Junior Doctors Contract

Lord Prior of Brampton Excerpts

Monday 30th November 2015 Lords Chamber

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

My Lords, with the leave of the House, I shall now repeat a Statement made earlier today by my right honourable friend the Secretary of State for Health in the other place. The Statement is as follows:

“With permission, Mr Speaker, I would like to update the House on the junior doctors’ strike. Earlier this month, the union representing doctors, the BMA, balloted for industrial action over contract reform. Because the first strike is tomorrow, I wish to update the House on contingency plans being made.

Following last week’s spending review, no one can be in any doubt about this Government’s commitment to the NHS, but additional resources have to be matched with even safer services for patients. That is why, on the back of mounting academic evidence that mortality rates are higher at weekends than in the week, we made a manifesto commitment to deliver truly seven-day hospital services for urgent and emergency care.

However, it is important to note that seven-day services are not just about junior doctor contract reform. The Academy of Medical Royal Colleges noted that,

‘the weekend effect is very likely attributable to deficiencies in care processes linked to the absence of skilled and empowered senior staff in a system which is not configured to provide full diagnostic and support services 7 days a week’.

So our plans will support the many junior doctors who already work weekends with better consultant cover at weekends, seven-day diagnostics and other support services and the ability to discharge at weekends into other parts of the NHS and the social care system.

But reforming both the consultants’ and junior doctors’ contracts is a key part of the mix because the current contracts have the unintended consequence of making it too hard for hospitals to roster urgent and emergency care evenly across seven days. Our plans are deliberately intended to be good for doctors. They will see more generous rates for weekend work than those offered to police officers, fire officers and pilots. They protect pay for all junior doctors working within their legal contracted hours, compensating for a reduction in anti-social hours with a basic pay rise averaging 11%. They reduce the maximum hours a doctor can work in any one week from 91 to 72 and stop altogether the practice of asking doctors to work five nights in a row. Most of all, they will improve the experience of doctors working over the weekend by making it easier for them to deliver the care they would like to be able to deliver to their patients.

Our preference has always been a negotiated solution but, as the House knows, the BMA has refused to enter negotiations since June. However, last week I agreed for officials to meet it under the auspices of the ACAS conciliation service. I am pleased to report to the House that, after working through the weekend, discussions led to a potential agreement early this afternoon between the BMA leadership and the Government. This agreement would allow a time-limited period during which negotiations can take place, and during which the BMA agrees to suspend strike action and the Government agree not to proceed unilaterally with implementing a new contract. This agreement is now sitting with the BMA junior doctors’ executive committee, which will decide later today if it is able to support it.

However, it is important for the House to know that right now strikes are still planned to start at 8 am, so I will now turn to the contingency planning we have undertaken. The Government’s first responsibility is to keep their citizens safe. This particularly applies to those needing care in our hospitals, so we are making every effort to minimise any harm or risks caused by the strike. I have chaired three contingency planning meetings to date and will continue to chair further such meetings for the duration of any strikes.

NHS England is collating feedback from all trusts but currently we estimate that the planned action will mean that up to 20,000 patients may have vital operations cancelled, including approximately 1,500 cataract operations, 900 skin lesion removals, 630 hip and knee operations, 400 spine operations, 250 gall bladder removals and nearly 300 tonsil and grommet operations.

NHS England has also written to all trusts asking for detailed information on the impact of the strikes planned for 8 and 16 December, which will involve the withdrawal of not just elective care but urgent and emergency care. We are giving particular emphasis to the staffing at major trauma centres and are drawing up a list of trusts where we have concerns about patient safety. All trusts will have to cancel considerable quantities of elective care in order to free up consultant capacity and beds. So far the BMA has not been willing to provide assurances that it will ask its members to provide urgent and emergency cover in areas where patients may be at risk, and we will continue to press for such assurances.

It is regrettable that this strike was called even before the BMA had seen the Government’s offer, and the whole House will be hoping that the strike is called off so that talks can resume. But whether or not there is a strike, providing safe services for patients will remain the priority of this Government as we work towards our long-term ambition to make NHS care the safest and highest-quality in the world. I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, I, too, thank the Minister for repeating the Statement. I, too, understand that the junior doctors have now agreed to call off tomorrow’s strike. Will the Government therefore apologise to the 4,000 patients whose treatments tomorrow will have been delayed by this going right up to the wire and the Government being so reluctant to go to ACAS for negotiation?

I understand that more detailed negotiations will now take place. Will the Government be entering those negotiations without prejudice and with the well-being of patients—and the well-being of doctors, upon which the well-being of patients depends—in their minds as they negotiate? Will they take very seriously the concerns that have been put to them by conscientious junior doctors, who work very hard for us?

I, too, have some scepticism about the data in relation to the so-called weekend effect. I echo the call of the noble Lord, Lord Hunt, for some independent research into the causes of the less good outcomes that undoubtedly occur in some places—to what degree, we do not know. I am quite sure that the junior doctors and their contract are not the only cause of any such weekend effect.

[Lord Prior of Brampton]

My Lords, first, I am very pleased to confirm to the House that in the past few minutes the BMA and the Government have reached an agreement, which will allow time for negotiations to take place. The BMA has agreed to suspend industrial action, including that planned for tomorrow, and the Government have agreed not to proceed unilaterally with implementing the new contract. By any standards, that is very good news.

The noble Lord referred to the brain drain. The best thing we can do in the short term is to sort out the contractual dispute with the junior doctors. That is absolutely fundamental to restoring morale among doctors. There is a feeling among some junior doctors that they are not properly valued. This goes way beyond some of the issues being discussed on the contract. It is about their training and a lot of other issues that bear on this.

There have been, I think, two studies published in the BMJ now about the weekend effect, along with studies in other parts of the world as well, such as the US. There is no doubt that there is a weekend effect. It is to do with lack of senior cover at the weekends, diagnostics and all those kinds of issues. This is a broad issue, which can be addressed only if we have a seven-day service. It is certainly not just about junior doctors.

We do not have much time but I will say this about the Secretary of State: patient safety is his motif. If he wishes to be remembered for anything, it is patient safety. That is why he agreed to go to ACAS when the BMA suggested it. He was absolutely right to do so and I congratulate both the BMA and the Secretary of State for coming to this agreement just in time.

[Lord Patel (CB)]

My Lords, I am not allowed by the rules to make any statement but only to ask a question, which is a pity because I wanted to make some comments about what the Minister just said. We will leave for another day the discussion of this mounting academic evidence that mortality rates are higher. They might be, but we need to investigate the cause-and-effect scenario. Leaving that aside, the Statement says:

“So our plans will support the many junior doctors who already work weekends with better consultant cover at weekends, seven-day diagnostics and other support services, and the ability to discharge at weekends into other parts of the NHS and the social care system”.

Is the Minister able to update us on whether we will have another Statement related to this or whether there are plans in process to deliver all that the Statement says?

[Lord Prior of Brampton]

There is a recognition that the weekend effect is caused by many factors. It is certainly not just the ability of trusts to roster junior doctors at weekends but the absence of senior cover and the fact that much diagnostic capacity is not available at weekends. Of course, you also have to be able to discharge patients at weekends, which means that social care has to be working as well. To have a truly seven-day NHS requires a lot more people and resources to be available than just junior doctors.

[Lord Lansley (Con)]

My Lords, my noble friend the Minister’s repetition of the Statement and what he was able to say additionally in response to noble Lords was very welcome. Does he agree that going back more than 20 years, to when the new deal for junior doctors was first brought in and we supported them on their concerns about Modernising Medical Careers, we on these Benches have never been lacking in support for junior doctors? We understand that when one is on the ward in a hospital at the weekend, very often the doctor who you see is a junior doctor. The point is that it is in the best interests of junior doctors and patients for seven-day working to be introduced, with proper rostering, rather than discriminating between Monday to Friday and the weekend as if they were different parts of what is in truth the same service. If we get it right, as my noble friend says, it should be possible to achieve such an agreement without bringing any detriment to junior doctors as a consequence, but rather by supporting them in the work that they have to do.

[Lord Prior of Brampton]

I thank my noble friend for those comments. One of the issues often raised by junior doctors is that they do not always feel properly supported at weekends. I think that having more seniors available at weekends—and late at night, for that matter—will be welcomed by junior doctors. There is also sometimes a misunderstanding in the public mind, as junior doctors can actually be quite senior doctors. A medical registrar is, by most standards, a senior doctor so junior doctors are not just people who have recently finished their training.

[Lord Tugendhat (Con)]

My Lords, does the Minister agree that during the build-up to this strike, which has now happily been called off, a great burden was put on to the shoulders of the NHS management? It is often much maligned and compared unfavourably with the doctors and nurses and other medical staff but, once again, the management staff have shown their ability to rise to the challenge. I hope that the Minister might feel it appropriate to give them a word of praise.

[Lord Prior of Brampton]

I am delighted to do that, having been the chairman of an NHS trust for 12 years myself and knowing that my noble friend was chairman of the Imperial NHS trust and that the noble Lord, Lord Hunt, who is opposite, was chairman of the Heart of England NHS Foundation Trust. Given the pressure and stresses on management and the complexity of its day-to-day role, I think that no other organisation is as challenging as a large acute hospital. Managers have to do their work in the full glare of publicity as well and it is extremely difficult, so I certainly join my noble friend in paying tribute to the extraordinary work that many of them do in the NHS.

[Baroness Masham of Ilton (CB)]

My Lords, the Statement says that the Government’s ambition is,

“to make NHS care the safest and highest quality in the world”.

How is this to be achieved without enough high-quality doctors? Do the Government agree that, regarding the teams—the therapists and nurses, as well as the doctors—we need hard-working but contented staff?

[Lord Prior of Brampton]

The noble Baroness is absolutely right that the biggest asset in the NHS is the people who work in it. That is not just doctors and nurses but therapists, allied health professionals and all those people such as porters, caterers and the like. We have an extraordinary workforce, which, sadly, we often take for granted. I am always struck by the results of the NHS staff survey, which are nothing like as good as one would expect to see in many other businesses, so I agree entirely with the noble Baroness.

