations made by the Lancet commission, as well as other initiatives we are taking.

Health: Adult Pneumococcal Vaccination

Lord Prior of Brampton Excerpts

Tuesday 8th December 2015 Lords Chamber

[Baroness Greengross]

To ask Her Majesty’s Government what plans they have to improve the efficacy of the adult pneumococcal vaccination programme and to ensure optimal coverage of target populations in the United Kingdom.

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

My Lords, vaccination of children, adults and risk groups with pneumococcal and influenza vaccines has led to a significant reduction in pneumococcal disease in the UK. The Joint Committee on Vaccination and Immunisation published an interim statement on adult pneumococcal vaccination on 18 November. The JCVI statement is subject to stakeholder consultation before being finalised. The interim statement advises continuation of the existing adult pneumococcal vaccination programmes. The Government will respond fully once the advice is finalised.

[Baroness Greengross (CB)]

I thank the Minister for that reply. As he knows, this disease puts an enormous pressure on the NHS and on patients. The recent report that he mentioned from the ONS showed that pneumonia was the underlying cause in almost a fifth—19%—of the 43,900 excess deaths in England and Wales just last winter. The recent review by the Joint Committee mentioned by the Minister recommended no changes to the adult pneumococcal vaccination programme at this time, which is a bit surprising. The committee is currently consulting, as the Minister mentioned, and it acknowledged that there are weaknesses with the levels of protection offered to at-risk adults. Will the Minister look into this issue and work to make sure that the pneumococcal vaccination programme provides optimal protection for vulnerable adults?

[Lord Prior of Brampton]

My Lords, the report by the JCVI was very clear in its recommendation that the existing vaccination, PPV, was the most appropriate for those aged over 65 and that PCV 13, which is the vaccination used for young children, because it provides herd protection—that is, young people who are treated with it can no longer carry the disease—offered the best long-term protection for the elderly as well.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this year community pharmacists have been given the opportunity to provide NHS vaccinations. Can the Minister say something about how successful that has been? Does he think that there is much greater potential for community pharmacists to do more work for the NHS in this and other areas?

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[Lord Prior of Brampton]

My Lords, there is a huge and growing role for community pharmacy in delivering services that have traditionally been supplied by the NHS. If we were to discuss this in five years’ time, I am sure that we would see a far greater role played by community pharmacy. I am not sure that I can give the noble Lord a specific answer on vaccinations. I can just say that the flu vaccination rate so far this year to date is 66%. Last year, by the end of the winter, it was 72%, so we are roughly on target to do the same as last year.

[Baroness Walmsley (LD)]

My Lords, the service standards say that local authority directors of public health have a key role to play in ensuring good coverage of vulnerable groups in their area. Given that fact, what assessment has the Minister’s department made of their ability to carry out that role, given the recent large cuts in public health budgets?

[Lord Prior of Brampton]

My Lords, the principal role for pneumococcal vaccination—the subject of the Question—lies with GPs. Take-up of the PPV for those aged over 65 is 70%; for those aged over 75, it is 80%. For young children, the rate is more than 95%.

[Lord Walton of Detchant (CB)]

My Lords, one of the great advantages of the pneumococcal vaccination programme is that it is widely believed that a single injection gives lifelong protection—or at least substantially lifelong protection—against pneumococcal pneumonia and pneumococcal meningitis. Is the Minister satisfied that that is still sufficient?

[Lord Prior of Brampton]

My Lords, the noble Lord knows far more about this than I do. I can tell him that the PCV 13 vaccination for young children provides long-term protection and, as importantly, prevents the disease spreading. The PPV—the polysaccharide vaccination provided to older people—does not have the longevity of PCV 13, but it provides wider protection against 23 of the serotypes, rather than 13. It does not provide the length of protection that PCV 13 does, but it still provides some protection.

Sex-selective Abortion

Lord Prior of Brampton Excerpts

Monday 7th December 2015 Lords Chamber

[Baroness Knight of Collingtree]

To ask Her Majesty’s Government whether they plan to take action to protect unborn girls from abortion for the sole reason of their sex.

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

My Lords, abortion on the grounds of gender alone is illegal, and we have made this very clear on a number of occasions. The Government published an analysis on 27 August this year which found no substantiated evidence of gender abortions taking place in Great Britain. We are committed to continuing to monitor this issue carefully and will examine any evidence that comes to light.

