Medical Students

Lord Prior of Brampton Excerpts

Wednesday 26th October 2016 Lords Chamber

[Lord Naseby (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and, in doing so, declare an interest in that my wife is a retired full-time GP practitioner.

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

My Lords, my right honourable friend the Health Secretary announced on 4 October that the Government plan to increase the number of medical school places by up to 25%. From September 2018, the Government will fund up to 1,500 additional medical school places each year. Students will be able to apply for the extra places from 2017 in order to take them up from the academic year 2018-19.

[Lord Naseby]

Is my noble friend clear that the Secretary of State is to be congratulated on beginning to grasp this nettle? In the last three years, we have lost 3,500 medical students, but the problem goes deeper, does it not? Today, 56% of the intake of medical students is female. Furthermore, 70% of female GPs today work part-time, and a recent survey by the King’s Fund says that 90% of all medical students in training want to work part-time. Given that it costs £200,000 to train anybody as a medical practitioner, surely the time has come to consider a minimum full-time commitment of at least four years after qualification, similar to what they do in Singapore and, indeed, in our own Armed Forces.

[Lord Prior of Brampton]

My noble friend is absolutely right that more than 55% of those who go to medical school are now women; that is a fantastic change that has happened over the past 20 years. It is true that more women than men tend to work part-time, as they have children and bring them up, and that is taken into account in the planning done by HEE. When my right honourable friend the Health Secretary made his announcement, he said that we will be looking in our consultation at requiring people whom we have paid to go through medical school to give at least four years back to the NHS, which I think is reasonable. The figure is actually six years if you become an Army doctor, so four years is not unreasonable.

[Lord Winston (Lab)]

My Lords, is the Minister aware that, although there may be enough people wanting to apply to medical school, many of the brightest and the best are now completely turned off doing medicine because of the relationship with the Secretary of State for Health? This is a very serious mistrust and, whether they are male or female, the brightest and best are often not applying. There is increasing evidence for this in most medical schools, and indeed in schools as well.

[Lord Prior of Brampton]

I respect the views of the noble Lord but I have looked very carefully at the number of applications coming into medical schools in 2016 compared with the previous year. In 2016, there were 20,100 applications for all medical schools, including in Scotland. The previous year the figure was 20,390, so there is no firm evidence to support the view that the noble Lord expresses. There were some rumours that St George’s was having trouble filling its places. I have investigated that and understand that it was a result not of any lack of demand but of the fact that it wanted to wait until A-level results had come through so that it could choose the best candidates based on those results. So I do not think there is any evidence to substantiate the noble Lord’s point.

[Baroness Walmsley (LD)]

My Lords, one of the objectives in Health Education England’s mandate is to reduce our dependency on temporary staff. However, the National Audit Office tells us that we are short of 50,000 clinicians, and that HEE is failing to be sufficiently proactive in addressing the,

“variations in workforce pressures in different parts of the country”.

Is the noble Lord’s department monitoring how well HEE is responding to these challenges?

[Lord Prior of Brampton]

My Lords, predicting the future requirement for doctors is extremely difficult. It is more a matter of prophesy than science. The fact that we are now going to fund an extra 1,500 doctor places a year, which is a 25% increase, should make a huge difference.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. Beyond undergraduate medical education, do the Government believe that there are sufficient opportunities for the established workforce to continue to develop itself to meet the changing needs of the population of our country?

[Lord Prior of Brampton]

That is a very big question, which is hard to answer. My personal view is that I do not think that the training we give to our young doctors in management, leadership and how to structure new models of care is sufficiently broad. You could argue that the curriculum at medical school is too narrow and should be broadened.

[Baroness Gardner of Parkes (Con)]

Can the Minister tell me how many overseas doctors, particularly Commonwealth doctors—if he has a figure for that—are working in our National Health Service? On a separate topic, what can be done to encourage people to go into some specialties that we are told do not attract doctors, which is why there are not sufficient numbers in them?

[Lord Prior of Brampton]

My Lords, overseas doctors account for about 25% of the total number of doctors employed by the NHS, which is a very high number. I do not have the breakdown for the Commonwealth countries but it is an interesting question; I will research it and write to my noble friend. She is absolutely right that there are shortages in particular specialties. General practice and psychiatry are probably the two areas where there is the biggest shortage. HEE is determined to increase the intake in those areas. Certainly, the number of doctors going into GP specialty training this year is just over 3,000. That is an increase on last year but is still not enough.

[Lord Clark of Windermere (Lab)]

My Lords, we welcome the increase, but is it sufficient to meet the problem? I understand that about 100,000 overseas doctors, including European doctors, work in the NHS. Given an extra 1,500 places a year, it will take many years to reach the target. Why do we not make a gesture to those overseas doctors working in the health service and offer them permanent residence here?

[Lord Prior of Brampton]

I think it will be helpful if I quote from the Health Secretary’s speech at the Conservative Party conference, talking about overseas doctors. He said:

“They do a fantastic job and the NHS would fall over without them. When it comes to … EU nationals, we’ve been clear we want them to … stay post-Brexit”.

Let us be absolutely clear: we want overseas doctors from the EU or elsewhere to stay here post-Brexit.

[Baroness Masham of Ilton (CB)]

My Lords, how many medical students drop out during training? How many, when qualified, do not take up medicine and go into other specialties?

[Lord Prior of Brampton]

My Lords, the attrition rate for students at medical school is about 5%. Some of those leave for medical reasons and come back subsequently, so the figure will be less than 5%. I do not have the drop-out rate for doctors who are further advanced in their training but I will find out and write to the noble Baroness.

Breast Cancer: Innovative Drugs

Lord Prior of Brampton Excerpts

Monday 24th October 2016 Lords Chamber

[Baroness Massey of Darwen]

To ask Her Majesty’s Government whether the Accelerated Access Review will address the availability of innovative drugs for breast cancer.

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

My Lords, the report of the Accelerated Access Review, published today, makes recommendations to the Government on reforms to accelerate access for National Health Service patients to innovative medicines and medical technologies, which may include drugs for breast cancer, making our country the best place in the world to design, develop and deploy these products. I warmly welcome publication of the report. The Government will consider the recommendations in the review carefully and provide a formal response in due course.

[Baroness Massey of Darwen (Lab)]

I thank the Minister for that Answer. I am aware that, fortuitously, the final report of the Accelerated Access Review was published this morning, and, again, it is fortuitous that Thursday of this week will be breast cancer awareness day. The Secretary of State for Health has commented that we wish to make the UK the best place in the world to develop new drugs, as the Minister said. Do the Government therefore intend to commit to full delivery of the Accelerated Access Review, and what estimates have been made of the resources that will be necessary for this, if any resources are required?

[Lord Prior of Brampton]

We received the report today. We warmly welcome its principles and believe that by combining the great depth of our research base in this country with the NHS, which is the largest single integrated provider of health services in the world, we can create a world-leading life sciences base in this country. The detailed response to the report and the costs attached to it will come in due course.

[Baroness Walmsley (LD)]

My Lords, repurposed off-patent drugs often fall in the cracks between the processes of NICE and the processes of NHS England, both of which organisations take the role of approving these drugs. The Accelerated Access Review recognises this problem and recommends that the new streamlined process involve both organisations talking to each other to make quite sure that that does not happen. What will the Minister’s department do to ensure that under this new streamlined process these drugs do not fall between the cracks, because many of them are very useful to patients?

[Lord Prior of Brampton]

My Lords, I need to consider the report in detail. I do not believe that repurposed generic drugs naturally fall within the AAR streamlined procedures, although it is very important that they do not fall between the cracks. The AAR is largely designed for new products rather than for repurposing old products.

[Baroness Greengross (CB)]

As the Minister will know, there is an enormous delay in innovative drug production due to the regulatory bodies internationally not working very closely together or taking a very long time to work together. Will the Minister tell us whether there has been any progress on bringing those regulatory bodies together, as was initiated after the former Prime Minister did a lot of good work in this respect regarding dementia?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. The delay in bringing a new drug to the market can very often be between 12 and 14 years, which is a huge amount of time. Part of the reason for that is indeed the regulatory process. The whole purpose of the Accelerated Access Review is to truncate that time. The report talks about reducing for some drugs the time it takes to bring them to market by up to four years, which would be very considerable progress. In terms of international regulatory bodies, if one takes the EMA in Europe and the FDA in the US, clearly they do work together at one level but probably not closely enough, and I suspect that there is too much duplication in regulation. Certainly, as we leave the European Union, we need to be very careful that we do not have a duplicatory regulatory system in this country.

[Baroness Wheeler (Lab)]

My Lords, the Minister will know that since 2014 the Government have received nearly £1.5 billion from the branded pharmaceutical sector as part of the PPRS to hold down pharmaceutical costs. Why is not some of that sum being used to fund innovative drugs for breast cancer?

[Lord Prior of Brampton]

My Lords, I think it is a mistake to regard the PPRS and the savings made in that scheme as a separate pot of money. Any savings generated from the PPRS are funnelled back into the NHS. As for new innovative drugs, the cancer drugs fund has been changed substantially and one should regard it now largely as an incubator fund with the same purpose as the Accelerated Access Review, which is to bring forward new drugs more quickly.

[Lord Hamilton of Epsom (Con)]

Can my noble friend give the House some indication of the costs of bringing new drugs on to replace old? Invariably, new drugs are far more expensive than the ones that they replace.

[Lord Prior of Brampton]

My noble friend makes a perceptive point. There is always going to be tension between new drugs and affordability, although there are new drugs and new medical devices that can, in the long run, actually save money. The whole purpose of the Accelerated Access Review is to try to square the circle. There are three factors that we have to consider: first, we want a strong and vibrant life sciences industry in this country; secondly, we want to bring forward new drugs as soon as possible if there are big patient benefits; and thirdly, it must be affordable.

[Baroness Finlay of Llandaff (CB)]

Following the statement of the Academy of Medical Royal Colleges this morning urging caution over chemotherapy in advanced cancer, does the Minister agree that it is very important that, at the time of diagnosis, patients have a serious illness conversation and are prepared for what might come so that they are not hanging on with false hopes for drugs which might not be of benefit to them but can have treatments that are appropriately targeted to the individual patient and their needs?

[Lord Prior of Brampton]

The noble Baroness is describing good clinical practice. One would hope that that conversation would take place between a doctor and patient. What was disturbing about the report from the Academy of Medical Royal Colleges was its overall estimate that £2 billion a year was being wasted on unnecessary tests, drugs and the like. The issue that the noble Baroness raises is where people’s lives are prolonged right at the end but they are not given any quality of life at the same time.

Mental Health: Young People

Lord Prior of Brampton Excerpts

Tuesday 11th October 2016 Lords Chamber

[Lord Farmer]

To ask Her Majesty’s Government how they intend to amend the 2012 national suicide prevention strategy to take account of the mental health challenges faced by young people.

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

My Lords, we will publish later this month the next annual progress report of the national suicide prevention strategy, which will set out details of how we are strengthening the strategy in key areas, including to target specific groups such as children and young people. The national strategy recognises children and young people as a group with specific mental health challenges that require a tailored approach to meet those needs.

[Lord Farmer (Con)]

I thank the Minister for that informative Answer. Front-line clinicians and local authorities are very aware of the role that family dysfunction and relationship breakdown frequently play in the onset of pronounced mental illness in adolescents. What steps are the Government taking to prevent mental health problems from developing, particularly where family breakdown is a root cause?