NHS: Food Banks

Lord Prior of Brampton Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Beecham]

To ask Her Majesty’s Government what assessment they have made of the provision of food banks at, and the distribution of food to people in need by, NHS hospitals.

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

My Lords, decisions about such schemes are rightly made locally. The Government’s policy approach is that economic growth, productivity and employment offer the best route to give people a better future and reduce poverty. We implemented a long-term economic plan which is working. The employment rate is at a new record high and earnings are growing. We also announced that a new national living wage will be introduced from April 2016 for those aged 25 and above.

[Lord Beecham (Lab)]

My Lords, four weeks ago the Guardian reported that hospitals in Tameside in Greater Manchester and in Birmingham were opening food banks on their premises. In the ward I represent in Newcastle, all six primary schools and the local secondary school run a breakfast club for their pupils. These stark facts are reflective not of lifestyle choices, as some would have it, but of real need. When will the Departments of Health, Education, Work and Pensions and the Treasury come together to develop and implement policies to address the scandal of food poverty in what is still one of the richest countries in the world?

[Lord Prior of Brampton]

My Lords, the people running the schemes in the two hospitals in Birmingham and in Tameside are to be congratulated. I am not sure that there is a similar scheme in Newcastle. I know from experience of homelessness how difficult it is, for example, to discharge patients when they have nowhere to go, with the risk of discharging people onto the street who will then come back into hospital. The work they are doing in those two hospitals is to be applauded. We have a welfare safety net in this country. Tragically, anywhere around the world there will be some people who fall through that net. The fact that there are voluntary groups and charities prepared to help pick those people up is a cause for celebration. It is that combination of a state welfare net with an active civic society which makes this country as good as it is.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that the location of food banks should not be at the top of the priority list of cash-strapped NHS hospitals, most of which are in deficit at the moment? Does he also agree that food banks need to be conveniently located so that those who need them can visit them regularly? I would rather hope that those people would not have to visit hospitals regularly.

[Lord Prior of Brampton]

I do not think that anyone is saying that the food banks in the hospitals in Birmingham and Tameside are their top priority, I just think that it is a very human reaction of people working in those hospitals who want to help very vulnerable people who are being discharged.

[Lord McFall of Alcluith (Lab)]

My Lords, more than a year ago I visited Drumchapel citizens advice bureau and the food bank there to see what the situation was. I have now looked at the updated figures. In a two-year period from 2012 to 2014, referrals for benefit changes and delays went up from 127 in 2012 to 1,192—an increase of almost 850%. Is it not time for an independent investigation into what is now becoming a very worrying and scandalous situation in this country?

[Lord Prior of Brampton]

It is interesting that the use of food banks is increasing not just in England but in America, Canada, Germany and across Europe. The policy response of this Government is that we should focus on a strong economy, more jobs and the national living wage.

[Lord Hylton (CB)]

My Lords, is it not paradoxical that, seven years after the world economic crisis, more and more people in this country are needing food banks? Will the Government look much more carefully than they have done up to now into the connection between benefit sanctions and food poverty?

[Lord Prior of Brampton]

It is interesting that the previous Secretary of State for Energy and Climate Change, Ed Davey, said that there was no statistical link between the Government’s benefit reforms and the provision of food banks—so I am not sure that there is that link. It is also a paradox that we have this issue with food banks at a time when obesity is one of the biggest threats to the future. It is a strange situation around the world when we have both a problem of obesity and an issue of nutrition.

[Baroness Gardner of Parkes (Con)]

Will the Minister assure me that the decision in these matters will be up to hospitals themselves, as some hospitals have adequate space and are ideally situated for this purpose whereas others may not be? The Minister said that food banks already exist in some hospitals, which means that there is no bar from the Department of Health on having them. Food banks are doing very important work, but their locations should be assessed against where else would be more convenient. That point has been brought out in the debate. There are many aspects to consider, and it should be a free choice on the part of the hospital and the people who live in that area who may see that as the best place.

[Lord Prior of Brampton]

I thank my noble friend for that remark. It is entirely up to local organisations and local institutions, and those doing the work in Birmingham and Tameside are to be congratulated.

[Lord Cashman (Lab)]

My Lords, I do not doubt the Minister’s sincerity in his answers, but I point out that food banks result because people are going hungry. People are starving in this country and should not have to rely on such charity. Does he agree that obesity often occurs when people on very meagre budgets have to have the worst kind of food in order to feel satisfied?

[Lord Prior of Brampton]

The factors behind obesity and malnutrition are extremely complex. The all-party inquiry referred to complex and frequently overlapping factors. The work done by the University of Warwick found that there was no systematic evidence on drivers of food aid in the UK—and the evidence was drawn not just from the UK but from the US, Canada and Germany.

[The Archbishop of Canterbury]

Does the Minister recognise that the comments at the time of the previous Government about there being no link between benefit changes and food banks was significantly challenged at the time and that our experience in Church of England, which is involved in the vast majority of food banks across the country, is that between 35% and 45% of people coming to get support from food banks report that the reason for running out of food is to do with changes to the benefit system and sanctions?

[Lord Prior of Brampton]

All I can do is repeat what I said before which is that, as Ed Davey said, there is no statistical link, in his view, between the Government’s benefits reforms and the provision of food banks. I think that the issue is much more complex than the most reverend Primate is suggesting.

Health

Lord Prior of Brampton Excerpts

Thursday 26th November 2015 Lords Chamber

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

My Lords, I shall try to do this without hesitation, repetition or deviation, but I fear I shall fail on all three counts.

First, I echo what all noble Lords have said and thank the noble Lord, Lord Crisp, for introducing this debate, which has been fascinating. He brings to it a lifetime of experience in healthcare, both in the NHS in the UK and, of course, globally. He mentioned two quotes in his speech. The first was:

“Modern societies actively market unhealthy life styles”.

In a sense, that lies at the heart of much of what he said.

He also referred to the African saying: health is made at home, hospitals are for repairs. That is something we should take to heart. He has always said that we have much to learn from other countries, and perhaps we can learn a great deal from that particular saying.

I want to pick up some of the important issues raised by noble Lords in this debate. The noble Baroness, Lady Jay, talked about localism, about which she has some reservations. I suspect that that is an issue we will come to many times over the next few years. While I do not regard her as “a centralised dinosaur”, as she put it, the thrust of much of government policy over the course of this Parliament will be very much towards accountable localism.

The noble Baroness, Lady Williams, started her speech by almost praying for a whole-party approach to healthcare. It is probably unlikely, but it would be nice. She talked about prevention and education. I think that the curriculum for those aged up to 14 now has more time for nutrition and healthy eating, but she and other noble Lords mentioned the lack of time for PE. She also talked about mental health, domestic violence and equality of treatment for those suffering from mental health issues, something we all support in this House.

The noble Baroness, Lady Campbell, spoke movingly about what she called the empowerment model of putting patients—service users, or clients—much more in charge. We should not be so hamstrung by the medical model that has dominated healthcare for so long.

I congratulate my noble friend Lady Redfern on her wonderful maiden speech. She talked about nutrition—perhaps not surprisingly, as she said that she comes from a place where beetroot and celery are much talked about. She also talked about rehabilitation and reablement. Acute hospitals need to do a lot in the field of rehabilitation and reablement so that we can get much earlier discharge of care.

The noble Lord, Lord Best, reminded us that housing and health used to be part of the same department. I do not know how many years ago that was, but it is an interesting observation. He reminded us that home can become a trap, a prison—indeed, a fridge if the temperature is not right. Those were very important observations.

The noble Baroness, Lady Masham, talked very powerfully about the Paralympics and the power of sport. However, she also reminded us that there is no room for complacency about infectious disease and the treatment of people with drug and alcohol problems, and, of course, about the importance of hospital food.

I congratulate the noble Lord, Lord Foster, on his maiden speech. Like many of us, he was once a young rising star, but sadly those days are behind most of us. What he had to say about personal responsibility is very important. We can look to the state and to government institutions, but we need to take responsibility for ourselves as well, wherever possible.

The noble Lord, Lord Alton, made some very interesting comments about variation across the system. It is patchy. We talk about a National Health Service, but it is very different depending on where you live. It was interesting to hear him say that 660 million antidepressants have been prescribed where the underlying problem is loneliness, and that medicine is not a remedy for that. The right reverend Prelate the Bishop of Bristol quoted John Donne:

“No man is an island”.

We are all “part of the main”. I fear that the bell might be tolling for myself this evening, but he again made a very strong point. Social isolation and loneliness were common themes from many of your Lordships.

The noble Baroness, Lady Lane-Fox, knows a great deal about the internet. When she said that the organising principle of our age is the internet, she made a profound point. I have absolutely no doubt that the power of the mobile phone and of the various apps being developed will reshape healthcare. It will shift power away from medical professionals towards individual users. I believe that there is now an app that can monitor your life signs from a drop of blood taken once a month. That is hugely powerful. She warned us of the risk that so much of this technology is concentrated in a small number of highly successful technology firms based in California. We need to be well aware of that.

My noble friend Lord Smith talked about the importance of clubs, participation and social interaction. He reminded me of Burke’s “little platoons”, which are such an important part of society. He also reminded us that in 1666, the average life expectancy was 35, so we have come a long way since then.

The noble Baroness, Lady Neuberger, talked about loneliness and how hugging a young baby or child actually helps develop their brain. It is not just about the very young, but the old as well. Lonely people suffer both physically and mentally. We all love human interaction and know that it is not just the elderly who suffer from isolation; many parts of society suffer from loneliness. I fear that computers have not done us proud when it comes to interacting as individuals with others.