[Baroness Knight of Collingtree (Con)]

My Lords, I am most pleased to hear what my noble friend just told us. Why are there constantly reports in the papers of such abortions being carried out? It seems to be fairly usual if we look at the papers. Is he as concerned as I am that there seems to be no great battle against this?

[Lord Prior of Brampton]

My Lords, abortion on the basis of gender alone is illegal; there should be no doubt about that. There is no evidence at all on a population basis of any such abortions taking place. However, my noble friend has mentioned that there is anecdotal evidence to the effect that that may not always be the case. To that extent, she is right to be eternally vigilant about these matters. If it is happening, it is totally unacceptable, abhorrent, and against everything we stand for in this country.

[Baroness Walmsley (LD)]

My Lords, with which stakeholders are the Government working in order to fulfil their commitment to explore pressure and coercion on women in relation to boy preference and its possible link with domestic violence?

[Lord Prior of Brampton]

My Lords, I have a long list of stakeholders, which covers all the usual suspects in this area, if I can put it like that. In the way that the methodology was developed to assess whether there was a population basis for gender abortions taking place, we took advice from the Office for National Statistics and a number of the royal colleges.

[Baroness Armstrong of Hill Top (Lab)]

My Lords, has the Minister yet had the opportunity to consider the judgment made last week about abortion in Northern Ireland? What advice and work are the Government going to do with the devolved Administration to ensure that women in Northern Ireland get the same human rights as women in the rest of the United Kingdom?

[Lord Prior of Brampton]

My Lords, it is a devolved matter for the Northern Ireland Executive and not really for me or for us.

[Lord Dobbs (Con)]

My Lords, there may not be sufficient evidence for gender-based abortion prosecutions, but there is sufficient evidence, surely, for greater effort to be made about female genital mutilation. Tens of thousands of women in this country have suffered from it yet we still have not had a single successful prosecution. Does he accept that far more needs to be done to deal with this evil?

[Lord Prior of Brampton]

My Lords, my noble friend makes an important point. Gender-based abortion, female genital mutilation, honour crimes and various other issues still take place in some ethnic communities in England. Across the board, we have to be vigilant about all of these issues and make it clear that they are not acceptable. They are against the law and anyone aware of these practices going on should report them to the police.

[Lord Elton (Con)]

My Lords, my noble friend has twice referred to evidence on a population basis, which I take to mean that the evidence is taken without distinction of which part of the country it comes from. Has any effort been made to correlate the evidence with clusters of cases, which might point to some social activity that would be possible to countermand?

[Lord Prior of Brampton]

My Lords, the statistics are collected on the basis of birth across the population. They are then analysed in 500 different ways. In only one of those 500, which concerned the third or further child given birth to by women from Nepal, was there any variation from what one would expect. I can assure noble Lords that the statistical analysis is very robust.

[Baroness Nicholson of Winterbourne (LD)]

My Lords, while welcoming the appointment of the noble Baroness, Lady Verma, as the Minister with responsibility for women and children and for tackling violence against women and children overseas, given the prevalence of this abortion of female foetuses and the prevalence of FGM among certain girls under five, are the Government thinking of appointing a Minister for violence against women and children in the United Kingdom?

[Lord Prior of Brampton]

My Lords, I am not aware that we are giving consideration to that, but I will find out and write to the noble Baroness.

[Baroness Masham of Ilton (CB)]

My Lords, can the Minister confirm that unborn babies are covered by the discrimination Act?

[Lord Prior of Brampton]

My Lords, I am afraid I cannot confirm or deny that. I will write to the noble Baroness.

[Baroness Hayter of Kentish Town (Lab)]

I thank the Minister for his original reply; it is one with which we concur—we do not have the evidence and, like him, we consider that the Act is sufficient as it is. Some of the stories are partly, I think, just about the lack of self-worth that some girl children sometimes feel; that is partly about their education and that of their mothers. Can the Minister say something about what the Government do to encourage greater self-worth among young women and, indeed, older women?

[Lord Prior of Brampton]

My Lords, I encourage anyone with an interest in this matter to read some of the case stories put together by Jeena International—they are really quite shocking. They are anecdotal, but they are very real for a small minority of women who lack self-worth. That is, tragically, part of some of the cultures in England and we must do everything we can to improve women’s self-worth. I think that, in the long run, that will be done by education, education, education.