[Lord Prior of Brampton]

My Lords, in his recent national confidential inquiry, Louis Appleby reported that in 36% of all suicides of people aged under 20, family breakdown or family circumstances were part of the cause. My noble friend is absolutely right that families are critically important. That is very much part of the strategy in our Future in Mind paper. I was horrified by the figure that 43% of all people who took their own lives under the age of 20 had had no prior contact with any agency—no contact with GPs, no contact with CAMH units, no contact with schools—about their condition. Nearly half the people who took their own lives were completely below the radar. That is a shocking figure.

[Baroness Walmsley (LD)]

My Lords, I ask the Minister about young people with mental health problems in the criminal justice system, where they are particularly vulnerable to self-harm and suicide attempts. Recent draft NICE guidelines recommend that all staff working in the criminal justice receive training to recognise and respond to mental health problems. Although the NHS is not responsible for the physical or mental health of those in custody, the guidelines recommend co-operation between healthcare and the criminal justice system on mental health, so how will his department respond to them, and who will fund the training?

[Lord Prior of Brampton]

My Lords, I do not think I can answer the question about who will fund the training; I will write to the noble Baroness to answer it. She is absolutely right that a huge proportion of people who are in the criminal justice system, in prison, also suffer from mental health problems. Tackling the mental health problems of people in prison is just as important as tackling them outside. If I may, I shall write to the noble Baroness on this matter.

[Lord Watts (Lab)]

I must tell the Minister that there is very little sign of any investment in mental health services taking place in Merseyside. Will he investigate what is happening to that investment strategy and why Merseyside is failing our children and failing to invest in this vital service?

[Lord Prior of Brampton]

My Lords, I am obviously disappointed to hear what the noble Lord says about Merseyside; I cannot answer specifically on Merseyside today. We have the Future in Mind strategy, which pledged £1.4 billion of extra spending over the lifetime of this Parliament for children and young people. If it is not reaching the front line in Merseyside, we should look at that.

[Baroness Finlay of Llandaff (CB)]

Can the Government provide assurance that the phenomenon of suicide contagion is now being recognised? That is contagion both from personal contact with somebody who has attempted or committed suicide and through media reporting, where the higher the profile in the media, the more likely there is to be suicide contagion. That appears to be a linear relationship. Do the Government recognise that the best way to deal with the complex problem of suicide contagion among children and adolescents at school is to provide suicide screening within schools—for the precise reason that the Minister outlined, which is that many of these people are below what you might call the healthcare radar?

[Lord Prior of Brampton]

My Lords, the issue of suicide clusters and contagion is serious and real. By 2017, as recommended by the Five-Year Forward View on Mental Health prepared by Paul Farmer, every authority will have a multiagency plan addressing that issue. I agree with the noble Baroness that we need to do a lot more in schools. Interestingly, 255 schools are now part of a pilot scheme where there is a single point of contact within the school, so that when a child is feeling suicidal or has mental health problems, it is at least clear who they should go to to seek advice.

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is clearly not just an issue of funding, but you cannot escape the issue of funding. Yesterday, police chiefs said that they were being forced to act as emergency mental health services because of the inadequacy of provision up and down the country. Recently, an FoI request showed that two-thirds of CCGs which responded are spending less as a proportion of their budget on mental health this year, rather than more, as Ministers required them to do. The Minister mentioned the review to come out later this month, which will reflect on this distressing issue. The question is how one can have confidence in what the Government are saying, because they clearly are having such little impact on what the NHS does locally.

[Lord Prior of Brampton]

My Lords, this is a difficult issue. As the noble Lord will know, a key part of the five-year forward view is to take resources out of acute physical care, out of acute hospitals, so that there is more available for mental health care, community care and primary care. It is very difficult to do that. As the noble Lord will know, we have been trying to do this since 2000 but all that has happened is that more and more of the available resource has been sucked into the big acute hospitals. Getting that resource out and into the community and into mental health is extremely difficult. The STP process is going on at the moment. We are committed to seeing more money going into mental health, but I acknowledge the difficulties.

[Lord Alton of Liverpool (CB)]

My Lords, will the noble Lord confirm that last year we saw the highest level of teenage suicides in 17 years? Welcome though the review of the 2012 strategy is, will the noble Lord say that, as well as looking at issues such as family breakdown, he will look at issues such as cyberbullying? Did he see the case only last week of an 11 year-old boy who committed suicide? His mother said that he had been subjected to cruel and overwhelming social-media and cyber bullying. Will the review examine these links with breakdowns in mental health and teenage suicide, and the very poor state of mental health provision inside the National Health Service for young people?

[Lord Prior of Brampton]

My Lords, on the noble Lord’s last point, the very poor state of mental health provision in the NHS has been with us since 1948, if not earlier. We are trying to address this problem but there is a huge way to go. I acknowledge absolutely the difficulties to which the noble Lord, Lord Hunt, also alluded. Professor Appleby, in his report which came out in May of this year, cites cyberbullying as one of a number of factors. They tend to be multifactorial. When someone takes their own life it is normally the end result of often years of misery and a whole range of things. It could have to do with sexuality, bullying, family breakdown or bereavement. This is not an easy situation to solve. Last year, 145 people under the age of 20 took their own lives. This is a tragedy for them and, of course, for their families as well.

[The Lord Bishop of Peterborough]

My Lords, may I draw to the Minister’s attention the specific needs of children and young people from refugee and recent immigrant families? In many cases, they have been through dreadful trauma in other countries and find themselves dislocated and here, sometimes, without their families. There is a need for proactive mental health care as well as for reactive and responsive care, both of which seem to be in short supply.

[Lord Prior of Brampton]

My Lords, the right reverend Prelate makes a very important point. The life history of some of these children and young people in refugee camps who have fled from desperate parts of the world is truly shocking. I can only completely agree with the sentiments to which he has drawn our attention.

Drug-Resistant Infections

Lord Prior of Brampton Excerpts

Thursday 15th September 2016 Lords Chamber

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

My Lords, this has been an excellent and informative debate. I join others in thanking my noble friend Lord Lansley for securing it, and for his very important contribution to it. However, it is slightly sobering to think that this issue was raised in the House of Lords as long ago as 1998, as the noble Lord, Lord Trees, said, and again in 2003, as the noble Baroness, Lady Walmsley, said. It is easy to write these reports but quite a different thing to act upon them.

I was struck by the comments of the noble Lord, Lord Rees of Ludlow, on longitude, and how that prize won in the 18th century by one of the great British entrepreneurs, John Harrison, transformed navigation. Prizes have a role to play, not just for the money but in raising the profile of issues and gaining public knowledge about what is going on. However, there is another issue here. We should not be afraid of money. If scientists working in British hospitals or universities are able to make money from winning a prize, or indeed from royalties or shared royalties for an invention, we should encourage that. I sometimes think that we are way off the pace compared with the culture in the US in that regard. My noble friend Lord Colwyn referred to reactive oxygen technology. That may well be one of the new technologies that could win a prize of this kind. Certainly, we should look at that technology very closely in our fight against infection.

I pause for a moment to try to imagine a world without antibiotics, before Alexander Fleming’s great discovery of penicillin in 1928. It is worth noting that he discovered penicillin in 1928, but its use was not commercialised until the mid-1940s, so the take-up of new inventions and innovations was not as fast then as we would have liked. In those days, even a minor infection following a wound caused by a thorn in the garden or a shaving cut could result in disastrous consequences. In that pre-antibiotic age, 40% of deaths were due to infections. The emergence of antibiotics changed all that. Today, the equivalent figure has fallen from 40% to 7%. Much of modern medicine, such as cancer treatment, and much of modern surgery, is possible only because of antibiotics. However, we have been wasteful with this precious resource. As my noble friend Lord Lansley pointed out, when Alexander Fleming won the Nobel Prize in 1945, he said in his acceptance speech that,

“the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism”.

He was, indeed, prophetic. As my noble friend Lord Selborne almost said, in the evolutionary race, bacteria have a huge advantage over human beings. Populations of bacteria can reproduce and double within four to 20 minutes in the right circumstances. Our profligate use of antibiotics in humans and animals has accelerated that evolutionary process.

Fleming was, of course, right in voicing his fears, because that is precisely what has happened today. In a post-antibiotic era, routine operations such as removing an appendix, inserting a pacemaker or a standard hip replacement could again be very hazardous. Childbirth, too, may once again threaten a woman’s life and child mortality could increase. As the noble Baroness, Lady Hayman, said, this problem could indeed set back all the successes that we have had in combating malaria.

The dilemma we face today is in two parts: a rise in antibiotic-resistant bacteria on the one hand; and the lack of new antibiotics coming on to the market on the other. In fact, we have not seen any truly new antibiotics for decades. This is in stark contrast to the rapid post-war development of new antibiotics. Already in the UK, we are seeing 5,000 deaths per year from sepsis, half of which are due to a resistant form of the bacteria. The numbers of infections complicated by AMR are expected to increase markedly over the next 20 years. If a widespread outbreak were to occur, we could expect around 200,000 people to be affected by a bacterial blood infection that could not be treated effectively with existing drugs. High numbers of deaths could also be expected from other forms of AMR. This is precisely why the Government asked my noble friend Lord O’Neill to conduct a review of the economic and social consequences of antimicrobial resistance. It is interesting to note that a senior, well-respected economist with particular expertise in emerging economies was chosen to conduct the review, as this issue goes beyond just a health problem. It is potentially a health, social and economic problem that threatens us on a global basis. In the Government’s risk register, AMR is a tier 1 risk, along with terrorism and a flu pandemic.

As the review has pointed out, antimicrobial resistance is not just a human health problem; it is of huge significance in the animal health, environment and agriculture sectors. It is only by tackling the problem in the round—a One Health approach—that we will make a difference globally. It is worth quoting from the foreword to the report of my noble friend Lord O’Neill, which states that,

“without policies to stop the worrying spread of AMR, today’s already large 700,000 deaths every year would become an extremely disturbing 10 million every year, more people than currently die from cancer. Indeed, even at the current rates, it is fair to assume that over one million people will have died from AMR since I started this Review in the summer of 2014 … The cost in terms of lost global production between now and 2050 would be an enormous 100 trillion USD if we do not take action”.

The review’s final report makes it clear that action is in part for nations to take in response to their particular circumstances, and that in other respects action will have to be taken globally. This mirrors the approach the UK has been taking towards AMR. As regards the Government’s response on a domestic level, the UK’s approach has been built around a five-year antimicrobial resistance strategy, first published in 2013. The report from my noble friend’s review has now given us the opportunity to reinvigorate and strengthen key elements of our existing strategy. New ambitions announced at the G7 leaders’ summit in May this year, and by our new Prime Minister at the G20 last week, are an example of the immediate effect of the review. Our aim now is to halve by 2020 the number of inappropriate antibiotic prescriptions within the NHS. We are also taking steps to halve the number of the healthcare-associated Gram-negative bloodstream infections, like E.coli, which pose the biggest threat to human health. This is not to say that the NHS has not made progress already on antibiotic prescribing. In fact, between April and December 2015, 2 million fewer prescriptions were dispensed compared with the same period in 2014. That is a reduction of a little over 7%. However, we have a long way to go and we know how difficult it is to change behaviour. More accurate diagnostics will clearly be a key part of this programme. As my noble friends Lord Colwyn, Lord Lansley and Lord Selborne said, the take-up of innovation is hugely important.

In response to the comments of the noble Lord, Lord Hunt, about the regulatory regime in a post-Brexit world, I say that the Brexit situation enables us to look again at our regulatory and licensing regime to see whether we can streamline it to make it quicker and less expensive than any other regulatory system in the world. Maybe in another debate we should come back on that in the context of life sciences more generally in a post-Brexit era.