The noble Lord, Lord Rea, talked about the importance of primary prevention. He quoted from Sir Michael Marmot’s book on health inequalities, which of, course, is very powerful. I will write to him, if I may, on Sure Start centres after this debate. The noble Earl, Lord Listowel, talked before to me about loneliness and isolation, in particular the importance of relationships for looked-after children, adolescents and those in their early years. I am not familiar with the Bromley-by-Bow model raised by the noble Lord, Lord Mawson, but I would like to learn about it. I was fascinated by his strictures about replication: you cannot just pick up a model in Bromley and dump it in Birmingham, or probably in any other part of London. There are aspects, however, that can be translated. He said it is always better to start small, rather than trying to start big. In the NHS, we perhaps get ahead of ourselves sometimes.

I turn to the comments made by the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt. This has been an important debate that reaches across a wide part of government. It raises issues that are not just pertinent to this country, but global. At their base, they reflect the fact that our population is increasingly elderly and people are suffering from many chronic long-term conditions. Lifestyles are causing a growing disease burden, particularly from obesity but also from alcohol and smoking. People’s expectations are changing all the time, and, of course, the cost of new surgical and pharmaceutical developments is huge. I suspect that genomic development and genomics will only add to those costs.

At the moment, however you measure how we fund these things—whether it is 16% of national wealth in America or more like 8.5% in this country or 11% in Germany—healthcare is consuming a vast amount of our GNP. Whatever health system you are in, there is an issue of sustainability. I believe that a strong economy is fundamental to any strategy that any of our parties would wish to have. We must have a strong economy, but that is not just so that we can afford better healthcare: it is actually more profound than that. It is because we have a strong economy that we will have high levels of employment. Work is a critical part of addressing some of the concerns of my noble friend Lord Crisp. If people have decent employment, they will tend to have higher levels of physical and mental health.

Education is also fundamental. It was Sir Michael Marmot, I think—or somebody else—who said that you could pretty much predict people’s future lifestyles from the age of 11. If their educational attainment is well below average at the age of 11, the outlook for the rest of their lives is not good. We also need to consider that the transition from adolescence into adulthood is also a critically important time. So I welcome the last Government’s and this Government’s increased commitment to apprenticeships.

The life expectancy of people living in Kensington and Chelsea was referred to earlier in the debate. I think I am right in saying that the life expectancy of people living in Salford is something like 25 years less than that of people living in Kensington. That cannot be explained just by reference to healthcare. Healthcare is demonstrably a very small explanatory component of such a difference in life expectancy. The differences are much more profound than just those associated with the NHS. When we talk about the health of the nation, it is tempting to focus just on the NHS, but it is only a very small part of it.

I wish to expand on devolution a little more because the driving force for devolution, particularly in Manchester but increasingly in the Black Country and other parts of the country, is to try to get greater economic regeneration. I believe that that, together with devolving more power to local authorities, will help to build a healthier society. I do not want to make a party-political point on this at all but I congratulate the principles underlying the work that Iain Duncan Smith has done in developing the universal benefit to try to make it easier for people to move from welfare into work. It is my fundamental belief that work is a crucial part of building a healthier society.

I wish to give noble Lords two quotes. Having said that the NHS is not a big part of this, I want to dwell briefly on it. The first quote is from the NHS Plan 2000. Perhaps the noble Lord, Lord Hunt, was a member of the Government in 2000. The NHS Plan states:

“The NHS is a 1940s system operating in a 21st century world”.

I believe that that comment, made in 2000, was profound. Now here we are in 2015 and the NHS Five Year Forward View states that,

“there is broad consensus on what that future needs to be. … It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment. One that no longer sees expertise locked into often out-dated buildings, with services fragmented, patients having to visit multiple professionals for multiple appointments, endlessly repeating their details because they use separate paper records. One organised to support people with multiple health conditions, not just single diseases”.

So we all know what the issue is and yet getting change in the NHS has proved extremely difficult. I take issue with the noble Lord, Lord Hunt: I think that we have to push these new models of care and treat more people outside hospital settings, not because it is lower cost but because it is better care.

[Lord Hunt of Kings Heath]

I am not arguing against the models; all I am saying is that I think there is a simplistic view that, if you develop the models, you can reduce the pressure on your acute care capacity. I, and I think many commentators, are doubtful about that, given that our acute care capacity is so much less than that of most comparable countries. That is the point I was making.

[Lord Prior of Brampton]

I understand that fully. To be clear, at the heart of the Five Year Forward View are both the new care models—the vanguards referred to by the noble Baroness, Lady Walmsley—and a change in productivity. I wish to dwell on productivity for a minute because the NHS is a lean system. I do not argue against that at all. It is a very high-value system. I was at a meeting with people from the Mayo clinic very recently and they said that they felt the NHS was the highest value healthcare system in the world. That does not mean that it is perfect. However, although we are always highly critical of it, by world standards it is a very good system.

We are going to address productivity through using much greater transparency—using the work of the noble Lord, Lord Carter—as well as trying to get a much higher degree of clinical engagement so that we get real traction. In the past we have had a top-down approach to try to drive through productivity improvements. This time we hope to have a much more bottom-up approach, with a much higher degree of clinical engagement.

The noble Lord, Lord Crisp, divided this issue into three, and the third aspect was the most important. The message is that it can be done. For example, the number of teenage pregnancies has been reduced by half. The number of people who die in fires has been reduced by half. Smoking prevalence has come down from 40% to 18%. Health-acquired infections such as MRSA and C. diff have come down very significantly. We can do it, if people work together.

Some of your Lordships may have read the McKinsey Global Institute report into obesity. It is a very good report. Obesity is a global problem: 2.1 billion people in the world are overweight—30% of the global population. It is going to rise to 50% by 2030. It costs billions of pounds and wrecks millions of lives. The McKinsey analysis makes three good points. First, there is no single intervention—no silver bullet. It is not just passing a sugar tax or a new regulation. In its view, when it comes to tackling obesity there are 74 separate interventions that must be done: housing, education, personal responsibility—it is a combination of all these things. Secondly, no part of society can do it on its own. It cannot just be top-down from government. It cannot just be bottom-up from individuals or the community. It has to be top-down, bottom-up and in between. Thirdly, you can never have all the evidence. If we wait until we have all the evidence about every single intervention, we will end up doing nothing. That is quite a good illustration of what the noble Lord, Lord Crisp, is aiming at. If we are going to have an effective strategy for obesity, which we will be revealing early in the new year, it has to be multifaceted. There is no silver bullet.

Treating illness is the tip of the iceberg that we all focus on but the much greater part of the iceberg is below the water. Improving and reducing health inequalities will require an effort that goes way beyond the NHS. Of course, the NHS has a big part to play but there is a much bigger and wider role for society as a whole. I thank the noble Lord, Lord Crisp, for raising this issue. It has been a fascinating debate and I look forward to pursuing discussions with him and others outside the Chamber.

Gender-based Violence: Women with HIV

Lord Prior of Brampton Excerpts

Wednesday 25th November 2015 Lords Chamber

[Baroness Gould of Potternewton]

To ask Her Majesty’s Government what action they have taken to assist women with HIV who are experiencing gender-based violence.

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

My Lords, sexual health and HIV services are already sensitive to the risk of domestic abuse and sexual violence, including gender-based violence, in their routine consultations. In recent years, the Government have put nearly £40 million into specialist domestic and sexual violence support services and national helplines. We have also set up 15 new female rape support centres to raise the total to 86. We have taken strong action in the fight to eradicate female genital mutilation.

[Baroness Gould of Potternewton (Lab)]

I thank the Minister for that reply but, with respect, it is not sufficient to answer the Question that I asked, which was about the relationship between HIV and sexual and gender abuse. Does the Minister not accept that the Government have a responsibility to work across the relevant departments, as others have said, to ascertain the number of women who are in this dire situation, to encourage them to seek support and help, which they so desperately need but which many are prevented from doing because of the stigma of their situation; and crucially to provide the resources, both staffing and financial, to help these women in such terrible situations?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Baroness raises the very profound point about stigma. Where people suffer from both HIV and domestic abuse, they are extremely vulnerable and feel it very difficult to raise these issues. The Government have done a lot to try and remove the stigma and make it easier for these very vulnerable women to come forward. I am sure that the noble Baroness is aware of the sexual assault referral centres. There are now 43 of those, funded by NHS England, the police and local authorities. They are a good example of cross-government support.

[Baroness Walmsley (LD)]

My Lords, in 2012 the coalition Government set up a new research and innovation fund to collect information about violence against women in 10 African and Asian countries with the view to setting a new prevention strategy. Could the Minister tell us anything about how that strategy is progressing? Given the risk of HIV to many of these women, will that issue be covered in the strategy?

[Lord Prior of Brampton]

I think I am right that there are some 16 million women worldwide who suffer from HIV/AIDS so it is a huge problem, particularly in sub-Saharan Africa. I am not familiar with the innovation fund to which the noble Baroness referred, but I will investigate that and write to her.

[Baroness Masham of Ilton (CB)]

My Lords, is the Minister aware that there are many African men living in the UK who deny that they may be HIV positive, refuse to have a test and therefore put women at risk? What will the Government do about that?

[Lord Prior of Brampton]

I believe that some 103,000 people are HIV positive in England, of whom two-thirds are men. The majority of people who are HIV positive come from sub-Saharan Africa. The noble Baroness made the point that some who know they are HIV positive are not taking appropriate action and asked what we can do about them. It is also worth pointing out that some 18% of people who are HIV positive are ignorant of the fact. We have a very big communication programme ongoing to try and educate and inform these men, and we will continue putting the necessary resources into those programmes.

[Baroness Hayter of Kentish Town (Lab)]

My Lords, given that today is the UN International Day for the Elimination of Violence against Women, has the Minister taken a moment to see the associated ActionAid exhibition in the Upper Waiting Hall? In respect of women with HIV, the only survey we seem able to find about the prevalence of domestic violence is a 2013 one from Homerton, which showed that probably half of women with HIV reported experience of partner violence. Could the Minister undertake that there should be more research on this and that, if such a figure is found to be confirmed, everyone dealing with HIV women should be taught to be aware of their vulnerability to domestic violence?