[Baroness Hussein-Ece (LD)]

My Lords, if, as anecdotal evidence suggests, there are such terminations of female foetuses, surely that would be reflected in the overall population of girls being born. The figures I have seen show that women are, thankfully, still in the majority in this country.

[Lord Prior of Brampton]

The statistical evidence is absolutely clear and points to the fact that there is no widespread gender abortion happening in this country. One would expect a ratio of 105 to 100 boys to girls and it is actually 105.2 to 100 in England, Scotland and Wales, so it is exactly where we would expect it be. There is one exception, which is the third and fourth born of Nepalese women, but this has been looked at two or three times and it is just a random variation in the statistics that we use.

National Health Service (Licensing and Pricing) (Amendment) Regulations 2015

Lord Prior of Brampton Excerpts

Tuesday 1st December 2015 Lords Chamber

Moved by

[Lord Prior of Brampton]

That the draft Regulations laid before the House on 2 November be approved.

Relevant documents: 9th Report from the Joint Committee on Statutory Instruments, 14th Report from the Secondary Legislation Scrutiny Committee

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

My Lords, I am grateful to the noble Lord, Lord Hunt, for his interest in this matter, and I know he has great knowledge through his work at the NHS Confederation, in healthcare and as a Minister. Naturally, I am disappointed to understand from his amendment that he feels that the draft regulations are fundamentally unfair and in contradiction to the assurances given by my predecessor, my noble friend Lord Howe. I will take this opportunity today to reassure him—I hope—and wider stakeholders that this is not the case.

I want to begin by giving some context to the regulations. They seek to rebalance the objection mechanism that exists within the statutory processes of setting the national tariff for healthcare services. They increase the objection percentages for clinical commissioning groups and relevant providers of services. They will also remove the prescribed objection percentage for providers weighted according to their share of the supply in England of such services as may be prescribed.

Everyone knows the scale of the financial challenge facing the NHS. That is why the Government have committed to investing £10 billion by 2020-21 to fund the NHS’s own plan for the future, with £6 billion frontloaded in the first two years of the six-year period.

Along with the implementation of a range of provider support measures we have available, this will help to ensure the health and care system remains on a sustainable footing over the longer term. But as Simon Stevens made clear in the Five Year Forward View, the NHS must play its part in delivering these efficiencies.

Delivering a financially stable NHS is a key priority for the new chief executive of NHS Improvement, Jim Mackey, working closely with the department and NHS England to support the system at a local level to deliver the transformational changes needed to drive efficiencies.

Nevertheless, we do not underestimate the challenges facing the system from an increasingly ageing population with more complex needs, which I am sure all noble Lords are aware of. This is why we support the ambition of the Five Year Forward View set out by NHS England to ensure we protect the model of universal coverage free at the point of delivery for future generations.

But to realise this vision, we need to support the whole health system. This will not be easy, but this principle lies at the heart of the regulations, which we believe will ensure sufficient stability and timeliness in publication of the national tariff but also ensure that as much as possible of the additional funding that this Government have provided for the NHS reaches patient services, rather than being tied up in processes or reinforcing acknowledged barriers to transforming health and care.

Let me give noble Lords some background to the regulation—where this refers to statutory duties, I will use the name Monitor rather than NHS Improvement. The Health and Social Care Act 2012 introduced a new independent, transparent and fair pricing system that requires Monitor and NHS England to collaborate to set prices and further develop new payment models across different services. The intention of this system was to create a more stable, predictable environment, allowing providers and commissioners to invest in technology and innovative service models to improve patient care.

Monitor has the specific duty of promoting healthcare services that represent value for money and maintain or improve quality. It achieves this by working with NHS England to regulate prices and establish rules for local pricing and flexibilities. NHS England defines the “units of service” for which prices or rules will be specified. Units of service include, for example, the pregnancy-related services that a woman may need through antenatal, delivery and postnatal care, with levels of payment aligned to clinical factors—often complexity. At all stages, Monitor and NHS England have to agree elements of the tariff with each other.

The Act also includes a statutory basis for providers and commissioners to raise formal objections to the methodology that Monitor proposes for calculating national prices rather than the price itself. It is vital that tariff proposals reflect wider views across the sector but, as NHS providers acknowledge:

“The ultimate responsibility for setting NHS tariffs must lie with Monitor … and NHS England as the statutory price-setting bodies”.