The Government will additionally set an overall target for antibiotic use in livestock and fish farmed for food. The use of antibiotics as an aid to growth or a prophylactic against infectious disease is clearly highly undesirable. As the noble Lord, Lord Trees, said, we have largely ruled it out within the UK and Europe but in many parts of the world it is still a major problem.

Other recommendations in my noble friend’s review range from the issue of awareness-raising and behaviour change through to the question of how we might create the incentives to antimicrobial research and development that are so very much needed. Infectious disease has slipped down the priority list over the last 70 years and it is time that it came back to the top of the list. The Government will publish in the course of the next few days a full account of how they will address each of the recommendations in my noble friend’s review.

On the international dimension of the Government’s response to antimicrobial resistance, your Lordships will be well aware of the significant part that Dame Sally Davies, the Chief Medical Officer, has played—the noble Lord, Lord Rees, and other noble Lords drew attention to it—in raising the profile of AMR not only in this country but around the world. She has been and will continue to be a tireless champion, raising awareness of this huge threat to public health. The Government share her views fully. AMR has to be tackled on a global basis. In fact, in the last two years, the UK has played a central role in the WHO’s global action plan, which is largely mirrored by the World Organisation for Animal Health and the UN Food and Agriculture Organization. Each of these is important and each creates clear aspirations.

Our current focus is on the UN General Assembly high-level meeting next week to drive further international commitment and action to tackle AMR on a global scale. This objective will not be achieved easily or without perseverance. There is, however, good reason to believe that the effort and investment will bring real results. Indeed, the leaders’ communiqué from the G20 summit earlier this month acknowledged the threat that AMR poses to public health, growth and global economic stability, and committed to return to the subject next year. In the meantime, the leaders have asked international organisations with a particular interest, including the WHO and the OECD, to report back on options to address the serious shortfall in the number of new antibiotic and other drugs—a topic central to the analysis in my noble friend’s report. We are confident that the UN General Assembly high-level meeting on 21 September will not only raise awareness but pave the way for a positive declaration that will include a strong UN follow-up mechanism to monitor progress, locking in global commitments.

Our commitment will continue to allow us to provide support to low and middle-income countries. For example, our £265 million Fleming fund will support these countries to improve laboratory capacity and surveillance to tackle infectious disease. We are also working hard to promote research and innovation in antimicrobial resistance; for example, in fields of new diagnostics and vaccines. We have also committed £50 million towards setting up a global AMR research innovation fund to help countries tackle the threat.

The noble Baroness, Lady Hayman, asked a question on the Ross fund. The fund will provide £1 billion to develop, test and deliver a range of new products for infectious disease, such as malaria, Ebola and other neglected tropical diseases. The UK has invested over £200 million in product development, which has contributed to the launch of over 13 new vaccines, diagnostics and drugs in the last five years. This is a fourfold increase compared to the total global product development for the world’s most vulnerable between 1975 and 2000.

In conclusion, this is a hugely serious issue. AMR kills many people at the moment and could kill many millions more in the future. It also has huge economic consequences for the world. I will end by giving the last word to my noble friend Lord O’Neill, who has done so much to raise awareness of this great issue. I quote the last paragraph of his foreword to the latest report:

“Although AMR is a massive challenge, it is one that I believe is well within our ability to tackle effectively. The human and economic costs compel us to act: if we fail to do so, the brunt of these will be borne by our children and grandchildren, and felt most keenly in the poorest parts of the world”.

Smoking-Related Diseases

Lord Prior of Brampton Excerpts

Wednesday 14th September 2016 Lords Chamber

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

My Lords, I thank the noble Lord, Lord Faulkner, and my noble friend Lord Young of Cookham for enabling us to have this debate today. The fact that there are so many speakers, with only three minutes each, shows how important this subject is to many noble Lords in this House.

I was particularly taken by how many noble Lords addressed the issue of smoking within the context of health inequalities. I had not appreciated that it accounts for maybe 50% of the difference in life expectancy between people from poorer backgrounds who smoke and those who do not. It is one indication of just how serious smoking is. Linking it to Theresa May’s first speech when she became Prime Minister was a clever move. I hope she will read this debate with interest during the Recess.

The noble Lord, Lord Faulkner, said that he has spoken on this issue many times over many years in this House and elsewhere. It was actually back in 1604 that King James wrote a treatise called A Counterblaste to Tobacco, describing smoking as:

“A custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black, stinking fume thereof, nearest resembling the horrible Stygian smoke of the pit that is bottomless”.

He did not mince his words. Slightly depressingly, however, that was in 1604 and here we are over 400 years later, still struggling. Although we have made great progress, 7 million people are still smoking in this country and, as we will discuss later on, I saw a frightening statistic recently showing that by 2030 it is estimated that nearly 500 million people in Africa might be smoking. This is a global problem and it is not going away.

Of course, we have taken action. Many noble Lords pointed out the success that we have had in this country. Over the last 25 years the number of people smoking in England has fallen from just over 28% in 1992 to just under 17% at the end of 2015. Despite this progress, in England smoking still kills around 200 people a day. The noble Baroness, Lady Masham, gave us a moving story of a friend of hers who recently died from lung cancer. I remember when I was chairman of a hospital watching an operation and seeing the inside of a patient’s lung. I am sure that my noble friend Lord Ribeiro has seen similar things. The colour of a heavy smoker’s lungs is absolutely vile. They are blackened.

I want to reassure noble Lords that this Government have always and will continue to take very seriously tackling the great harm caused by tobacco. In the last year, we have introduced a number of important measures to achieve this. First, we introduced a tranche of legislation that has greatly strengthened tobacco control and reduced even further children’s exposure to tobacco branding and second-hand smoke. This included the introduction of standardised packaging, which I am pleased to say is already in shops across England. I am sure that noble Lords have seen the standardised packaging. It represents a big step forward. This measure aims to motivate more people to quit while also deterring greater numbers of young people from ever taking up smoking in the first place. This is a fantastic achievement.

Secondly, we have delivered a range of impactful mass media campaigns which promote quitting. In just two weeks from now, we will launch a fifth ‘Stoptober’ campaign. This campaign has proven extremely successful. In 2015, more than 130,000 people successfully quit for 28 days for Stoptober. That is an impressive figure. Looking ahead, a number of noble Lords raised the issue of a new tobacco control plan. I am unable to commit to a publication date, but I can confirm that a new plan will set out renewed national ambitions to reduce prevalence even further and build on the success of the previous tobacco control plan. I was very struck by noble Lords’ comparison of countries with a tobacco control plan such as Australia and Sweden—

[Lord Faulkner of Worcester]

Canada.

[Lord Prior of Brampton]

I apologise, it was Canada. We can contrast that with the experience in countries such as France and Germany, where there is no control plan. The Government fully support renewing the tobacco control plan. During the last five-year plan, the proportion of smokers in England reduced by more than 10%.

Addressing the inequalities caused by smoking will be a central component of this plan. As has been highlighted in this debate, there remains significant geographical and demographic variation. The noble Baroness, Lady Janke, mentioned the situation in Bristol, for example. Staggeringly, smoking prevalence today in Sevenoaks is 6% and in Corby it is 29.8%, which demonstrates the variation around the country. Reducing smoking rates in populations with comparatively high prevalence will be a priority in reducing this variation and the health inequalities caused by tobacco.

In particular, we are considering what more can and will be done to support those with mental health conditions in quitting smoking. In developing this aspect of the plan, the recommendations set out in The Five Year Forward View for Mental Health, authored by Paul Farmer, are being taken into consideration. The noble Baroness, Lady Gale, mentioned the importance of improving maternity outcomes, and giving children the best start in life is an important priority for this Government. We have already set out an ambition of achieving a 50% reduction in stillbirths and neonatal deaths by 2030.

Supporting pregnant women in quitting smoking will be an important factor in working towards that. This was a priority in the previous tobacco control plan, during which prevalence for this group fell by 3 percentage points. I can confirm that it will remain a priority. Exposure to smoke during and after pregnancy can have devastating health consequences for babies. As well as these immediate health risks, evidence also shows that children who have a parent who smokes are two to three times more likely to be smokers themselves. Supporting adults to quit is therefore vital to ending the cycle of children who take up smoking, in order to cut off the pipeline of new smokers at risk of smoking-related disease. This is a battle we are winning. The proportion of young people smoking continues to fall, as my noble friend Lord Ribeiro pointed out, with prevalence amongst 15 year-olds more than halving in the last decade.

I will touch on a couple of other important elements of tobacco control. First, my noble friend Lord Borwick and the noble Baroness, Lady Walmsley, commented on e-cigarettes. I am well aware of the report by the Royal College of Physicians, which said that vaping was 95% better than smoking. I saw the recent reports in the paper, and I have read the BMJ article that supported them, saying that 18,000 people gave up smoking last year because of vaping.

Clearly, e-cigarettes have an important role to play, but they are not risk free. We do not want to encourage young people to take up vaping. In the UK we are adopting the right approach, which reduces the risks of harm to children and provides assurance on safety for users. In the UK, our e-cigarette policy has been successful, with minimal long-term take-up by children and non-smokers. This is not the case everywhere. In the US, for example, there is an upward trend of children who have never smoked cigarettes using e-cigarettes. This is why the Government have taken a precautionary approach to any possible risk of renormalising smoking behaviours that we have fought long and hard to denormalise. If any noble Lord has seen some of the advertising around vaping, they can see the potential dangers of attracting children who would never have smoked to the habit of smoking.

The UK’s approach to the regulation of e-cigarettes has and will remain pragmatic and evidence-based. The Government will continue to monitor and develop this evidence base, adapting policy accordingly, to ensure that policy on e-cigarettes best supports the protection and improvement of public health.

Secondly, through PHE we will maintain a programme of evidence-based mass-marketing campaigns to encourage more people to quit smoking, and raise awareness about products and services that can help. The noble Lord, Lord Rennard, in particular raised this issue. I can tell him that £4 million has been allocated for tobacco-specific marketing activities, £1 million of which is for the Stoptober campaign launching next month. On top of this there is further funding for multiple-issue campaigns, such as the One You and Be Clear on Cancer campaigns, which also contain messages about smoking. We also need to consider Heat Not Burn and other novel tobacco-containing products that are starting to emerge.

Difficult decisions have had to be made across government to reduce the deficit and ensure the sustainability of public services, as the noble Lord, Lord Hunt, has drawn to my attention on a number of occasions. However, councils will still receive £16 billion over the next five years for public health, on top of what the NHS will spend on vaccines, screening and other public health measures. The noble Lord asked whether I can draw to PHE’s attention its powers in this area to make sure action is taken locally. I certainly will draw that to the attention of my colleague in the other House, Nicola Blackwood, the Minister for Public Health, to ensure that happens.

Tobacco use is, as the noble Lord, Lord Crisp, and the noble Baroness, Lady Northover, pointed out, very much a global issue and an international priority. Tobacco companies are becoming increasingly active in the developing world. By 2030, more than 80% of the world’s tobacco-related mortality will be in low and middle-income countries. The uptake of cigarette smoking in Africa is pretty alarming. The UK will continue to work collaboratively with other countries to reduce the burden that smoking places on individuals, families and economies across the globe.