[Lord Prior of Brampton]

I have not been to the Upper Waiting Hall to see the exhibition but will endeavour to do so if I have time after Questions this afternoon. The noble Baroness referred to the research done at the Homerton in 2013. I think the figure that study came up with was 52%. There has been a subsequent study but I cannot remember the name of it. It may not have been as extensive as the one done at the Homerton and put a figure slightly less than 52%—but it was still very significant. I will ask officials the status of that subsequent research to see whether we need more.

[Baroness Gould of Potternewton]

To help the Minister, it was Positively UK that did the other piece of work.

Health and Care Professions Council (Registration and Fees) (Amendment) (No. 2) Rules Order of Council 2015

Lord Prior of Brampton Excerpts

Tuesday 24th November 2015 Grand Committee

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

My Lords, I thank the noble Lord for introducing this short debate on the HCPC. It raises other issues beyond the HCPC that are of great interest to us.

The HCPC is a statutory regulator established to protect the public. To do this, it keeps a register of professionals who meet its standards for professional skills and behaviour. The noble Lord knows all that, but this is a preamble. There are 330,000 professionals across 16 health, psychological and social work professions. It is a very large regulator. It is self-financing, with funding coming entirely from registrant fees. It does not receive any regular funding from the Government.

The HCPC’s registration fees are the lowest, and have consistently been so, of all the UK statutory regulators of health and care professionals overseen by the Professional Standards Authority. Its fees are £90 a year. The next lowest regulator, the NMC, charges £120 per year. By way of comparison, the GMC is £420 a year. However, as a self-funding regulator, like all the professional regulators, its needs to keep its fees under regular review so that it can respond to demands on finances and resources, and to continue its role of delivering effective public protection.

As noble Lords will know, from 27 March 2015 to 6 May 2015 the HCPC consulted on raising its fees by an average of 12%, or £10 a year. That is 26 days. I appreciate that it was over an election period but that decision on consultation had to be with the council of the HCPC and the decision to formally review and consult on an increase to its fees was the result of three factors: first, as the noble Lord mentioned, because the PSA fee regulations came into effect, as a result of the Government deciding that the PSA should be funded by the regulators that it oversees, rather than the public purse; secondly, to improve how fitness-to -practise hearings are run; and thirdly, to invest in essential IT systems.

In relation to the first point, the Professional Standards Authority for Health and Social Care (Fees) Regulations 2015 came into force on 1 April 2015. This marked the realisation of the previous Administration’s commitment, set out in the Department of Health’s report Liberating the NHS: Report of the arm’s-length bodies review, to move the PSA away from government funding, to becoming funded by a fee on the nine regulatory bodies that it oversees. As required by those regulations, the PSA’s fee is calculated on each regulatory body’s registrant numbers. The HCPC is the second largest regulator by registrant numbers and will contribute to around 22% of the PSA’s funding. The PSA fee will be determined each year.

This methodology was considered fair because available evidence suggests that the level of PSA resource given to each regulatory body is very much influenced by the number of registrants as this critically informs the level of Section 29 work that the PSA undertakes for each regulator. Section 29 work is where a fitness-to-practise case is heard in court.

While around one-third of the 2015 fee increase was to meet the PSA’s fees, as I have said, the HCPC is also making improvements in the way it works. The HCPC is also looking to improve its fitness-to-practise processes. In doing so, the HCPC plans to introduce dedicated facilities for fitness-to-practise hearings. The HCPC’s existing office space was not purpose built for holding public fitness-to-practise hearings, which affects its ability to run a high-quality and modern adjudication service. It believes that introducing dedicated space will be consistent with the modern adjudication facilities provided by other regulators.

The HCPC also says that that the number and length of hearings are key cost drivers of the fitness-to-practise process. It has said that it aims to keep the cost of hearings low—for example, by proactively looking to conclude cases with the consent of the registrant involved, where appropriate. This avoids the need to have a contested hearing, with all the costs this involves. However, the HCPC says that it has seen an increase in the complexity of the cases since 2012. This has meant that the average length of a hearing has increased over time. The average number of witnesses required for each hearing has also increased to between three and four for each hearing. The HCPC’s primary objective is public protection, and it says that every allegation it receives must therefore be considered on its merits.

On the third point, the HCPC says that the new IT system it is looking to introduce will make its work more efficient by replacing a number of other legacy systems, by driving and delivering time and resource savings. Additionally, a project looking at redesigning the HCPC’s registration processes and systems should improve the level of service that it is able to provide to applicants and registrants by allowing them to carry out many more tasks online.

Finally, in determining budget forecasts for future years and the level of fees, the HCPC says that it had to make assumptions about costs and activity level—in particular, the volume of fitness-to-practise cases. It says that these forecasts indicated that despite generating a surplus in previous years, without the 2015 fee increase it would make operating deficits in 2015-16 and 2016-17. This would not be sustainable and would threaten its ability to fulfil its role of protecting the public. Additionally, the HCPC registers each profession on a two-year cycle, so it will take two full financial years before any increase in the renewal fee has full effect.

The HCPC says that it has not changed its ongoing commitment to the principle of small, regular increases in the fees where possible and necessary. Its latest five-year plan does not forecast any further increase in fees until 2019-2020. That said, in the past the Government have expressed a view on registration fees and the expectation that they should not increase beyond their current levels unless there is a clear and robust business case that any increase is essential to ensure the exercise of statutory duties.

The noble Lord raised a number of issues. First, he asked that in a consultation exercise there should be a detailed breakdown of the reason for a fee increase, which strikes me as a reasonable request, which I will draw to the attention of the PSA. He said that the fees should not increase by greater than the amount of the increase paid to NHS staff. All I can say is that the fee increase must be kept to an absolute minimum. I entirely appreciate that we live in a very difficult world, and fees must be kept to an absolute minimum. I do not think that we can make any commitment that they should be kept to the absolute level of increases of salaries paid to NHS staff.

The noble Lord asked that the PSA should take a more proactive role. Of course, the PSA undertakes an annual assessment of all the organisations that it is responsible for, which is tabled before Parliament. It is of course up to the Health Select Committee, if it wishes to do so, to have any individual regulator before it.

The noble Lord also asked about part-time workers; I hope that it will be all right if I write to him about part-time workers, as I am not sure of my answer on that. As regards the work the Law Commission has done, I think we all accept that it has done an outstanding job and made some extremely important and what could be very useful recommendations. The Government are currently reviewing how to take forward the work of the Law Commission.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to the noble Lord, Lord Prior. He is right to acknowledge the issue of pay restraint. However, I have three points. On consultation, I hope that the HCPC and the PSA will take note that it is reasonable to have a proper consultation in relation to fee increases in the future. Secondly, I noted what the Minister had to say about the introduction of IT and new systems and that it would lead to resource savings in the future. I have some experience of IT systems in the health service, and I certainly hope that that comes true. I noted the expectation of no further increase until 2019-20. Given the expected resource savings from new IT systems, it would be very disappointing if the HCPC came forward with any other proposal in the next Parliament.

Thirdly, I understand the Government’s reluctance to bring health legislation through Parliament, but one has received so many representations from the regulatory bodies. Given the extensive work of the Law Commission, I hope that the Government will give further consideration to bringing a Bill before Parliament before too long. The debate has been very helpful and I am most grateful.

National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) (No. 2) Regulations 2015

Lord Prior of Brampton Excerpts

Tuesday 24th November 2015 Grand Committee

[Lord Lansley (Con)]

My Lords, this is the first time I have had the opportunity to say something in Grand Committee, so I hope that I will be forgiven if I trespass on any of the procedures. I was tempted to speak, not least by the noble Lord’s reference in his Motion to the potential perverse incentives surrounding the referral to treatment time targets.

We do not need to speculate on where there might be perverse incentives in the system of targets and the impact they can have on how the NHS manages such targets, as we can see them. We saw them under the previous Labour Government. They had two referral to treatment time targets relating to admitted and non-admitted patients for complete pathways. The net result, of course, was a perverse incentive not to treat patients once they had passed beyond the 18-week point. It was precisely for that reason, after the 2010 election, that my colleagues and I in the Department of Health thought it was necessary to have a third target. For example, we were presented with 18,000-plus patients who at the time of the May 2010 election had waited for their treatment beyond 52 weeks.

There was a perverse incentive. It was very straightforward: if they were brought in in any significant numbers, and they and others like them had gone well beyond the 18 weeks into treatment, they would not be counted for the then 90% or 95% target—particularly the admitted patients on the 90% target. They were simply ignored. That was not acceptable. It was not what the targets were intended to do and it was not for the benefit of patients. So we introduced the incomplete pathway which had a salutary effect. It brought the numbers waiting beyond 52 weeks from more than 18,000 down to the low hundreds. It is still only about 800 patients who have waited. We introduced zero tolerance subsequently, once we had brought the numbers down for beyond a 52-week wait. We do not need to speculate about perverse incentives; they were there.

I can understand where Sir Bruce Keogh has seen that the combination of these targets can create a degree of confusion. The success of having introduced the incomplete pathway standard is something that we can build on. That is what Sir Bruce and NHS England are aiming to do—a simple standard that no less than 92% should be treated within 18 weeks. That reinforces the 18-week standard and it is very clear in the minds of patients.

Of course, there is scope for perverse incentives; there always is. In this instance, we know that by failing to distinguish, as the previous targets have done, between admitted and non-admitted patients—non-admitted patients having been less costly and complex to treat—there is a perverse incentive to concentrate on the non-admitted patients relative to the admitted patients. It is fair to say that if we see that emerging, we would have to respond in terms of the structure of the targets. To introduce something that dealt with the transparent detriment to patients of waiting beyond 18 weeks and then simply being dropped from the system and ignored was the right thing to do. When the noble Lord talks about perverse incentives, we have dealt with what was the principal perverse incentive. It is perfectly reasonable for NHS England and for the Government now to focus on one standard to make life more straightforward for those who have the responsibility of managing an increasing workload in hospitals.

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

My Lords, once again I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this to the Committee. My noble friend Lord Lansley has pretty much done my job for me, but I think I had better go through with this to put it on the record. I thank my noble friend for that articulate and eloquent exposition of why we now have one incomplete standard and not the three that we had before.