Following comprehensive engagement with commissioners and providers, Monitor is required to publish a final draft of the national tariff and allow 28 days for commissioners and providers to consider the proposals. Commissioners and providers may formally object to the proposed methodology for calculating tariff prices for specified services. This draft instrument seeks to amend regulations made in 2013. Those regulations exercise a duty to prescribe two objection thresholds and a power to prescribe a third. Thus, under the current rules, Monitor will calculate the following after the consultation: the percentage of commissioners objecting; the percentage of providers objecting; and the percentage share of supply held by the objecting providers, which allows the objections of providers to be weighted proportionate to the nationally-priced services.

Each threshold is currently set at 51%. If any of these are met, the unexpired tariff remains in force. Monitor cannot publish the national tariff and has to either put forward alternative proposals and publish them for consultation, or refer the method and the objections received to the Competition and Markets Authority.

I shall now explain the outcome of the two tariff processes that took place in 2014-15 and 2015-16 under these new arrangements. No objection threshold was met when the first proposed national tariff was consulted on in 2014-15 and the tariff was published on time. For 2015-16, the objection tariff mechanism was triggered as the share of supply objection threshold was met as 73.7% of providers by share of supply objected. As a result, the unexpired 2014-15 tariff remained in place.

A key motivation for providers’ objections to the tariff proposals was the efficiency requirement of 3.8%. A further significant trigger for formal objections related to a variation to the payment of national prices for specialised services rather than the underlying method for the price, which is the only ground on which objections can be made. As a result of the objection mechanism being triggered, the 2015-16 tariff was not published and the unexpired 2014-15 tariff remained in place at a potential considerable cost to the health service.

Following further engagement, a large majority of providers agreed a local variation to the 2014-15 tariff prices while a minority have continued to be paid the unvaried 2014-15 tariff prices. Overall for 2015-16, this has meant an additional cost pressure estimated at £0.5 billion. We cannot afford this and any repetition would ultimately affect patient care and prevent crucial investment in front-line care. This cannot be right. It would also distract the system from implementing the five-year forward view which would place the NHS on a sustainable footing.

The objection mechanism is intended to be a process that is triggered in exceptional circumstances. When the thresholds were prescribed in 2013, it was made clear in the Explanatory Memorandum:

“The Department also intends to review the objections thresholds in due course once the new system beds down”.

The circumstance that national prices in the tariff are set predominantly for acute care rather than mental health and community services means that objections from acute providers then carry most weight in calculations against the share of supply threshold. While the larger acute providers have perhaps exercised their own role in using the objection mechanism in a broadly reasonable manner, the share of supply mechanism cannot fairly reflect the balance of wider interests across the healthcare sector. This should not be read as the Government placing less value on the crucial role played by the acute sector, but as a greater emphasis on the interests of the NHS as a whole. Indeed, we welcome the role that the acute sector is playing in new collaborative roles within its health economies.

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[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners, an academic health science centre which has a number of important providers. The Minister made a very important point about the five-year forward view and the need to encourage new models of care working that ensure collaboration beyond institutional boundaries —and, indeed, to go further and look at new models of funding, including those of accountable care organisations. With a view to a potential journey towards more effective commissioning, and therefore more intuitive constructing of a tariff to support general acute services and more specialised services, will the proposals that the Minister brings to the House today aid that journey? Will looking at these regulations in the way proposed help institutions to work more effectively together, recognising the opportunity to look at tariffs that focus on pathways of care rather than individual segments of care, so ensuring the Government’s objective to ensure that valuable resources committed to the provision of healthcare are used most efficiently? There is a recognition that there will have to be greater attention to these matters as we go forward, and every opportunity should be used to ensure that that objective is achieved. One of the most important is the approach to setting the tariff and, therefore, these regulations.

[Lord Prior of Brampton]

My Lords, as always in these debates, we have had some pertinent and useful contributions. I shall take some of the points raised in reverse order. On the very important point raised by the noble Lord, Lord Kakkar, a profound change is happening in how we will deliver care over the next five years, which will be very much more based around a system rather than the institution. I think that the noble Lord, Lord Hunt, would agree with that; we will move from a payment-by-results system that has been very much based around individual pieces of care delivered in acute hospitals, to other payments systems, such as a capitation system or a whole pathway system. That is going to happen.