The Government intend to invest part of the development assistance funds to strengthen the implementation of the WHO’s Framework Convention on Tobacco Control—known as the FCTC. This project will be delivered by the WHO. For a number of years the UK has been rated the best country in Europe for tobacco control policy. Through this project we will share the UK’s experience to support low and middle-income countries in saving lives by putting effective measures in place to stop people using tobacco. This project will involve assistance to implement the “time-bound” measures of the FCTC: to ban tobacco advertising and to require health warnings on tobacco packs. We will also support countries to strengthen tobacco taxation to improve public health and raise new revenues for governments.

In conclusion, I am very pleased that we have had the opportunity to have this debate. It is probably disappointing to some noble Lords that I cannot give a specific date for the new tobacco control plan, but I can assure them that it is coming, that there will be one and that it will build on the success of the previous tobacco plan. The noble Lord, Lord Crisp, and the noble Baroness, Lady Northover, asked a particular question about a new initiative for which we were being given funds by the WHO to deliver. I will have to write to them on that matter if that is acceptable. Obviously, we will reflect on all the points that have been raised this evening. I am sure they will add to the new tobacco control plan.

NHS: Health and Social Care Act 2012

Lord Prior of Brampton Excerpts

Thursday 8th September 2016 Lords Chamber

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

My Lords, first, that was an extremely good, incisive speech from the noble Lord, Lord Hunt. I do not agree with all of it—he would not expect me to do so—but it raised all the right issues.

I join everyone in thanking the noble Viscount, Lord Hanworth, for raising this subject. I do not recognise the picture that he painted of the NHS and I have been involved with it since 2002. For the avoidance of any doubt at all, I put it on the record that Jeremy Hunt, myself and the Conservative Government believe wholeheartedly in a tax-funded comprehensive National Health Service. I do not want there to be any doubt about that and I want it to be on the record. I know that Jeremy Hunt would absolutely refute any thought that he believed in an insurance-based National Health Service.

I want to focus noble Lords’ attention on today’s debate, which is about the Act. Therefore, if noble Lords will forgive me, I will not address the social care settlement and will not give our response to the Public Health Post-2013 report, which was raised by the noble Lord, Lord Rea. We have only just received this report. I think that response will come in due course. I say to my noble friend Lord Colwyn that I will not address in any detail the questions he raised about dentistry.

The noble Baroness, Lady Walmsley, gave a list of all the people who opposed the Act. I hope she will not think me churlish if I remind her that the Liberal Democrats supported the Act at the time. On the impact of the Act, I find myself in almost total agreement with the noble Lord, Lord Lipsey—not total agreement, but almost—because if we look at what drives healthcare and the changes in healthcare in this country, it is not the numerous reorganisations, however big or large they may be. It is in part demography, as the noble Baronesses, Lady Armstrong and Lady Pitkeathley, mentioned. Demography is at the heart of it. We have an ageing population yet we have a healthcare service which is not geared up to serve an ageing population, many of whom have multiple long-term conditions. It is also a question of lifestyles. I was in America for much of August and obesity is a massive problem there. It is a huge problem in this country as well. The comments made about Michael Marmot and the social determinants of healthcare were equally true. Poverty is a huge contributor to health inequalities, as we know.

The noble Lord, Lord Kakkar, raised technology and its uptake. Technology will have a huge impact on how we deliver healthcare over the next five, 10 and 20 years. Genomics, bioelectronics, integrated health records, big data and personalised medicine will have a huge impact. We will publish the accelerated access review later in September, which I think will address some of the questions that the noble Lord raised.

The noble Lord, Lord Hunt, raised the much wider issue about life sciences in the post-Brexit world. We cannot address those issues today but it is an absolutely critical area that we as a country have to address.

My noble friend Lord Lansley was absolutely right that money is critical in this regard. When the Act came in, he did not know then as Secretary of State that we were looking at a 10-year period with an approximate 1% real growth in healthcare spending against a background when we were spending 4% or 5% a year for many years, and, of course, a very tight local authority financial settlement as well. Finally, there is an issue of culture. People always say culture eats strategy before breakfast. Well, it devours reorganisations. In a people-centred organisation like the NHS, where you have deep vocational and professional attitudes, culture is hugely powerful. We may think that we can tinker with the healthcare system in this House or in the other House, but getting behavioural change from clinicians takes many years. Let us look at NPfIT, the national programme for information technology, which the noble Lord, Lord Hunt, was very much involved with. You can fiddle around with these things in Richmond House, but to persuade people to change the way they work is much more difficult. I think Sir Muir Gray and the noble Lord, Lord Lipsey, are by and large right: we exaggerate the impact these reorganisations can have.

Let us look at the current performance. I acknowledge it is really tough. The targets for acute hospitals—the four-hour waiting times, the 18-week RTT—and the ambulance service are very hard to meet. I totally acknowledge that. It is not surprising, because over the last five years, the number of attendances in A&E have gone up by 2.4 million people. Over the same period, 1.7 million extra people with suspected cancer have been seen; 6 million more diagnostic tests are taking place this year than five years ago; and there are 22,000 more daily out-patient appointments. I could go on. The growth in demand over this period, at a time of great financial stringency, makes things extremely difficult. We should be under no illusion about it. The NHS is doing magnificently against this difficult background; the noble Lord, Lord Lipsey, gave a personal example. The Economist Intelligence Unit recently found that, in its view, our end-of-life care was the best in the world. The Commonwealth rankings are still very favourable. The OECD has reported on improving outcomes in a number of cancer specialties. However, the noble Lord, Lord Hunt, is right; we have fewer doctors per capita in this country, fewer nurses, fewer MRI machines, and fewer CT machines. Despite all the PFI investment over the years, many hospitals are in desperate need of refurbishment, renovation and rebuilding. The NHS performs fantastically well in very difficult circumstances. I still believe that it is the best-value healthcare service in the world. All this has been helped a great deal by the overhead savings that came out of the Act introduced by the noble Lord, Lord Lansley: £6.9 billion of overhead reduction in the last Parliament, at a one-off reorganisation cost of £1.3 billion. I accept that is a huge amount of money, but nevertheless the overhead savings have been significant.

At the heart of many reorganisations is the issue of how we drive improvement. During the new Labour years, we went through a period of command and control from the centre, moved to targets and then moved to more devolution with foundation trusts. Competition and choice were put at the heart of the new Labour efforts to get sustainable change in the NHS. The Act went no further than that. In many ways it put things on a more even footing. Talking to my noble friend Lord Lansley, it is clear that he is agnostic. I think we are all agnostic about who supplies. The noble Baroness, Lady Walmsley, is agnostic; the noble Lord, Lord Hunt, is agnostic. We want the best suppliers to the NHS, whether they are from the public, private or third sector, or anywhere else. I clearly remember the then Secretary of State for Health, John Reid, now the noble Lord, Lord Reid, talking in 2007 or 2008 about perhaps 15% of supply for elective surgery coming from the private sector. Today, the scale of private provision is 7%.

This is where we come back to culture being stronger than anything that we, or the previous Labour Government, do in these Houses. The culture in the NHS is not all that open to private provision, but where private sector companies can provide a better service at a better price, they should be entitled to do so. However, we have to recognise that the opening up of the market, with choice and competition, has not had the success that we would have hoped for. Healthcare is not a perfect market; it is about as imperfect a market as you can find. So we have moved beyond choice and competition to a new approach—one based on transparency and on trying to identify and eliminate unwarranted variation, whether through the Right Care programme in NHS England or the Getting It Right First Time programme in NHS Improvement. I have huge hopes that we will be able to engage clinicians and try to drive improvement through a process of transparency.

Turning to the future, I want to give noble Lords two short quotations. The first is from the NHS Plan of 2000:

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

I think we would all agree with that. There is a similar quotation from 2014—14 years later—from Simon Stevens in the NHS Five Year Forward View. He says 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 … endlessly repeating their details because they use separate paper records. One organised to support people with multiple health conditions, not just single diseases. A future that sees far more care delivered locally but with some services in specialist centres where that clearly produces better results”.

We are all agreed on what the future should be. The noble Baroness, Lady Pitkeathley, says that she has heard this for 15 or 20 years. That is true, but it does not make it wrong. We have to join up health and social care; we have to integrate healthcare. Yet, since 2000—the date of the first quotation I gave—we have gone in almost the opposite direction. We have driven more and more care into acute hospitals.

I shall give your Lordships an interesting statistic. Between 2000 and 2014, the number of hospital consultants rose by 82%, the number of GPs by 22% and the number of community nurses by 14%. That shows where the money has gone—it has, I am afraid, gone to the wrong place. We have to reverse that trend but it is very difficult to do so. We have to take resource away from where it has been going for the last 15, 20 or 40 years and put it back into the community, back into mental health and back into primary care. That is the genesis and essence of the five-year forward view. It is the essence of the devolution to Manchester and it is behind the STPs that we have been talking about.

In response to the question, “Does the 2012 Act hinder or facilitate this process?”, I have to say that I do not think we would have had the five-year forward view without the Act. If that forward view had not been an NHS forward view—if it had involved Tony Blair and Alan Milburn or Jeremy Hunt and David Cameron—it would not have happened. The devolution of a great deal of operational power—away from politicians and away from the Department of Health and Richmond House to the NHS—at least gives us a chance of integrating care in the way that we all know it should happen. Whether we are going to be able to do it, I do not know. We have heard a lot of pessimism today about the STP process. However, I am much more optimistic. I shall not stand here and say that I think we are going to have 44 STPs and that they are absolutely marvellous, but most of these plans are genuinely local. They are being drawn up by local people—by hospital trusts, but also by CCGs and local authorities—many of them are led by local authorities.

I think the jury is out. These plans will come out at the end of October; we will have a chance then to see them. They will not all be good, but if a number of them are good and we can get behind them, it will make a difference. In Simon Stevens’s document, there are a number of care models, which are nearly all based on reducing demand on acute hospitals. It may be that finally we have won the argument. I hope that this will not embarrass the noble Baroness, Lady Armstrong, but three or four months ago Paul Corrigan wrote a very good blog—he is always incisive, and it was a very incisive blog—in which he said that the pressures on acute hospitals are great, and that if we carry on putting resources into acute hospitals, they will not change; there will be no need to change.

For the first time, there is a real possibility that we will get this change, although I do not for one minute underestimate the practical difficulties of doing so. I think it was Mao Tse-Tung who said, when asked about the impact of the French Revolution, that it was too early to say. It probably is too early to give a final verdict on the impact of the Act brought in by my noble friend Lord Lansley. However, like all reorganisations, it will be smaller than originally anticipated. If it enables the fulfilment and the implementation of the five-year forward view, I think it will be judged a resounding success.

Junior Doctors: Industrial Action

Lord Prior of Brampton Excerpts

Monday 5th September 2016 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 will now repeat a Statement made in the other place by my right honourable friend the Secretary of State for Health on the junior doctors’ industrial action:

“Mr Speaker, I regret to inform the House that last week the British Medical Association announced it was initiating further rounds of industrial action over the junior doctors’ contract. It involves a series of week-long all-out strikes between now and Christmas which was scheduled to start next Monday, although this afternoon the BMA delayed the first strike until 5 October. This afternoon’s news delaying the first strike is of course welcome, but we must not let it obscure the fact that the remaining planned industrial action is unprecedented in length and severity, and it will be damaging for patients, some of whom will already have had operations cancelled.

Many NHS organisations, including NHS England, NHS Providers, the NHS Confederation and NHS Improvement, have expressed concern about the potential impact on patient safety. Indeed, this morning the General Medical Council published its advice to doctors on the strike action. While recognising a doctor’s legal right to take industrial action, it urges all doctors in training to pause and consider the implications for patients, saying that,

‘given the scale and repeated nature of what is proposed, we believe that, despite everyone’s best efforts, patients will suffer’.