We all accept that waiting times are critical. I should pay tribute to the Government of which the noble Lord was once a member. Bringing down waiting times was a huge success and there is no doubt that targets were one of the instruments used to do so. However, the noble Lord accepts that they are a blunt instrument and can lead to distorting clinical priorities. They can lead to gaming and extra cost, so they are not the whole answer. In particular, they can lead to perverse consequences. That is why the Secretary of State for Health and Simon Stevens accepted the recommendations made by Bruce Keogh earlier in the year. I will place a copy of his letter to the Secretary of State and Simon Stevens in the Library. The noble Lord may already have seen the letter but I will place it there.

Sir Bruce’s clinical advice on the standards used to measure the 18 weeks NHS constitution right was to remove the two standards that looked at how long people who have started treatment waited and to focus on the incomplete pathway standard—that is, the people who are still waiting. Perhaps I can explain that by using the analogy of a bus. The two earlier standards measured the people on the bus and the incomplete standard is designed to measure those who are left behind at the bus stop. As all three standards were written into the standing rules regulations, this statutory instrument, which took effect from 1 October, was required to make that change.

The change affects the metrics by which we measure the NHS’s performance on waiting times. It does not change the patient’s right. It is important that that is on the record. Patients can still expect to start treatment within a maximum of 18 weeks if they want to and it is clinically appropriate. If this is not possible, patients have the right to ask to be referred to an alternative provider that can see them more quickly, and the NHS must take all reasonable steps to meet patients’ requests. Sir Bruce Keogh recommended this change because having a set of three standards could be confusing and give rise to perverse incentives.

My noble friend described those perverse incentives. The perverse incentive was such that you could treat only one patient who had waited for more than 18 weeks as opposed to nine who had waited for less. There is no doubt that hospitals were managing their waiting lists on that basis. As a consequence, there were people waiting beyond 18 weeks for far too long. That was the wrong that the incomplete standard tried to address. As Sir Bruce said in June, while hospitals may be the ones penalised directly when they breached waiting time standards, the true penalty was laid on the patient who was waiting for much longer than he should have done. I wholly agree that that was not right.

In 2012—I think my noble friend was Secretary of State at the time—the Government introduced the incomplete pathway standard that a minimum of 92% of patients yet to start their treatment should have been waiting less than 18 weeks, to give NHS organisations a reason to prioritise patients who had been waiting a long time. The removal of the two completed pathway standards further minimises the potential for management of the waiting list to cut across clinical decision-making. Clinical priority should always be the main determinant of when patients should be treated. This clinical priority should not have been distorted because it should have been possible to meet all the clinical priorities and meet the waiting time standard, but in practice that was not always the case. Clinicians should make decisions about patients’ treatment and patients should not experience undue delay at any stage of their referral, diagnosis or treatment.

These changes will mean that there is a simplified, clearer focus on only one standard, covering all patients on the waiting list, and ensuring that those who have been waiting a long time are not left languishing. The noble Lord raised the issue, which was addressed by my noble friend, of whether having just the one standard will result in new and different perverse incentives. My noble friend made the important point that it could lead to priorities being skewed in favour of non-admitted, simpler, cases rather than admitted, more complex, cases. That is something we need to keep a very close eye on. NHS England will continue to measure trusts’ performance against all the standards except that there will be only the one measure in the contract.

I stress that changing the standards is not moving the goalposts in response to poor performance. This change has been made on the basis of clinical advice and in the best interests of patients, and has received widespread support, for example from the Nuffield Trust and the Patients Association. More than a million NHS patients start treatment with a consultant each month and the overwhelming majority are seen and treated within 18 weeks. However, the NHS is busier than ever, which is why we are investing the extra £8 billion that NHS leaders have asked for to support the five-year forward view. I hope that the noble Lord will accept that this was done in good faith and in the interests of patients and that it was a decision informed by clinicians, not by politicians. I have not addressed the concerns he raised about the eligibility criteria for nursing, because they are not strictly relevant to these regulations, but perhaps I could write to him on that matter.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful for that. I must say that the intervention from the noble Lord, Lord Lansley, was very helpful. It reminded me that in 2001 I was resplendent in the title of Minister for targets in the Department of Health. I remember asking officials to count up how many targets we had set. When we reached 450, we decided we ought to start again, first by trying to refine the targets and then by setting up foundation trusts, in order to take them out of a directly managed form of control from the centre. Whether that has been entirely successful, in light of today’s circumstances, is up for some debate, though I still maintain that the concept of foundation trusts, with separate governance and local accountability, is the right way forward. I hope that NHS Improvement will see the benefit of trying to protect foundation trusts, and the good bits of their governance—the role of governors, the accountability of the board to local people—from overmanagement from the centre. I know that the noble Lord also chaired a foundation trust; he will know what I mean.

There is no doubt whatever about the targets. The waiting time in 1997 was more than 18 months. It was brought down to 18 weeks, which was driven by a target that people had to meet. That is always justifiable. However, we know that in both the public and private sectors, people who have to meet targets are very clever and sometimes the temptation for perverse behaviour is all too apparent. I hope that we can continue to rely on NHS England to monitor behaviour closely and that if it needs to adjust targets to meet any perversity, it is important that that is done quickly and responds to problems that arise.

I do not oppose these regulations at all; I think it is a sensible approach. However, it would be helpful if we saw that NHS England was fleet of foot in responding very quickly when new problems arise with targets, as inevitably they will. This is a good example of that.

Mesothelioma (Amendment) Bill [HL]

Lord Prior of Brampton Excerpts

Friday 20th November 2015 Lords Chamber

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

My Lords, it is always very dangerous when you are told to tear up your lines to take, however tempting that might be. The noble Lord, Lord Alton, whom I have only met once before, which was quite briefly yesterday, told me that he was a street-fighter so I come here forewarned that he is not as he appears. I suspect that as I stand here, he is sharpening his knife and polishing his knuckledusters to set about me in a few minutes’ time. I thank him, though, for bringing this issue to the House. It has been a fascinating debate. I am by no means an expert in mesothelioma but I feel much better educated about this issue now than I did two hours ago.

The debate has been trebly compelling because it has brought together people with authentic and tragic personal experience: the noble Lords, Lord McNally and Lord Freyberg, and the noble Baroness, Lady Murphy—and, right at the end, the noble Lord, Lord Campbell-Savours. That personal connection with this terrible disease is very powerful. The debate has brought that together with the clinical and medical academic knowledge of the noble Baroness, Lady Finlay, and the noble Lords, Lord Winston, Lord Kakkar and Lord Ribeiro, which is a very powerful combination. When you add to that the broad knowledge of other noble Lords who have contributed, whose interest in the subject goes back many, many years, it produces a very powerful cocktail.

Clearly, mesothelioma is a terrible and devastating condition. There is no cure and, as the noble Lord, Lord Winston, reminded us, it is a very difficult illness to tackle. Uncertainties remain about the best available approaches to diagnosis, treatment and care. It affects thousands of people. In my mind before this debate, I thought of it very much as a legacy disease—one that would gradually wither away. The noble Baroness, Lady Finlay, commented that many children will be suffering from this disease in 20, 30, 40 or 50 years’ time. As the noble Lord, Lord Giddens, mentioned, this is not just an English disease, although we have a particularly high incidence in this country; it is an international, global illness. The noble Lord mentioned it affecting literally millions of people.

It is therefore absolutely right that mesothelioma research has been discussed many times both in this House and in the House of Commons. I suspect that whatever the outcome of today’s debate and when we discuss the matter again in Committee, knowing the reputation of the noble Lord, Lord Alton, he will never let this sleep. I imagine that we will be hearing from him on many future occasions.

I want to talk about two aspects at the beginning. The first is funding. Funding is needed for research—that goes without saying. The four largest insurance companies have previously made a donation of £3 million between them and more recently, as has been pointed out, Zurich and Norwich Union have donated a further £1 million. That has helped to support valuable research into the disease, but a much higher level of funding has come from the Government through the Medical Research Council and the NIHR. Together, those funders spent more than £3 million in 2014-15. The MRC is supporting ongoing research relating to mesothelioma at its toxicology unit. It is also funding one current fellowship. The NIHR is funding three projects through its research programmes, and its clinical research network is recruiting patients to a total of 11 studies. In view of the comments of the noble Lord, Lord Winston, I can highlight that the NIHR is co-funding experimental cancer medicine centres with Cancer Research UK. These centres are supporting studies in mesothelioma. Money is also available through European Union research funding programmes. I am delighted that the University of Leicester is a partner in a successful bid for nearly €6 million for research on immunotherapy to treat malignant mesothelioma.

[Lord Wills]

I thank the Minister for giving way so early in his speech, but these figures are very important. Is he aware that the British Lung Foundation has done its own study on how much money is specifically directed to research into mesothelioma? A lot of the work that he just described may well have implications for mesothelioma, but it is generic. The British Lung Foundation figure specifically for mesothelioma research is £820,000, not the millions he has been talking about. Does he accept those figures in the context of what I have just said?

[Lord Prior of Brampton]

It is hard to know what the right figures are. After this debate, we need to sort out exactly what the figures are.

[Lord Winston]

I hate to disagree with my noble friend, but one problem with mesothelioma research is that Cancer Research UK, for example, puts such funding partly in the box of lung cancer funding—it is a different form of lung cancer. There is a risk that we may be underestimating the amount of money being spent. That always happens when these figures are bandied about. I am not suggesting that we should not be spending more—or less—but it is very difficult to be precise about the figures sometimes cited.

[Lord Prior of Brampton]

We probably cannot today sort out the figures in the way we would like. It will be very difficult to allocate some of the more generic research expenditure. Let us move on from funding, if we can.

[Lord Giddens]

Will the Minister get to work on this and send something back about what the precise figures seem to be in the light of the questions raised? This is a serious issue, so it would be good to get a response from the Government.