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[Lord Hunt of Kings Heath]

My Lords, I am very grateful to all noble Lords who have taken part in this interesting debate. We perhaps went rather wider than the terms of the regulations. I agree with the Minister that payment by results was brought in essentially to drive through reductions in waiting times by providing the right incentives. By and large that has been very successful, but we are moving, and this is a very good thing, into thinking about systems and how they work. There is a clear need to develop a funding mechanism to ensure that there are proper incentives for system-wide working, and I absolutely agree with that.

However, I also agree with the noble Lord, Lord Warner, my fellow former Minister. Looking at the Five Year Forward View, it seems to me that essentially we are moving again to a planning model but we are still stuck with the 2012 Act, and the two do not seem to mesh together. The Minister is struggling with these regulations because they are trying to operate a system that is still based on payment by results, when in essence we are trying to incentivise people to work together to produce a much more effective system and that is very difficult. If he were to tell me that the NHS amendment Act was to be brought forward, I think he would find a warm welcome in your Lordships’ House, but perhaps I dream too far.

I say to the noble Lord, Lord Patel, that I do not disagree at all with his idea of an independent commission; the funding challenges facing health and social care warrant that kind of independent consideration. I say to him, though, that all the work done by the King’s Fund and the Nuffield Trust suggests that if you could maintain real-terms growth at 4% a year, which is the historic annual real-terms growth of the NHS, we would get a pretty good system without some of the pressures that we are facing at the moment. It is not a question of having to increase money to the NHS and social care hugely, but it needs some increase or we will be faced with the kind of problems that we have at the moment. The Barker commission, which was sponsored by the King’s Fund, shows some of the thinking that one might ask a royal commission to go into.

My noble friend Lord Turnberg mentioned the particular challenges of highly specialist providers, which of course are very much tied into the area that he knows so well: our whole R&D effort in this country and the link with the life sciences. While I understand the language of domination by specialist providers, we need to recognise that the link that these very same providers have with R&D and the life sciences is crucial to this country and to the lead that we often have in these areas. We have to be very careful not to undermine their financial viability because of the general financial challenge.

I am delighted that the noble Lord, Lord Warner, is working on, chairing or leading this work on specialised services, and I am sure he is right that we need to have much more effective commissioning. I certainly accept that that is likely to lead to a rationalisation of specialised services, which will not be universally popular. However, if we can show that by doing so we get more bang for our buck, getting better specialist services, and that they are a better investment, clearly, that has to be followed through. I hope that we will see the outcome of that work within the next few months.

I have no problem at all with putting more resources into mental health and community services—I entirely understand that. However, the regulations are a pretty poor show, and in effect disfranchising the providers, who get 96% of the tariff income, is not the way to go forward. However, I am very grateful to the noble Lord, Lord Prior, for what he said. I take his commitment to rebuilding the confidence, as he described it, of providers in the system, as a very strong one. He did not quite go as far as I would have wished with regard to endorsing the open book approach. Does that mean that that is still being considered, or has it been rejected? Can I take anything from that?

[Lord Prior of Brampton]

I will have to defer to Jim Mackey, the chief executive of NHS Improvement. It would not be fair for me to answer that question.

[Lord Hunt of Kings Heath]

I am sure of that, my Lords. I will just say to the Minister that I hope the spirit of this debate will be conveyed to him and NHS Improvement. I certainly have been very impressed by the chief executive’s words since his appointment, and of course the chairman, Ed Smith, commands great respect and authority, not least for the work he has done on behalf of Birmingham University, for which those of us in the city are very grateful.

With that, I thank all noble Lords who have spoken. The point has been made, we look forward to a better approach in the future, and I hope that the spirit of the proposal regarding early consultation and an open book process will be acceded to. I beg leave to withdraw my amendment to the Motion.

Accident and Emergency Departments

Lord Prior of Brampton Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Jordan]

To ask Her Majesty’s Government what steps they plan to take in the light of the investigation by the Royal Society for the Prevention of Accidents and the Royal College of Emergency Medicine into the part that accident prevention could play in relieving pressure on accident and emergency departments.

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

The Government welcome the investigation’s contribution to informing activity on public health and highlighting the part that accident prevention can play in relieving the pressure on accident and emergency departments. It is for local authorities with their local partners to consider the best actions to take to prevent accidents as part of their responsibilities for improving the health and well-being of their local communities.