Many others have also questioned whether escalating strikes is a proportionate or reasonable response to a contract that the BMA junior doctors’ leader, Dr Ellen McCourt, personally negotiated and supported in May. She said then the new contract was:

‘Safer for our patients, safer for our junior doctors … and also fair’.

She also said that with respect to junior doctors the new contract,

‘really values their time, values them as part of the workforce, will really reduce the problem of recruitment and retention, emphasises that all doctors are equal, and has put together a really good package of things for equalities’.

We recognise that since those comments the new contract was rejected in a ballot by BMA members, but it is deeply perplexing for patients, NHS leaders and indeed the Government that the reaction of the BMA leadership, who previously supported the contract, is now to initiate the most extreme strike action in NHS history, inflicting unprecedented misery on millions of patients up and down the country.

We currently anticipate around up to 100,000 elective operations will be cancelled and up to 1 million hospital appointments will be postponed, inevitably impacting upon our ability to hit the vital 18-week performance standard. Today I want to reassure the House that the Government and NHS are working around the clock to make preparations for the strikes. All hospitals will be reviewing their rotas to ensure critical services such as A&E, critical care, neonatal services and maternity services are maintained. The priority of all NHS organisations is to ensure patients have access to the healthcare they need and the risks to patients are minimised, but the impact of such long strikes will severely test this.

As with previous strikes, we cannot give an absolute guarantee that patients will be safe, but hospitals up and down the country will bust a gut to look after their patients in this unprecedented situation and communicate with people whose care is likely to be affected as soon as possible.

Turning to the long-term causes of the dispute, it is clear that for the BMA negotiators it has been about pay, but I recognise that for the majority of junior doctors there is a much broader range of concerns, including the way their training is structured, the ability to sustain family life during training periods, the gender pay gap and rota gaps. After the May agreement we set up a structured process to look at these concerns outside the contract and I intend this work to continue.

Health Education England has been undertaking a range of work to allow couples to apply to train in the same area, to offer training placements for those with caring responsibilities close to home, to introduce a new catch-up programme for doctors who take maternity leave or time off for other caring responsibilities and to look at the particular concerns of doctors in their first year of foundation training. Today HEE has set out further information for junior doctors about addressing these non-contractual concerns and we are proceeding with the gender pay review that I mentioned in my last Statement to the House on this issue.

We have also responded to specific concerns raised by Dr McCourt. First, the BMA, NHS Employers and Health Education England have agreed changes to strengthen whistleblowing protections for junior doctors beyond the scope of existing legislation so that junior doctors can take legal action against HEE, in relation to whistleblowing, as if HEE was their employer.

Secondly, in direct response to the concerns raised by Dr McCourt over the role of the independent guardian of safe working hours, NHS Employers has written to all NHS chief executives to set out in considerable detail the expectations for the new guardian role. As of 2 September, 186 out of 217 guardians had been appointed with the involvement of BMA representatives, with a further 15 interim arrangements in place, and it is expected that all will be appointed by early September.

Many junior doctors have expressed concern about rota gaps and the new contract acknowledges and tackles this concern. The guardians of safe working hours will report to trust and foundation trust boards on the issue of rota gaps within junior doctor rotas. This will shine a light on this issue and it will be escalated, potentially to the CQC and the GMC, where serious issues are not addressed. I would strongly urge all those contemplating taking industrial action to consider the progress that is being made in all these areas before making their final decision.

With respect to the broader debate about seven-day care, we recognise that many doctors have concerns about precisely what the Government mean by a seven-day NHS. As Sir David Dalton publicly stated last week, we offered to insert details of our seven- day plans into the May agreement, in particular to reassure doctors that we do not intend simply to stretch services currently delivered over five days over seven days. However the BMA asked us to remove that reassurance from the May agreement, so it is extremely disappointing that it now says the need for more clarity over seven-day services is one of the reasons for the strike.

Let me therefore repeat further reassurances on that front today. First, while the changes to the junior doctors contract are cost neutral—that is, the overall pay bill for the current cohort of junior doctors will not go up or down—our seven-day service policy is not cost neutral and will be funded out of the additional £10 billion provided to the NHS over this Parliament.

Secondly, while the pay bill for the current number of junior doctors will not increase, we do expect the overall pay bill to go up as we have committed to employ many more doctors to help meet our commitment on seven-day services. That means our plans are not predicated on simply stretching the existing workforce more thinly or diluting weekday cover.

Thirdly, we recognise that junior doctors already work very hard, including evenings and weekends, and while we do need to reduce weekend premium rates that make it difficult to deploy the correct levels of medical cover, we expect this policy to have greater implications for the working patterns of other workforce groups, including consultants and diagnostic staff.

Finally we have no policy to require all trusts to increase elective care at weekends. Our seven-day services policy is focused on meeting four clinical standards relating to urgent and emergency care, meaning vulnerable patients on hospital wards at weekends will get checked more regularly in ward rounds by clinicians, and clinicians will be able to order important test results for their patients at weekends.

Even despite these reassurances there may remain honest differences of opinion on seven-day care, but the way to resolve them is through co-operation and dialogue, not confrontation and strikes which harm patients. To those who say these changes are demoralising the NHS workforce, I say that nothing is more demoralising or more polarising than a damaging strike. It is not too late to turn decisively away from the path of confrontation and put patients first, and I urge everyone to consider how their own individual actions in the coming weeks will impact on people who desperately need the services our NHS offers.

This Government will not waver in their commitment to make the NHS the safest, highest-quality healthcare system in the world, and I commend this Statement to the House”.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Lord for making the Statement.

Clearly the prospect of a series of five-day strikes is very worrying, coming after the protracted negotiations, agreement between the negotiators and then the subsequent ballot rejection. The promised action, though now delayed, would have a damaging impact on patients, the NHS and the junior doctors themselves. However, the Secretary of State and the Government cannot escape their own responsibility for the threatening catastrophe.

At the heart of this dispute is a complete absence of trust by the junior doctors in the Government and, specifically, the Secretary of State. It is not hard to see why. Towards the end of the Statement the noble Lord mentioned a seven-day service. It is the conflation of the seven-day service issue with the junior doctors’ contract which has exacerbated an already difficult situation, particularly as it is the junior doctors on whom the service is so dependent for out-of-hours working.

The Minister did not mention the advice received from officials but he knows that the documents obtained by the media outlining the risks detailed by officials on the seven-day NHS were clear in their assessment that the NHS was likely to have too few staff and too little money to deliver a truly seven-day NHS. Moreover, it gives the lie to the last sentence of the Statement where the Secretary of State comes out with all that blah about making the NHS the safest, highest-quality service in the world when everyone knows that it is crumbling through a lack of resources, a lack of staff and a lack of leadership. We have a Secretary of State who is in his own world, one that is occupied by no one else. He is charging ahead with implementing the seven-day working week without the resources, staff and support needed to do it.

Let me be clear: no one more than I would like to see a truly seven-day working NHS, but that is dependent on the resources being available to ensure its proper implementation. What I deplore—and this is a core reason for the disenchantment among junior doctors—is the Secretary of State’s distortion of the statistics in relation to weekend mortality figures to justify the imposition of the contract.

I would like to ask the Minister a number of questions. First, he referred to the contingency plans being put in place by the NHS, but clearly with the postponement or cancellation of the first proposed action there is now time for the NHS to give more consideration to those contingency plans. I wonder if he can tell the House a little more about them. Secondly, the chief executive of NHS Providers has warned that with little notice the unprecedented action,

“will cause major disruption and risk patient safety”.

What discussions have taken place between Mr Hopson and Ministers to discuss his concerns? Thirdly, where elective operations and clinics may be cancelled as a result of the promised late action, what assurances can the public be given that new dates will be scheduled as quickly as possible?

Can the noble Lord say what discussions have taken place between the Department of Health and junior doctors? In its statement today announcing the postponement of the action, the BMA has said that it will call off further action if the Secretary of State stops his imposition of the contract, listens to the concerns of junior doctors and works with the BMA to negotiate a contract based on fresh agreed principles that have the confidence of junior doctors. What is the Minister’s response to that statement by the BMA? It has been reported in the media that the Secretary of State has refused to engage with the junior doctors. Can he confirm whether that is the case, and if so, why is that the position?

Finally, what are the Government’s plans to restore junior doctors’ trust in the National Health Service? There is a clear risk that the morale of a whole generation of doctors is being destroyed as we speak. When that is put alongside the implications of Brexit and the potential loss of experienced staff through the decision by many junior doctors to leave the profession or to go abroad, this is a worrying position. I have met a number of junior doctors over the past few months. They are clever, articulate and passionate about the NHS, but they have told me about the pressures that they are under, of the risky gaps that we now have in rotas which have developed over the past few years, of locums not always being available, of existing staff having to cover gaps at short notice, and of being hugely dependent on the good will of many staff, including junior doctors. The Statement of the Secretary of State is full of warm words about junior doctors’ working conditions, but as the Minister knows, the fact is that they do not have confidence in them. Frankly, I also do not think they have confidence in local management to implement the proposed contract in a way that is sensitive to their working conditions.

At the annual meeting of the Royal College of Physicians, its chairman pointed to the need for junior doctors to be valued, supported and motivated. Some months ago the RCP wrote to the Secretary of State outlining recommendations for improving conditions in training, including protected time for training and the promotion and support of flexible working, publishing rotas earlier and prioritising handover sessions. What progress has been made in responding to the sensible suggestions made by the Royal College of Physicians, and above all what are the Government going to do to endeavour to get back the confidence of junior doctors in the NHS and thus seek an end to this action?

[Lord Prior of Brampton]

My Lords, the noble Lord has raised many questions in his response to our Statement. He may well have read the article published earlier this week in the Times by Sir Simon Wessely, the president of the Royal College of Psychiatrists, which goes to the heart of what I would call the non-contractual issues that have bedevilled, coloured and provided the context for this dispute:

“Changes to the way that doctors are trained means that juniors face switching not just jobs but addresses every few months without much say about where they end up and when. Many seem condemned to spending years rootlessly shuffling from one place to another like lost luggage. Without any familiar faces, long hours are endured in relative isolation and managers who change all the time provide little or no recognition, let alone reward”.

This in a sense is what lies behind much of the dispute. The fact is that we had a contract that was wholeheartedly welcomed by Dr Ellen McCourt, now the president of the BMA, and by the association itself. The issues of difference in the contract were pretty small.

We have been discussing this contract for three years now and the Government have made 103 concessions. The Secretary of State’s door has been open throughout that time. The new contract is due to be introduced in October and at some point we really have to get on and introduce it. There is provision within it to review aspects as it goes forward. We have committed to looking at the gender pay issues that have been raised by the BMA and today HEE has published the work that it is doing on non-contractual issues with the BMA when the association is prepared to talk to it. The Government are bending over backwards to meet the BMA, but there comes a point where we just have to bite the bullet and go ahead with the contract that has been agreed, and that is the place we are in now.

The noble Lord referred to a lack of trust in local management and in the Secretary of State, but we now have the guardians of safe working hours built into the contract. They have a contractual commitment to report every quarter to the boards of trusts and to the GMC and the CQC every year. Plenty of independent safeguards have been built into the new contract. So while of course I understand many of the issues raised by the noble Lord, the Government have gone the extra yard every time they have been asked to do so and now we must get on and introduce this contract.