--- Later in debate ---

[Lord Prior of Brampton]

Perhaps I can take that away and come back to the House. I think it will be difficult to come up with precise figures, to be honest, because of the difficulty in allocating some of the more generic research to particular areas. I think that we can encapsulate some of the comments made by the noble Lords, Lord Winston and Lord Wills, and come back to the House with a more thought through, considered figure.

[Lord Alton of Liverpool]

I can see that the Minister wants to move on from the issue of funding, but before he does I should point out that the House has been given figures. It is important to record that in our debate, because they are figures that his predecessor, the noble Earl, Lord Howe, gave the House in reply to a Parliamentary Question tabled by my noble friend Lord Wigley, and referred to by my noble friend Lady Finlay earlier. The figures in the reply to Parliamentary Question HL5852 show that funding from the NIHR on,

“research centres and units, and research training awards on mesothelioma research”,

as the Minister said, in 2006-7 was £0.0 million; in 2007-8 was £0.0 million; in 2008-9 was £0.0 million; in 2009-10 was £0.0 million; in 2010-11 was £0.0 million; in 2011-12 was £0.0 million; in 2012-13 was £0.2 million; and, in 2014, was £0.4 million. Those are the Government’s own figures, which have already been given to Parliament.

[Lord Prior of Brampton]

I think that we are into some definitional issues here, to be honest, from what the noble Lord, Lord Winston, said, and from the figures that I gave earlier, which I am not making up—they are figures that have been given to me. We should come back with some greater clarification and perhaps some closer definition of what the funding figures are.

My impression, although it may be wrong, is that the essential problem is not a lack of funding but a lack of sufficient research applications. Of course, I accept that there is a connection between the two, which I shall perhaps come back to in a minute. The MRC received no mesothelioma applications in 2014-15, and only one in the current year. I want to clarify and stress that the work being funded is of high quality, consequent to high-quality applications. In response to questions raised by the noble Lord, Lord Kakkar, and others, the Government have taken measures to stimulate an increase in the level of research activity. Patients, carers, clinicians, academics and funders have worked in partnership with the James Lind Alliance to identify what the priorities in research should be.

I imagine that some noble Lords will have read the report by the James Lind Alliance, but for those who have not I can say that, following a survey and a workshop, the top 10 mesothelioma research priorities were announced in December 2014, and the NIHR published a final report from the priority-setting partnership in July. In advance of the identification of research questions by this partnership, the NIHR highlighted to the research community that it wanted to encourage research applications in mesothelioma. The NIHR subsequently invited researchers to apply for research funding, in particular to address the research questions identified by the partnership. Eight NIHR programmes participated in this themed call. Fifteen individual applications have been received, of which two have been approved for funding to date, two are under review, and 11 have been rejected. Some noble Lords may think that that is a very high level of rejection, but it is broadly consistent with the overall funding rate for applications to NIHR programmes, which is roughly about one in five.

In addition, the NIHR Research Design Service continues to be able to help prospective applicants to develop competitive research proposals. This service is well-established and has 10 regional bases across England. It supports researchers to develop and design high-quality proposals for submission to NIHR itself and to other national, peer-reviewed funding competitions for applied health or social care research.

The Government are not predisposed to support the Bill, but there is something that we ought to consider—perhaps outside the Chamber. We believe that the existing process for accessing research grants works well; we do not believe that money is the real shortage. It is interesting to note that the Government’s spend on research for medicine is a little over £1 billion—a very significant sum—but the Government are not keen on hypothecated grants for research. However, I have been thinking about this very carefully over the last couple of days, and the noble Lord, Lord Alton, touched on it slightly obliquely at the beginning, but it is an important point.

When the 2014 Bill went through Parliament, it was felt by the Department for Work and Pensions that the highest levy that could be taken from the insurers without forcing them to pass it on through higher premiums into industry was 3%. I understand that there is a shortfall between that 3% and the actual level of claims being made. I wonder whether the 1% that is being asked for in this Bill could be funded through the shortfall within the existing levy. That might be an avenue worth exploring. I say that because at the moment the fact that we are relying on two insurance companies is not equitable. Why should Zurich and Norwich Union cough up £1 million when other employers’ liability insurers are not contributing? This needs further discussion, but I wonder whether there is a way through this and whether we could not use the shortfall in the existing levy.

[Lord Wills]

What the Minister has just said is so profoundly important that I want to ask him to clarify it a little further. I moved an amendment to the then Mesothelioma Bill precisely to that effect: if there was this gap between the 3% that the insurers were prepared to pay and the 2.25% that the government actuaries thought would be needed, that would be devoted not to the insurance industry’s profits but to the relief to this terrible illness. At the time, the Minister in this House was quite resistant, but when it was debated in the other place the Minister there was quite clear. We heard the quote from the noble Lord, Lord Alton. Some months ago, when I asked a Parliamentary Question for Written Answer about this point, I recall that the Government said that they were not yet in a position to say whether there was a shortfall. I think I heard the Minister say that he believes there may be such a shortfall. If he said that, this is profoundly important as a way forward, as he suggests, so I would be grateful if he would clarify that.

[Lord Prior of Brampton]

If there is a shortfall—and there may be a shortfall—given that that levy is raised from the industry on an equitable basis rather than relying upon two or three insurers to do it on a voluntary basis, that strikes me as a better approach. The point has been made that compensation payments are somehow different from funding research, but it strikes me that the two are very closely related. I am just putting it out there for further discussion, and I would like to pursue that discussion with my noble friend Lord Freud, who is probably the expert on our side of the House on this matter and was intimately involved with the Bill which came through the House in 2014. I would like to have that discussion with him and perhaps with the noble Lord, Lord Alton.

I have not dealt with the veterans issue or the schools issue. I shall deal with them by letter, if that is all right. They are both extremely important. The situation with the veterans and the MoD is under active consideration by my noble friend Lord Howe. I will write to the noble Baroness, Lady Finlay, if she is happy with that, setting out the situation on schools in Wales.

The instinct of the Government is not to support the Bill, for the reasons I have given, but there may be a way through this which we are able to explore over the next month or two.

[Baroness Finlay of Llandaff]

When he writes to me, will the Minister include in the correspondence the noble Lord, Lord Wigley, who has done a lot of work on schools in Wales? He might want to meet him. Will the Minister clarify who has responsibility for free schools and academies? They are in a different position from maintained schools, yet they often occupy buildings which contain asbestos.

[Lord Prior of Brampton]

I think the answer to that question is that the Health and Safety Executive would have prime responsibility for them. I think the point that the noble Baroness is making is that the local authority no longer has the responsibility it would have over local authority schools. I will look into that issue and write to the noble Baroness.

[Lord Winston]

Before the Minister sits down, and I apologise for prolonging this debate for longer than necessary, does he agree that medical advances in every field are often very serendipitous? The classic example would be the completely unfunded discovery of penicillin when it was first produced, and it was subsequently only mediocrely funded until we had a wartime crisis.

In about an hour’s time the Minister will be answering a Question about doctors’ overtime. One of the critical issues that has not been discussed in that debate has been raised by Jeremy Farrar, the director of the Wellcome Trust, who points out that one of the real issues is the problem with young doctors being able to do research in a very generic way, which has all sorts of benefits, including clinical mesothelioma research. That is a fundamental problem. We in this country are very good at medical research and on the whole we fund it quite well, although obviously we would like to have more funding, but providing the environment for continuing research is essential for what we are discussing in this Second Reading debate.

[Lord Prior of Brampton]

I thank the noble Lord for that comment. We in this country are often highly self-critical but actually we have a remarkable record on research. We have three of the top medical academic institutions in the world in this country: Oxford, Cambridge and Imperial. We have UCLH, King’s and Manchester. We have some extraordinary research organisations in this country. There is, I guess, an issue over quality and quality control. There are an awful lot of clinicians who do research that may not be to the—

[Lord Giddens]

I am sorry to give the Minister such a torrid time, but I hope he recognises that he should look internationally. There are important models in other countries, such as the Pacific Lung Health Centre, which is integrated with the wider lung foundation and has produced significant research. We should not just think nationally; we should look at other models and see how they could be adopted here to deal with the issues that the noble Lord, Lord Winston, rightly raises. As I tried to stress, mesothelioma shares things in common with other cancers and, now that we have got to a deep enough genetic level to be able to understand why some of these processes happen, I think it would be worth while to get some information on what exists elsewhere to see how far it could be applied here.

[Lord Prior of Brampton]

I agree.

Junior Doctors Contract

Lord Prior of Brampton Excerpts

Friday 20th November 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 Minister of State for Community and Social Care on negotiations for a new junior doctors contract. The Statement is as follows.

“Three years ago negotiations began between the BMA, NHS Employers and the Department of Health. This was based on a common view that the current contract, agreed in 2000 when junior doctors were working very long hours, was outdated and needed reform. Between December 2012 and October 2014 an extensive and patient negotiation took place with an agreed target date for implementation of August 2015. These were abruptly terminated by the BMA’s unilateral withdrawal from those negotiations without warning in October 2014. This led to the independent and expert doctors’ and dentists’ review body being asked to take evidence from all parties, including the BMA, on reform of the contract and to make recommendations. This happened because of the unwillingness of the BMA to agree sensible changes to the contract and allowed an independent expert body to recommend a way forward.

The DDRB report, with 23 recommendations on the junior doctors contract, was published in July this year. The Secretary of State then invited the BMA to participate in negotiations based on those independent recommendations. Unfortunately, the Junior Doctors Committee of the BMA maintained its refusal to negotiate even though it was now on the basis of an independent report to which it had had an input. Both the Secretary of State and NHS Employers have invited the BMA repeatedly to participate in negotiations. It was made clear that there was a great deal to agree based on the DDRB recommendations.