[Lord Jordan (Lab)]

I thank the Minister for his reply and declare an interest as vice-president of RoSPA. At a time when A&E departments are facing mounting pressure, the RoSPA and Royal College of Emergency Medicine report shows that accidents to children represent a disproportionate number of the injuries that A&Es treat. It also shows that 72% of injuries to children under five occur at home, and that head injuries are among the most common and most serious. Will the Minister urge the Government to back the report’s analysis and its credible proposal to invest in proven techniques that would help to reduce some of the unacceptable pressure on A&Es and the spiralling costs of the NHS and, most importantly, make a significant contribution to reducing the pain, suffering and deaths caused to children by the failure to address this problem?

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[Lord Prior of Brampton]

My Lords, I thank RoSPA and the Royal College of Emergency Medicine for the important work they have done in producing this report, and the work done by Queen Mary’s College in substantiating it. The Government’s policy is to put the main responsibility for children under the age of five in the hands of local authorities in the belief that they, by knowing the local conditions better than central government, can have a greater impact.

[Baroness Walmsley (LD)]

My Lords, given that 15 to 24 year-olds are another of the three most vulnerable groups that are liable to have accidents, will the Government consider looking carefully at the national curriculum and ensure that PSHE, including personal safety and accident prevention, is taught in every single maintained school?

[Lord Prior of Brampton]

That is an interesting question. However, the report shows clearly that the main problem exists with the under-fives. Of course, there are issues at all ages, including falls and other aspects of accident prevention at the end of life. The interesting work that LifeForce has done in Birmingham shows that, for not very much money, we can have a big impact. Using the health visitors who are now employed by local authorities is a very important way in which we can address this important issue.

[Baroness Gardner of Parkes (Con)]

My Lords, while I strongly support the referral of accident cases, is the Minister aware of the report in today’s paper which says that all sorts of unnecessary referrals are made in response to telephone calls for advice on what are often simple things, such as the common cold? Does he not think that resolving that would be an alternative way to take some pressure off accident and emergency services?

[Lord Prior of Brampton]

My noble friend makes a very important point. Many people go to A&E departments who need not go there. The review of Sir Bruce Keogh, the medical director of NHS England, concerning how we structure emergency care in this country will be very important. Clearly, we can make much more of NHS 111.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the point that Minister’s noble friend made was that the Government’s decision to phase out NHS Direct, which used qualified nurses, and replace it with call handlers who simply use algorithms on their screens means that those call handlers are risk-averse, which therefore leads to many more people being sent to A&E. Is it not time to get qualified nurses back behind those screens and talking to patients?

[Lord Prior of Brampton]

The noble Lord makes a good point. If qualified people take the call, the level of risk they are prepared to absorb will be greater, and that applies throughout the whole system.

[Lord McKenzie of Luton (Lab)]

My Lords, I draw attention to my interest in the register. As we have heard from the Minister, the Government seem to accept the case that accident prevention programmes can have a significant beneficial impact on A&E attendances, but the Minister says that it is all down to local authorities. Given the huge cuts in local authority spending, with more announced just last week, what is the Minister’s assessment of the opportunities of local authorities to gain this benefit?

[Lord Prior of Brampton]

The report done by Queen Mary’s, which was based in Oxford, indicated that the under-fives attending A&E departments accounted for 7% of all attendances, which gives an idea of the scale of what we might try to achieve. The reduction, in real terms, in local authority spending over the next five years is 3.9% per annum. Our feeling is that local authorities are well equipped to live with that kind of reduction.

[Lord Patel (CB)]

How good are A&E departments nationally at collecting information on the nature of the accident, and at root cause analysis to prevent it, and how is this information fed into a national database?

[Lord Prior of Brampton]

I am afraid that I am not aware of how A&E departments collect and collate this information, but I will write to the noble Lord on that matter.

[Baroness Farrington of Ribbleton (Lab)]

My Lords, would the Minister care to reflect on the fact that when this Government talk about reducing public expenditure, it is often by putting those with full training, experience and knowledge in charge, because they have won a tender, of a particular answering service, and that the health service is just one example of that? I call to mind other mistakes or misjudgments, such as police officers with skill and experience being replaced by people who just answer the phone. Will he take that issue back to the Government?

[Lord Prior of Brampton]

The noble Baroness makes an interesting point. In the main, contracts, particularly in the health service, are now based on outcomes: it is outcomes, rather than inputs, that are most important.