[Baroness Walmsley (LD)]

My Lords, I apologise to the Minister for not getting up quickly enough to add my questions from the opposition side before he gave his last response. We on these Benches welcome the fact that the strike planned for next week has been postponed. I think we have all taken very much to heart what was said by the GMC this morning. I hope the Minister can give an assurance that the Secretary of State will take this breathing space as an opportunity to get back around the table with the junior doctors not only to explore the details of the contract, which may not yet have been hammered out to everyone’s satisfaction, but to get to the core of the reasons why they are so up in arms.

I am very impressed by the fact that when junior doctors are marching along the street, they are not shouting, “Save our weekend pay” or “Save our training structure”, they shout, “Save our NHS”. That is what every single doctor in this country is committed to. The reason why doctors are so concerned is not the Government’s intention to make tests or more frequent investigations available on Saturdays and Sundays for patients in hospital, it is the fact that there are gaps in the weekday rotas now. The Minister is saying that there will be extra money and extra doctors. Where are they going to come from? Does he know how many doctors have investigated the possibility of emigrating or have even actually emigrated since the beginning of this dispute? I ask this because I am hearing about it all the time. I wonder where the new doctors will come from in order first to fill the gaps in the weekday rotas and then to provide extra services at the weekend. The £10 billion mentioned in the Statement is clearly not enough when we already have a £22 billion black hole in the NHS.

Over the Summer Recess we had so many news stories about units being closed, not just to reconfigure the services and provide better service for patients, but to save money, because the system is desperate to do that in the short term. The sustainability and transformation plans clearly do not have the confidence of the doctors, partly because they are very opaque and partly because they are very short term. They are picking up on any short-term economies they can make, rather than looking at the very long-term savings that might be made and bring better provision for patients. Will the noble Lord say where the extra doctors are coming from and how the Government plan to convince existing doctors in this country that they will be fully supported if they are to implement the Government’s policy?

[Lord Prior of Brampton]

My Lords, the noble Baroness made a valid point when she said that when she meets junior doctors on their demonstrations or marches, they are concerned about the NHS—rightly so; it will be a sad day when doctors are not concerned about the future of the NHS—but that is no reason for going on strike over this contract. We are perfectly happy to have a debate with them. We will disagree and agree on some things, but to launch a wave of strikes over this cannot be right. As the noble Baroness indicated, it is not the contract that they are worried about at all; they are worried about much more general things than the state of the contract.

Staffing is a big issue. There is no question but that after the Mid Staffordshire tragedy, we saw a huge increase in agency staffing. We saw that increase because we did not train enough of our own doctors and nurses. That is a long-term issue about increasing training numbers, but, in the meantime, part of the £10 billion of extra money we agreed to put into the NHS, which the noble Baroness’s party agreed to do at the last general election, has to go towards increasing staffing in our hospitals.

[Viscount Hailsham (Con)]

My Lords, my noble friend should take every opportunity to remind the electorate and the public who will be affected by these strikes that junior doctors are now refusing to accept and proposing to strike against an agreement that many of their leadership, including those now defending the strike, characterised as safe and fair. That is an absurd proposition.

[Lord Prior of Brampton]

My Lords, it is important that we distinguish between junior doctors, who are working incredibly hard in the NHS, and the BMA leadership in this case. I think the vast majority of junior doctors bitterly regret having to go on strike and will be extremely concerned about the huge damage it will do to patients’ interests. We are perfectly entitled to remind everybody that it was the leadership of the BMA who characterised this contract as being safe for patients and good for doctors.

[Lord Warner (Non-Afl)]

My Lords, I ask the Minister to go back to the non-contractual issues. As Sir Simon Wessely explained very well, they are the nub of this. The Secretary of State now has a major trust problem because these negotiations have gone on for so long. It has become very personal. If he wishes to convince the medical profession, in particular those thinking of coming into the medical profession, that he is serious about putting the medical workforce’s house in order, he has to do something—possibly step aside—to develop these ideas with the profession.

Can the Minister confirm that the number of people applying to medical school has dropped by nearly 14% over the last two years? There are so many vacancies now in medical schools that they have to recruit people to fill those slots through UCAS clearing. One-fifth of middle grades in the junior grades are vacant. In this situation—with people emigrating and with Brexit—we cannot expect young people to join this profession. The Secretary of State has to take some responsibility for changing that culture, bringing in some people to help change it and convincing the profession that it has a future.

[Lord Prior of Brampton]

My Lords, the noble Lord makes a number of extremely good points. I am not aware of that 14% decline in applications to medical school. If that is true, it is clearly very serious. I did hear a rumour that one medical school had to use clearing to fill the number of students coming in, but overall there is still a huge demand for people who want to go to medical school and they are still recruiting people with the best academic and other qualifications. On the noble Lord’s fundamental point, we have to rebuild trust in the medical profession. It was for that reason, in the main, that the Secretary of State asked Health Education England to lead the discussions on non-contractual issues, rather than being involved with it directly himself. I am sure that is the right way to approach this issue.

[Lord Davies of Stamford (Lab)]

My Lords, during the previous Statement the Government were at great pains to emphasise that they are totally committed to implementing all the promises made by the Brexit campaign to the British people during the referendum. We now hear reports that the very prominent promise made to the British people during that campaign to give the NHS another £350 million a week will not be fulfilled. Why have the Government decided to renege on that particular promise?

[Lord Prior of Brampton]

I am not sure the Government ever made that promise. That was a promise made by the Brexit campaign. The Government have committed to putting an extra £10 billion into the NHS over the course of the Parliament, but they are certainly not in any way committed to fulfilling promises or pledges made by the Brexit campaign.

[Lord Ribeiro (Con)]

My Lords, we can all be gratified that the junior doctors have decided to postpone their strike. I am sure that this is partly as a result of the pressure being put on them by senior doctors. They are the ones who know the consequences for patient safety because they are ultimately responsible when things go wrong. David Watkin, a past president of the Association of Surgeons, has written a letter to the Times today in response to Simon Wessely’s letter. He makes the interesting point that there is a real issue about the way our junior doctors feel supported—or should I say unsupported. There has been the loss of the firm structure whereby junior doctors worked part and parcel in a team, and they and a consultant knew each other, trusted each other and could rely on each other. As mentioned by the noble Lord, Lord Hunt, that has gone partly because of shift working, rota gaps and the need to fill those gaps.

Brexit provides an opportunity, whether we like it or not, to take time and look again at two regulations: the European working time directive, and the new deal. The main thing about the European working time directive is that some junior trainees—particularly in my specialty, surgery—wanted to work longer than 48 hours a week. For all other specialties you have to acquire knowledge, but for surgery, cardiology, nephrology and some other specialist areas, you have to learn the skills. Learning and acquiring skills takes time. Can we look at Brexit as an opportunity to assure some of our junior doctors, who feel unloved and unsupported, that there may well be a way to look at and improve their working practices?

[Lord Prior of Brampton]

My Lords, the origins of this dispute and lack of trust go back many years, to the end of the old firm structure. Many junior doctors feel a lack of support. It is easy to lob bricks at the Government, but the senior doctors and the royal colleges need to look at themselves pretty carefully and pretty hard in the mirror because they have some responsibility for this as well. I hope they will be very much part of working through some of these non-contractual issues, along the lines my noble friend suggested.

[Lord Willis of Knaresborough (LD)]

My Lords, does the Minister accept that this does not impact simply on junior doctors but that these strikes and the current chaos affect all the manpower within the NHS, particularly the registered nurses, who have to pick up a great deal of the slack in the absence of junior doctors, particularly when they are on strike? Rather than look at these issues at silos, I implore the Minister to look at the whole workforce and try to ensure that the modern workforce serving a modern NHS is one where integrated services mean integration of staff as well.

[Lord Prior of Brampton]

My Lords, the noble Lord makes a very good point. The changes that are coming upon the NHS, whether from technology or forced upon us, in a sense, by demographic change in the UK— meaning that much care that has traditionally been delivered in hospitals will need to be delivered outside hospitals in people’s homes and much care will be delivered by technology rather than directly by people—are all going to have a huge impact on a whole range of different staff levels, not just junior doctors.

[Lord Naseby (Con)]

Is my noble friend aware that I am in a doctors’ family? My wife worked full-time in a big practice. She worked every weekend and did her share of out-of-hours work. My son is a doctor. I hope some of the grandchildren will be. These young men and women volunteer to enter this profession, do they not? They take an oath, do they not? What the public find incomprehensible is that after several years of negotiation, they understood there to be an agreement and a recommendation from the then leadership of the junior doctors—agreed to by even the present leadership of the junior doctors—but once again the public are back on the rack. Is that not totally unacceptable?

I am afraid that I draw an analogy with the three-day week. I was the director of an advertising agency, responsible for the standby advertising. The miners’ strike required the Government of the day to publish the terms that they were offering to the miners on that occasion. I urge my noble friend to consider whether the time has not come for the public—the people, the patients—to be told exactly what was agreed in the summer and what additional benefits will be put forward to the junior doctors; I understand there are some. The public are the ones who will suffer. I do not want—as I am sure the rest of the House does not—to see patients suffer.

[Lord Prior of Brampton]

My Lords, the contract that has been offered to the junior doctors is not confidential. It can be made available to the public. Indeed, I think the main terms of that contract have been made available to the public. My noble friend is absolutely right that members of his family—and, indeed, my family and others we know—enter the medical profession as a vocation or a calling. It is an awful shame that that seems to have been lost in the dispute that has been happening over the past few months.

[Lord Cormack (Con)]

My Lords, following on from that point, is there not a case for the presidents of the royal colleges to have a greater leadership role? Is there not a case for the Secretary of State and my noble friend, in whose negotiating skills I have very great confidence, calling in the presidents to discuss this and see whether there is not some opportunity of rebuilding trust between individuals at the head of the profession and those junior doctors who are clearly disenchanted, disaffected and, frankly, behaving in a way that is not compatible with a true vocation?

[Lord Prior of Brampton]

My Lords, I agree with my noble friend. I think there is a huge opportunity here—actually, a necessity—for senior leaders in the profession, in the royal colleges, to play a really serious leadership role. Rather than standing on the touchline, if you like, they need to get on the pitch. There is a role for them. To some extent, they were instrumental in getting the two sides back to work again back in May. They were successful in doing that. Certainly, I know the Secretary of State would be very happy to listen to any thoughts that they have.

Health: HIV

Lord Prior of Brampton Excerpts

Monday 5th September 2016 Lords Chamber

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

My Lords, this has been a very good debate and everyone who contributed to it has had something of interest to say. For me it has been a wake-up call. As has been reflected in a number of speeches, I thought this problem had somehow been sorted out, but clearly it has not been. My noble friend Lord Maude talked about the tragedy of his own brother, and of course for him it was not sorted out. I had thought that since then we had made huge progress, and of course we have done so. I would like also to echo the comments of my noble friend Lady Bottomley about our new Lord Speaker because I can feel his presence glowering down at me on this issue. He said to me not all that long ago that when he took up his new role he would not be able to pester me about the long-term sustainability of the NHS. But I can feel his presence this evening.

My noble friend Lord Black made an outstanding speech, which brought all the threads of the arguments together. Perhaps I may pick out a few of the individual points that have been raised. I know Jonathan Fielden, the deputy medical director at NHS England. He is a very humane, decent and experienced doctor and I think he would be horrified to feel that what he said or how he said it—I have not seen his exact words—would be interpreted in the way it has been. I will write to him with a transcript of this debate and I will leave how he would like to respond to it up to him. I am sure that the last thing he would want to do is leave the impression that he clearly has with the noble Lord, Lord Scriven, and indeed with the noble Lord, Lord Hunt.