We deeply regret that the BMA chose the path of confrontation rather than negotiation. While we continued to try to persuade it to develop a new contract with us, it instead chose to campaign against the independent DDRB’s recommendations including issuing a calculator, which it subsequently withdrew, which suggested wholly falsely that junior doctors would lose 30% of their pay. Instead the BMA issued demands, including a right of veto on any contract change, and was in effect asking us to ignore the DDRB’s recommendations, the heads of terms that were agreed back in 2013, and start again. Given the BMA’s refusal to engage and its wholly misleading statements about the impact of a new contract, NHS Employers issued a contract offer to juniors earlier this month. This offer has safety at its heart, strong contractual safeguards to ensure that no doctor is required to work more than 48 hours a week on average, and gives juniors the right to a work review when they believe hours are being exceeded. It reduces the maximum hours that a doctor can work in any week from 91 to 72. It pays doctors an 11% higher basic pay rate according to the hours that they work, including additional payments for unsocial hours. It reduces the number of consecutive nights that can be worked to four and long days to five, ending the week of nights.

The honourable lady has called for the parties to go to ACAS. The Secretary of State is not ruling out conciliation. We have always been willing to talk. The Government have repeatedly appealed to the BMA to return to the negotiating table and that offer is still open. We believe that talks not strikes are best for patients and for junior doctors. The Secretary of State has said that talks can take place without preconditions other than that an agreement should be within the pay envelope, but the Government reserve the right to make changes to contracts if no progress is made on the issues preventing a truly seven-day NHS, as promised in the manifesto and endorsed by the British people at the last election. It is regrettable that junior doctors have voted for industrial action which will put patients at risk and see between 50,000 and 60,000 operations cancelled or delayed each day. I would, therefore, call upon the honourable lady to join the Government in calling on the BMA, as it prepares for unprecedented strike action, to come back to the table for talks about the new contract for junior doctors. The Government remain firmly of the view that a strike by junior doctors is entirely avoidable and calls upon the BMA to also do all it can to avert any action that risks harm to the patients we all serve”.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Lord. The fact that we are here today, with 98% of junior doctors having voted to take significant industrial action for the first time in 40 years, is a matter of very serious concern to the NHS and its patients. Does the Minister agree that, over the course of the next week, everything that can be done should be done to stop the three days of planned industrial action? The Guardian this morning says that the noble Lord, Lord Prior, has urged on the Secretary of State the need for a settlement. Will the noble Lord confirm that? Will he also say why the Secretary of State appeared to dismiss the idea of independent mediation yesterday, has said today that they have not ruled out conciliation, but has again set preconditions, including the imposition of a contract? I have been bemused by the Secretary of State’s approach. Does he understand that the junior doctors are particularly angry about the way the Health Secretary has repeatedly conflated the reform of the junior doctors contract with seven-day services, including the highly selective and misleading use of statistics which has been disowned by the very authors of the research he quotes from?

Junior doctors already work weekends; they already work nights. Why on earth are the Government picking a fight with the very people who are so crucial to keeping the NHS running? There are nine days left before the first day of planned industrial action. I have one message for the Minister: it is time to talk.

[Lord Prior of Brampton]

My Lords, the noble Lord said that this was a serious concern. It is a tragedy that we are in this situation. Of course I want a settlement, as does the Secretary of State. The last thing we want is a strike. We want the junior doctors to come back to the negotiating table and not to go on strike. The only people who will suffer from a strike are patients. I cannot believe that there are many junior doctors who want to go on strike, so it is in all our interests to find a settlement, and the Secretary of State, myself and others are very keen that we do so. The Secretary of State has made it absolutely clear that there are no preconditions, save that we settle this issue within the existing pay envelope. The door is open to the BMA to come back for talks at any time.

[Lord Fowler (Con)]

My Lords, is my noble friend aware that in 1982, when I was Health Secretary, there was lengthy industrial action not involving doctors. When I went to St Thomas’ Hospital over the river, I was met by a deputation of doctors protesting at the damage that was being done to the health service. It is the successors of those very doctors who are now threatening industrial action. Should we not all, quite irrespective of party, condemn industrial action, which will damage patient care? Should we not also recognise that this action is not just against the Government? It also involves the rejection of the independent doctors’ and dentists’ remuneration review body, which is valued and respected throughout the health service and which doctors over the years have pressed to have. Surely we are faced with a failure of BMA leadership in this case, and the obvious course is to go back to the negotiating table very quickly.

--- Later in debate ---

[Lord Prior of Brampton]

I agree entirely that industrial action is the last thing that any of us want. I have worked with trade unions of one kind or another off and on since 1980—for 35 years. I think that the Junior Doctors Committee of the BMA is behaving in an extraordinary fashion.

[Baroness Finlay of Llandaff (CB)]

My Lords, can the Minister say how sincerely the Government are considering going to ACAS, which, as far as I understand it, is acceptable to the BMA Junior Doctors Committee, and can he explain why there is resistance to doing that? Given the threat of terrorism that we now face, have the Government assessed the impact and the security that would be needed on the strike days both in the event of a terrorist attack on the population at large, when those who are well versed in managing it will not be working, and in the event of a terrorist attack specifically targeted at demonstrations by junior doctors, when they will be injured and the hospitals will be empty?

[Lord Prior of Brampton]

The Secretary of State has said that he is open to conciliation. Frankly, it would be so much better if we could sort this out ourselves rather than go to conciliation, but he has said that he is open to it. If there is a terrorist attack, speed will be of the essence if people are severely injured. Junior doctors care hugely about their patients, so I think we have to rely on junior doctors to be available in hospitals in the event of some awful terrorist outrage, even if they are on strike. I will certainly draw to the attention of COBRA and the relevant authorities the question of the impact of terrorism on a demonstration by junior doctors.

[Baroness Barker (LD)]

My Lords, if, as appears to be the case, the Government’s proposals discriminate against junior female doctors who take time off to have children or against doctors who devote some of their time to research, will the Government be prepared to reconsider their proposals?

[Lord Prior of Brampton]

I probably did not make the situation clear enough. The Secretary of State said that there are no preconditions. If there are concerns about time off to have children or to carry out research, those are absolutely the kinds of issues that should be discussed around the table.

[Baroness Wall of New Barnet (Lab)]

I declare an interest as chairperson of Milton Keynes Hospital. Where in all this are we talking about patients? I am not going to enter into any discussion about who should be doing what. I spent this morning at Milton Keynes Hospital with my chief executive, medical director and all the consultants discussing this. I obviously associate myself with everybody’s plea that this does not go ahead, but if it does, how are we going to ensure that our patients get the best possible experience? I am equally surprised that the Minister has not referred to the letter from Sir Bruce Keogh, which went out to the chairman of the BMA and provided us with many opportunities. I am anxious that the Minister understands that the prime thing in this is patients. Whatever we have to do, patients need to be looked after.

--- Later in debate ---

[Lord Prior of Brampton]

I completely agree with the noble Baroness. I am not going to stand here and be sycophantic about the Secretary of State for Health, but the one thing he has prioritised above all else since he has been there is patient safety and patient quality.

[Lord Ribeiro (Con)]

My Lords, Sir Terrence English in his excellent article in the Telegraph made the point that medicine is a vocation and doctors who enter the profession should recognise that patients always come first. The Armed Forces do not go on strike and neither, I believe, should doctors. On the issue of preconditions, in response to a question from Sarah Wollaston in the other place, the Secretary of State made it clear that there are no preconditions. I have looked at Hansard, and that is what he said. There are no preconditions and the BMA should recognise that and go back to the table.

[Lord Prior of Brampton]

My Lords, the threshold for strike should be very high because of the vocational and professional dedication of doctors. Certainly, the threshold should be higher than it usually is for pay and conditions issues such as the one before us today.

[Lord Winston (Lab)]

My Lords, I deeply regret the tone of the statement. I understand that that is not the responsibility of the noble Lord, Lord Prior. I also respect very much his attitude, which is, I think, respected by the whole House. We have to say very clearly that this is an unprecedented situation. I do not think the nature of how junior doctors feel is understood. Already, there are more doctors in medical schools looking at going overseas—they are actually asking me whether they should be working in this country. The key issue is one we discussed in today’s earlier debate: the backbone of a good NHS is the good research we do. Research is massively threatened by what the Secretary of State is proposing. That has been emphasised by Jeremy Farrar, who, after all, is a very independent person as head of the Wellcome Trust. Would the Minister be kind enough to address that issue?

[Lord Prior of Brampton]

I agree. It is tragic that we are in this situation. My son is a medical student and I meet many of his friends; they do not want to be in this position. Concerns have been raised about whether junior doctors will have time to do research or will lose out on their progression if they do. That should be discussed and argued out with the BMA sitting around the table.

NHS: Costs of Operations

Lord Prior of Brampton Excerpts

Monday 9th November 2015 Lords Chamber

[Lord Naseby]

To ask Her Majesty’s Government whether the National Health Service will publish the average cost of all operations and procedures undertaken (1) by general practitioners, and (2) in hospitals.

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

My Lords, the department has published the average cost of operations and procedures in hospitals for the past 17 financial years. These reference costs are the average unit costs to NHS hospital trusts of providing acute, ambulance, mental health and community services, covering £58 billion, or 55%, of revenue expenditure in 2013-14. Reference costs for 2014-15 will be published this month. There are currently no plans to collect similar information from general practitioners.

[Lord Naseby (Con)]

Does my noble friend recall that one of the features of GP fundholding was that GPs had a budget, the patient could choose what hospital they went to and the hospital to which they were referred then sent a bill to the GP? If we introduced a new system whereby GPs and hospitals actually knew the cost of what they were or should be charging, would that not enable GPs and hospitals to stick to their budgets, and some of the overspend would then disappear?

[Lord Prior of Brampton]

My Lords, hospitals do know their costs; they know their reference costs and their HRGs. Increasingly, we will want to get patient-level costing into all our hospitals, as is already the case in some hospitals. If you know the actual cost by patient, the hospital management can have a much better discussion with hospital clinicians. Patient-level costing is important going forward in hospitals. For GPs, we have a calculated payment, as my noble friend will know: currently £75.77 per capita on the list, adjusted for various matters. A capitated figure for GPs is probably better than a much more detailed breakdown of costs.

[Baroness Walmsley (LD)]

Do the figures for hospitals discriminate between those that have to service expensive PFI contracts and those that do not? If so, and if the former are more expensive than the latter, is the department funding them appropriately to enable them to pay those costs?

[Lord Prior of Brampton]

The noble Baroness makes an important point. We have what we call a “market forces factor”, which is applied to the tariff to make adjustments for unavoidable differences in costs—for instance, providing care in London compared to providing it in a cheaper place. The way we measure the cost of capital is not entirely satisfactory, though, and if an individual trust has a very expensive PFI, that is not properly compensated for by the market forces factor. We should spend some more time looking at that issue.

[Baroness Wall of New Barnet (Lab)]

My Lords, is the Minister aware of the new system brought in by the department to measure every activity that goes on in a hospital, including the consultant’s time and all the extra things that are used? He talks about reference costs and even tariffs, but they are not actually a very good measure of the cost of materials and services that are already used in the health service.

[Lord Prior of Brampton]

The reference costs try to pick up all the costs attributable to certain procedures. As I was saying earlier, a patient-level costing system would probably be more accurate. I did not catch the first part of the noble Baroness’s question, so perhaps we could deal with this outside the Chamber. Hospitals are incredibly complex and picking up all the costs, particularly allocating overhead costs to individual procedures, is difficult. Compared to any other hospital costing system I have seen in the world, though, the NHS reference-cost system is pretty comprehensive.

[Lord Ribeiro (Con)]

My Lords, one category not included in the list is the independent sector treatment centres. Are these proving as cost-effective as we would like? If so, is it not time that NHS consultants have greater access to them to deal with their elective cases, many of which are often cancelled because of the need to bring in emergencies?

[Lord Prior of Brampton]

My noble friend raises an interesting question about independent treatment centres, which are for elective cases, not emergencies. They are able to plan their case mix more accurately, and are much choosier about the case mix they take. They can be extremely efficient, and if they have the volumes coming through, they are. Because of the case mix they take, they ought to be able to deliver significant cost advantages over providing such surgical care in a normal NHS hospital. The argument for ring-fencing orthopaedic procedures, for example, is overwhelming in terms both of cost and the quality of care delivered.

[Baroness Farrington of Ribbleton (Lab)]

My Lords, I have heard consultants getting very cross not with patients, but with patients with complications being referred from private hospitals when the procedure got too complicated for them to deal with. Could the Minister write to me detailing the available information he has about this? I stress that in both cases, the consultants were genuinely caring of the patients; but both said that in their view, this happened too often.

[Lord Prior of Brampton]

I will certainly look into this and write to the noble Baroness, as she requests. There is no question but that in complex cases, the NHS is better equipped than most private hospitals to deal with such complexity; and of course, even when a simple case is handled in a private hospital and something goes wrong, that may lead to a referral back to an NHS hospital. However, I will certainly look into this and write to the noble Baroness.

Atrial Fibrillation

Lord Prior of Brampton Excerpts

Wednesday 4th November 2015 Lords Chamber

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

My Lords, I thank my noble friend Lord Black for initiating this debate. It has been very interesting for me. I did not know anything about atrial fibrillation until I researched it for this debate. What always strikes me is the extraordinary depth of the contributions noble Lords make to these debates.

I shall draw out four themes that we often come across in these debates before I respond in detail. The first is how expert patients or carers of patients have become and what a contribution they can make to helping NHS England and clinical commissioning groups in structuring the right kind of care pathways for these serious illnesses. The second point is the variation around the country, from GP to GP, from CCG to CCG and from one region to another, every time we debate almost any disease in this Chamber. The third point, which was made strongly by the noble Lord, Lord Rennard, is the correlation always between quality and cost. We often think of them as separate and in opposition to each other, but good quality is usually also achieved at lower cost. The fourth point is the growing role of self-care. My noble friend Lady Gardner and others mentioned that as technology develops self-care will become an increasing part of how we deliver care. On education, the noble Baroness, Lady Masham, talked about basic first aid, such as learning to take your pulse at school. It is so obvious that you would not think it needed saying, but I have never done a first aid course and I am not proud of that fact.

I start with diagnosis of AF. Around 18% of cases of AF remain undetected. That means a lot more needs to be done. NHS England is encouraging clinical commissioning groups to work with local practices to target people at risk of AF. In addition, the NHS Health Check programme’s best practice guidance recommends that a pulse check is carried out as part of the process of taking a blood pressure reading. People found to have an irregular pulse rhythm should then be referred to their GP for further investigation. Other innovative approaches are being used to identify AF in older people, such as pulse testing at flu clinics and by some dentists.

There is also research under way. The National Institute for Health Research is funding a study into how a hand-held device can be used in primary care to provide an automatic diagnosis of atrial fibrillation. The National Institute for Health and Care Excellence—NICE—published an updated guideline on AF in June 2014 which includes recommendations on diagnosis. I looked at the care guideline before I came here. I did not find it as complicated as the noble Lord opposite but no doubt it could be simplified.

My noble friend Lord Black stressed the importance of screening. I do not think I have a very good answer. I have a response here on screening but I am not sure it will satisfy him—it did not entirely satisfy me. There are calls for screening for AF, as we have heard today. Ministers are advised by the UK National Screening Committee. In 2014, it recommended that a systematic population screening programme for people aged 65 and over should not be offered. This is because, based on the evidence in the review, the committee was not convinced that such a programme would bring more good than harm to the population offered screening. This position will be reviewed in 2017-18, or earlier if new evidence emerges. I am very happy to meet the noble Lord, Lord Black—or any other noble Lord—and the people from Public Health England responsible for the decision if he would like to understand more fully the reasons why. I am not saying they are wrong—they may well be right—but I should like to understand in more detail the reasons they believe that screening is not appropriate. I think the noble Baroness, Lady Murphy, suggested a reason in her speech. Maybe we should depend more on people taking responsibility for themselves and less on a screening programme, although I am not sure whether that was the point she was making. In any event, it is an issue that I would like to explore further with the national screening programme people.

As for the treatment of atrial fibrillation, NHS England has identified the improved management of AF as a priority for reducing premature mortality. NICE’s updated guidance suggests the use of anticoagulants unless there is a reason not to do so. I know there are concerns—they have been mentioned this evening—that aspirin is still being prescribed instead of anticoagulants, but NICE makes absolutely clear that aspirin on its own should not be used for stroke prevention in people with AF. There is NICE technology appraisal guidance recommending the use of newer anticoagulants for some people, which a number of noble Lords have mentioned this evening. NICE also published a quality standard on AF in July 2015, which sets out what a high-quality AF service should look like and will help drive improvement locally. The QOF contains indicators for the management of AF which cover the use of anticoagulation therapy. That provides a further incentive for doctors to ensure that AF patients receive anticoagulation where appropriate to manage their stroke risk. These actions should help ensure that people receive the anticoagulation treatment that is right for them.

I know there are concerns that some people with AF are not able to access the newer anticoagulants that NICE has approved for certain patients. There is a legal requirement on commissioners to provide funding for treatments and drugs recommended in NICE technology appraisal guidance within three months of that guidance being published. This is enshrined in the NHS constitution. The need to reduce variation and to strengthen compliance with and the uptake of NICE technology appraisals was identified in Innovation Health and Wealth, published in December 2011. In response, NHS England and the Health and Social Care Information Centre have developed an innovation scorecard, published on a monthly basis, to enable commissioners to benchmark their own position and increase transparency to patients and the public. This will assist the NHS in the identification of variation and the adoption of treatments such as NOACs that are recommended in NICE technology appraisals.

Some progress is being made. The uptake of newer anticoagulants—the NOACs—across England in 2014-15 was more than double that in 2013-14. In 2013-14, the figure was 45,708 per 100,000 of the resident population; that had risen to 126,845 in 2014-15. In addition, NHS IQ is promoting the use of GRASP-AF within GP practices in England. This audit tool, which was mentioned by the noble Lord, Lord Black, and other noble Lords this evening, simplifies the process of identifying patients with AF who are not receiving the right management to help reduce their risk of stroke. NHS IQ continues to support the use and rollout of this audit tool. In answer to the noble Lord’s question, I understand that, to date, 2,938 GP practices across the country have used the tool and have voluntarily uploaded their data to the online database. The database now contains information on the management of more than 327,000 patients with AF.

As to self-monitoring, when patients are taking warfarin, they need to have regular blood tests to monitor their internal normalisation ratio—their INR—which measures how fast blood clots. It is important that this remains in the correct range. Understandably, some patients find having to make regular trips for blood tests to monitor their INR disruptive. I am running out of time but it is worth just saying that NICE has recently recommended two point-of-care devices in diagnostics guidance for people taking long-term anticoagulation therapy who have AF or heart valve disease, if they prefer to use this type of monitoring.

To conclude, I hope that some of what I have said reassures noble Lords that we and the NHS take this illness extremely seriously. I am pleased that we are coming back to talk about stroke in more detail later in November and I reiterate my offer to have a meeting with the national screening people if noble Lords would like to find out more about their reasoning behind the decision not to screen for AF.

I am told I have three minutes; I thought I had to finish. I apologise. Having concluded, it is rather difficult to start again. At the beginning of the debate the noble Baroness opposite talked about stroke. I think we are coming back on 18 November to talk about stroke care in more detail. There have been enormous improvements over the past five years in the way that stroke has been treated in this country, in part because of the work done in London to concentrate stroke care in a smaller number of hyperacute hospitals where they can provide thrombolysis—clot-busting drugs—much more quickly. Certainly, in the hospital I was involved with in Norfolk we have seen a huge change in the quality of stroke care in the past three or four years. Before that, stroke had been a very poor relation compared to heart attacks or cancer, for example. In many parts of the country, if you had a stroke after 5 pm on a Friday your care was very poor. We are able now to provide stroke care on a much better basis.

It is hard to start again when you have finished, but my 12 minutes are up. The noble Lord, Lord Black, said that he is supervising a walk-in session on Tuesday for people who would like to have their pulse taken to see whether they suffer from AF. Sadly, I will not be able to make that walk-in session, but I encourage noble Lords to do so.