My noble friend Lord Maude talked about the cross-government and cross-ministerial issues and how difficult it can be for one department to bear the cost when the benefit is being received by another. It is worth saying that in this case the cost of treatment lies with NHS England, so it seems entirely reasonable that the cost of prevention should also lie with NHS England and that they are kept within the same budget. The noble Lord, Lord Patel, suggested having a cross-government Minister. All my experience of cross-government Ministers has been that they are not all that effective because the silos that we have created in British Government are very strong. The noble Lord also drew a comparison with the strategy for hepatitis C. In a sense we face the same problems dealing with hepatitis C as we do with PrEP and countless other drugs: there is a limit to the money we have available. There is a cost. The noble Lord says that it will all end up with the taxpayer, but the fact is that the taxpayer has given us a certain amount of money for the NHS. We would like to spend a lot of it on treating hepatitis C, on PrEP and on other drugs, but we simply do not always have the money to spend as we would like.

Perhaps I may turn to the speech that I had prepared beforehand. It falls short in some respects of what I have been asked to do this evening. I was struck by that when listening to the quality of the debate, but noble Lords will have to be the judge of my speech more than I can be myself. I am hugely impressed by what has been said this evening and I am sure it will have a big impact outside the Chamber as well as within it.

It is worth restating that the NHS provides excellent treatment and care for people living with HIV. The success of our treatment services means that the UK is already ahead in meeting two of the three ambitions set out in the UNAIDS 90-90-90 target: 90% of people with HIV being diagnosed; 90% on ARV treatment; and 90% viral suppression for those on ARV treatment by 2020. In 2014, of all those attending for care, 91% were on treatment, of whom 95% were virally suppressed and very unlikely to be infectious to others. So we have achieved more than 90% on two of those UN goals.

There are other positive indicators of success. Late diagnosis of HIV, defined as a diagnosis made after the point at which treatment is recommended, has declined from 50% of diagnoses in 2010 to 40% in 2013, but that is still too high. Reducing late diagnoses remains important since people who are diagnosed late have a tenfold increase in the likelihood of death in the first year of diagnosis compared with those diagnosed more promptly. Reducing late diagnosis is included as an indicator in the public health outcomes framework. We are also reducing the proportion of people with undiagnosed HIV, which was down to about 17% in 2014 from an estimated 25% in 2010. More progress is needed to reach the global goal, but things are improving in the right direction.

I had been doing a bit of work with a colleague of the medical director of NHS England, Bruce Keogh. She is a specialist in HIV. She sent me a note. I should say that she is very supportive of PrEP. I would not want to mischaracterise her view. She said that around 80% of HIV infections in men who have sex with men are transmitted by the 20% of individuals who are unaware that they are HIV positive. She tells me that people who are not aware of their diagnosis do not make the same effort to modify their behaviour—for example, the consistent use of condoms—to reduce transmission. Undiagnosed individuals are not on treatment, so have high levels of HIV in their blood, which makes them more likely to pass on the infection to others. There is no dispute between us on the importance of early diagnosis.

Overall, new diagnoses of HIV remain stable, with an estimated 6,151 new diagnoses in 2014, up very slightly from 6,000 in 2013. Of course, we must not be complacent. We know that much more needs to be done to reduce the new number of HIV infections, especially in men who have sex with men, where we continue to see increases in new infections. We also know that transmission is continuing among black African men and women who are acquiring their infection within the UK.

So what are we doing? To really tackle rates of HIV infection we must increase regular HIV testing and promote safer sexual behaviour, particularly condom use. In England, the Government continue to invest £2.4 million each year in national HIV prevention. This funding is allocated across three main areas. First, funding has been allocated to seven new innovative local HIV prevention projects. Activities being undertaken include providing full sexual health screening in saunas and other similar premises, to working with faith leaders to promote HIV prevention and testing among black and minority ethnic communities. A further round of funding for 2016 and 2017 was announced in June this year. The successful projects will be announced in September. We will be building on learning from the year one projects.

Secondly, we know that early testing and diagnosis reduce the risk of onward transmission of HIV. This is the basis of the new HIV home sampling service, which my noble friend Lord Black referred to. It is one of the first of its kind. Some 27,173 HIV self-sampling kits were ordered between November 2015 and May 2016; 13,992 kits were returned, of which 197—1.4%—were reactive. This is encouraging, given the challenge of identifying those living with undiagnosed HIV. Central funding was provided through PHE until January 2016, when the service transitioned to local authorities. Eighty are now signed up to funding the service. PHE will look to build on these numbers.

The third and final strand of funding is from the Terrence Higgins Trust, which has been awarded a new contract to lead and manage a national partnership to deliver information and resources to improve the proportion of individuals in highest-risk populations able to make safe and sustainable sexual health choices and reduce HIV incidence. The programme will focus on social marketing and local HIV prevention activity, as well as monitoring and evaluation activities.

I turn to PrEP, which, as most noble Lords will know, is a new use of HIV drugs that has shown clinical effectiveness in research trials at preventing HIV in people at higher risk of getting HIV. The trials recruited men who have sex with men engaged in high-risk behaviours and people with HIV positive partners—this is the PROUD clinical trial. As noble Lords mentioned, it has been extremely successful. It is important to note that the drug used for PrEP, Truvada, is not yet licensed for this use in the UK. It is licensed only for treatment, not for prevention. However, progress is being made with an application to the EMA and a licence is expected to be granted very shortly.

PrEP should not be seen as a silver bullet. It is only one of a range of activities to tackle HIV. As with any new intervention, PrEP will need to be properly assessed in relation to clinical and cost effectiveness, including how it compares with existing cost-effective approaches, to see how it could be commissioned in the most sustainable and integrated way. The NICE evidence review is considering the published evidence on PrEP and will be published shortly. We know, however, that cost-effectiveness is very sensitive to HIV incidence in the target population and effective targeting; the adherence to taking the medication, which affects clinical effectiveness—although I was interested in the comments of the noble Lord, Lord Patel, about intermittently taking the drug—and the cost of PrEP drugs.

Time is running out. There has been criticism about the handling of this by NHS England. NHS England has provided an assurance that all the proposals considered as part of its prioritisation process will be subject to the same robust assessment of clinical and cost effectiveness and relative prioritisation within the resources available, as well as the impact on people from vulnerable and protected groups.

I felt that the leader in the Times got the balance about right when it said:

“There are reasons, however, to resist the conclusion that HIV prevention should be left to the HIV-positive. Few would be comfortable if the state stepped back from HIV treatment altogether, just as it would be thought indecent of a society to let smokers die of lung cancer or allow the obese to succumb to heart disease on the basis that such illnesses are behaviourally induced”.

There is no intention at all on the part of NHS England or the Government to discriminate in any way against the use of PrEP because of people’s lifestyle choices. I can give that absolute assurance to noble Lords. The appeal is taking place on 15 September and I cannot comment further on the court case, but I can assure noble Lords that the decision on whether or not to use PrEP will be assessed in an absolutely normal way.

I will make just one last comment, which I do not expect some Members of this House to agree with. The decisions about which drugs to prioritise and how to prioritise drugs should surely be made by clinicians and NHS England, not politicians. The noble Lord is shaking his head but that is the whole thrust of the way that the NHS has been set up, and the involvement of politicians in picking one drug against another is surely not the right way forward. I have to leave it as it stands.

House adjourned at 8.43 pm.

NHS and Social Care: Impact of Brexit

Lord Prior of Brampton Excerpts

Thursday 21st July 2016 Lords Chamber

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

My Lords, this has been a very helpful debate for me. It has been interesting and insightful, and provocative at times, and has also brought to my attention issues that I had not taken on board before.

I thank the noble Baroness, Lady Watkins, for tabling this debate. It has come earlier than I might have liked, because I have not had a chance to think about all the issues raised, but that is no bad thing. Maybe we should have a similar debate in three or four months’ time, once the Government have had more of a chance to react to the Brexit decision. I also thank the noble Baronesses, Lady Watkins and Lady Emerton, for all the work that they do to promote the great cause of British nursing. It is a very important issue and I think that the work they do is appreciated by everyone in the House.

I will make a couple of introductory comments. First, I will just put something on record, which I think everyone in the House will agree with, to recognise the fantastic job that is done by EU nationals and nationals from around the world. The NHS could not survive in its current form without the extraordinary contributions that they make. The second thing is to agree with the words of the noble Lord, Lord Hunt, and other noble Lords in condemning any racist or hate behaviour. It is totally unacceptable, and people who do it should be exposed to the full force of the law. I also say to my noble friend Lord Shinkwin how moved I was by his personal story, which brings home to everyone that nursing and medicine is a noble profession.

There has been a lot of doom and gloom—there have been points in this debate when I felt like slitting my wrists, to be honest with your Lordships. There is of course a lot of uncertainty at the moment, which is a worry to many people, but we should just remind ourselves, as the noble Lord, Lord Crisp, mentioned, that we have some of the finest medical research and life sciences research in the world and punch well above our weight. Just in London, we have UCL, Imperial and King’s. We have Oxford, Cambridge and Manchester—we have some extraordinary research going on. We have some of the finest medical education, and some of the oldest and best medical schools in the world in England, Scotland and Northern Ireland. Many people still regard the NHS as having some of the best standards in the world. The comprehensive nature of our offering to people is still hugely admired around the world. We have some of the most efficient hospitals and the best primary care in the world. Of course there are some serious risks and issues, but let us not forget the extraordinary institution that the NHS is.

I turn to the Motion before us. Healthcare employment is a hugely dynamic area. We are focused today on the implications of Brexit, but the pressures and dynamics that come into play with our healthcare workforce are huge. For example, there is the changing role of technology and the growth of self-care enabled by telemedicine and other apps that we now have. There are demographic changes and the new models of care that are being developed. There is the impact of pay policy, for example the cap on the public sector. There is the huge underlying impact of our economy. There is the need to move more care out of acute or hospital settings. These are all having a big impact on workforce planning.

Brexit is one factor—it is an important factor but by no means the only one. It has a huge impact in two respects. First, in that it has an impact on our economy, it will have a huge impact on how we provide healthcare in this country. Any tax-funded system such as the NHS is going to be hugely impacted by the size of our overall economy, but there is not much point in debating that today—you can argue whether there will be a short-term or long-term impact from Brexit, or whether it is going to be positive in the long run, but these are all issues that will have to be decided in the future. The big impact will be on workforce mobility. For all kinds of historical and current reasons, we have a very high number of people from other countries working in our system, which I will turn to later.

I will start with safe staffing, which was referred to by a number of noble Lords and is a key part of the Motion before us. Responsibility for safe staffing rests with hospital boards: there should not be any one-size-fits-all staffing level. Trusts should have arrangements in place to ensure they have the right numbers and skill mix of staff needed to deliver quality care, patient safety and efficiency, taking into account factors such as acuity and case mix, ward layout and the like.

On 6 July, the National Quality Board published refreshed guidance on safe staffing. It has been drafted with members of the board, which includes NICE and the CQC, and has been independently reviewed and approved by Sir Robert Francis. It is worth noting that when Robert Francis wrote his report on Mid Staffs—I am probably one of the few Members here who have read the entirety of that report—he specifically did not recommend fixed staffing levels. He was very clear about that.

The guidance reminds the NHS that in making decisions about safe staffing, trusts should focus on outcomes rather than inputs and make use of a range of resources and metrics, including the care hours per patient day metric, to measure and deploy staffing resources most effectively. I will quote just a short part of the report because it is important, and because it stresses professional judgment. It states:

“Professional judgement and knowledge are used to inform the skill mix of staff. They are also used at all levels to inform real-time decisions about staffing taken to reflect changes in case mix, acuity/dependency and activity”.

That is important. You cannot rely on just formulae and algorithms—this is true throughout medical care—you have also to rely on professional judgment. When a new patient comes into a ward who may be likely to fall or who suffers from psychosis of one kind or another, you will have to change your staffing mix. There is a danger in laying down staffing ratios: everyone then works to the minimum, gaming starts and you start counting certain people in the mix but not others. The importance of the new advice is that we must rely on the professional judgment of ward sisters and the like.

I turn to the impact of Brexit. Until exit negotiations are concluded, the UK remains a full member of the European Union and all the rights and obligations of EU membership continue to apply. The working time directive and directives on speaking English, to which the noble Viscount, Lord Bridgeman, and others referred, still apply. But when we leave the European Union, depending on the outcome of the negotiations, it will be for us to decide whether we want to keep the working time directive, for example, and whether or not we want to change it to make it more in line with the recommendations of the Royal College of Surgeons. That decision will be ours to take at the time.

The Government’s position is clear. We agree with Simon Stevens that it should not be controversial to provide early reassurance to NHS employees from the EU that they continue to be welcome in this country. This is something we have done already. The Prime Minister has been clear that she wants to secure the status of UK nationals abroad as well as EU nationals already living here. Indeed, in his final PMQs, the previous Prime Minister also made that absolutely clear.

We are about to begin these negotiations and it would be wrong to set out unilateral positions in advance, but be in no doubt: we recognise that all NHS staff from overseas make a huge contribution to our country. We have had lots of figures today and I think you are all sick of them, but currently, there are estimated to be 53,000 workers from EU member states in the NHS and 80,000 in the social care system. The proportion of overseas and EU staff is much higher in some parts of the country, especially London. Great Ormond Street was mentioned as an example. There are some London hospitals, in particular, where there is a very high proportion of EU staff.

It is very important that the staff are not unnecessarily concerned about their future. A message of reassurance to all NHS staff has already been sent by Bruce Keogh and Jeremy Hunt emphasising the vital role played by EU nationals working in our health and social care system. This is as true for non-clinical staff and those working in social care as it is for the 10% of NHS doctors and 4% of nurses who are from the EU. It will be a key priority in our negotiations to seek to ensure that those dedicated staff are able to continue making their outstanding contribution.

We are top of the OECD table in the number of people working in our health and social care system who come from overseas. In part, this is a legacy of empire and the English language and, now, because of our membership of the EU. One in three doctors and one in eight nurses were trained overseas. In a sense, for an employer it is a quick fix to employ a lot of people from overseas; it saves us the cost of training and you can get them straightaway. But I just do not think that it can be desirable that we should depend to that extent on people trained overseas. It did not just apply to those from low-income countries. The noble Lord, Lord Crisp, talked about the WHO commitment that we made to reduce our dependence on those people; it is outrageous to bring people in from low-income countries. It may be different in some parts of the world where they produce deliberately more than they need—in the Philippines, for example. But as a general rule, to import doctors and nurses from low-income countries is ethically completely wrong.

It is a risk that with Brexit we will, in the short term at least, find that there are fewer people from the EU whom we can recruit, but this is a huge opportunity to train our own people—to train more people in this country to be doctors and nurses. This is one of the great humanitarian professions. In 2002, 50% of all new nursing posts were made up from people coming from overseas. It peaked at 50% in 2002 and came progressively down to about 10% in 2008, but since the Mid Staffs report it has climbed again to a point where it is 30%. It strikes me that that is too high, and that we must do more to increase the supply of nurses and doctors, and to retain them, ourselves.

So what have we done to boost the supply of domestically trained staff? We have already increased the number of key professional groups being trained. For example, the number of nurse training places being commissioned each year has increased by 15% since 2013, and we are committed to ensuring 5,000 more doctors working in general practice by 2020. The reforms to the funding of training for nurses and allied health professionals will further boost supply by removing restrictions on the number of training places and will result in 10,000 more nurses being able to enter the workforce by 2020. Health Education England estimates that in total 40,000 more nurses will be available by 2020. I accept that, as the noble Baroness, Lady Watkins, said, there is a risk that removing the bursaries and going to a loans system might deter some nurses—but all the evidence suggests that that is not the case and that, on the contrary, many thousands of young men and women, as well as older men and women, who wish to become nurses, are unable to be trained because of the cap on nursing because of the bursary system. So there is strong evidence to suggest that moving to loans will increase the availability of nurses and AHPs.

Following the Carter review, we are also looking to increase the efficiency with which we use our existing staff and improve productivity, by changing skill mix through the introduction of new roles. This will ensure that highly trained professional staff are properly supported and able to use their skills to do things only they can do. We have talked about the new nursing associate role, and I am very happy to meet the noble Baronesses, Lady Watkins and Lady Emerton, with Health Education England, to discuss that role in more detail, if they would like to do so—perhaps after the summer. If they would like to have a meeting with HEE, I am very happy to arrange that. We are also introducing the role of physician associate, which is a postgraduate qualification; following an undergraduate degree in science, say, there are 90 weeks of training to become a physician associate. That, again, will improve our skill mix.

The Government’s expanded apprenticeship programme will help NHS employers to recruit staff and reduce reliance on expensive agencies. Through the programme, the NHS is developing a clear progression route for healthcare support workers to become qualified healthcare professionals. This will allow trusts to develop their healthcare support workforce and provide individuals an opportunity to earn and learn. We are investing in new technology across the health and social care system to improve productivity for our staff. I give one example only, because time is running out. Most trusts now have new rostering systems, which enables us to ensure that the workforce is spread more evenly across the day, so that we do not have peaks and troughs when in some parts of the day we are understaffed and in others we are overstaffed. There is a lot we can do to improve the productivity of the workforce we already have.

I should turn to social care because it is a hugely important area. We have so often done a disservice to social care. People who work in social care do incredibly important jobs. I am sure other noble Lords have visited nursing homes, care homes and care homes for dementia. People who work in those jobs, often on minimum wage, do an extraordinary job. Somehow working in nursing homes and residential homes does not have the status that it ought to have. It is a vital service for many older and disabled people and provides support to the most vulnerable people in our society. The latest figures estimate that people with EU nationality make up 6% of the 1.3 million adult social care workforce, which is about 80,000 jobs. EU workers are highly represented in regulated professions in this sector—nurses, OTs and social workers—and account for around 9% of those jobs.

Social care is a sector of opportunity with vacancies for the right people. We have to change the status of people who work in social care so that we can attract more people from this country into that profession. What are we doing? The Cavendish review brought in the care certificate, so we are trying to improve the training of people in this area. We are trying to integrate social care much more with healthcare. The Airedale care home vanguard programme is a good example of that. The national living wage is important in rewarding people who work in this important sector, who are often on very low earnings.

I want to conclude more generally. The noble Baroness, Lady Greengross, said that the turnover rate in social care was 24.3%, which is a huge figure. If we do not treat people properly, get them engaged in what they are doing and trust them, we will have high levels of disengagement, absenteeism, sickness and staff turnover. I do not know so much about social care, but I do not think that in the NHS we do a great job in engaging our workforce although of course some hospitals are exceptions to that. For example, the workforce race equality standard shows very high levels of bullying of people from BME backgrounds. Actually, there are very high levels of bullying of people from all backgrounds in the NHS. This is not because I am pro-private sector or anti-public sector or anything like that, but some of our best private sector companies treat their workforce with a far higher degree of trust and dignity and give them much more support and more training opportunities than we sometimes do in the NHS. In terms of retaining the staff we have, having trained them, there is a great deal that we can do. We can do that job much better.

My time is running out so, as summer beckons, we should retire, perhaps with a glass of Cobra Beer, and enjoy it.

Bread and Flour Regulations (Folic Acid) Bill [HL]

Lord Prior of Brampton Excerpts

Friday 8th July 2016 Lords Chamber

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

I, too, congratulate the noble Lord, Lord Rooker. I think he has raised this issue in the House—I wrote this down—10 times in the past three years, as well as in a great many Written Questions. I have been a Minister for just over a year, and he has certainly raised it three times with me. You could say he hopes that doing so will be a triumph of hope over expectation, but it reflects his real passion and genuine heartfelt concern about such tragedies. He mentioned a letter he had received from a colleague whose mother had lost three children from spina bifida, and other noble Lords have brought home to the House what the impact can be. We can sometimes have rather arcane debates in this House, but that impact is very profound not just on the children but on the parents and families of those children. Far from being an irritation to those of us on this side of the House, his single-minded determination to keep this issue before the House has won him a great deal of admiration and respect in all parts of the House.

Perhaps I may start with the science, although frankly my argument will not be with the science. The noble Lord and others have argued that the science is absolutely black and white; I would say that it is clearly strong but there are still some residual issues.

The SACN has advised that the fortification of white bread flour with folic acid should be introduced only if it is accompanied by a number of preconditions: for example, action to reduce folic acid intakes from voluntary fortified foods, to ensure that individuals do not substantially exceed their safe maximum daily intake of folic acid. The noble Lord, Lord Turnberg, addressed that in his speech so it is perhaps questionable how strong that argument is. It also told us that there is inconclusive evidence on several possible adverse health effects of the mandatory fortification of flour with folic acid. For example, for people aged 65 and over, folate fortification of flour may result in cases of vitamin B12 deficiency not being diagnosed and treated.

However, there is no doubt, certainly in my mind, that the scientific evidence is strong. Regarding other countries, the noble Lord, Lord Rooker, mentioned the huge controlled experiment in America. I certainly would not feel comfortable standing here today and arguing with him on the science. Mine is a different argument: fundamentally, it is not a scientific dispute but more of a philosophical dispute. The science is to inform policy but not to determine it. For policy, we must look more to philosophers than scientists, more to moral choice than scientific experiment, and of course to Parliament and not the laboratory.

The nub of the question is this balance between state and individual responsibility. I know that when we bring it down to this issue, it may be felt to be beside the point but that balance is important because it is fundamental to the kind of society that we choose to live in. It is perhaps especially important now, when lifestyle behaviour is becoming such a big driver of healthcare demand. It is such a big driver that unless it is addressed, there is a serious risk that no healthcare system anywhere in the world will be able to afford the level of healthcare that we expect. I know that a special committee of the House of Lords is looking at this now.

[Lord Hughes of Woodside]

My Lords, can the Minister explain whether his argument on philosophy applies only to this measure? Does it apply to the treatment of water for safety purposes or to vaccination? It is equivalent to saying that vaccination should not be compulsory in any sense of the word. Where does the line fall as to where the philosophy overcomes the practicality of the matter?

[Lord Prior of Brampton]

The noble Lord makes a very good point and I hope to address that issue as I go through this, because where the line is drawn is critical to the debate that we should be having.

The ways in which we live our lives—what we eat or drink, how much exercise we should take and how we should look after ourselves and one another—all directly impact on the likelihood of getting cancer, a stroke or diabetes, or premature death. In this case it directly affects the health of children, so prevention has never been more important. I am sure everyone in this House would agree. The question, as raised by the noble Lord, is then: what are this Government or any Government to do? At one extreme, the answer is to do nothing and, at the other, it is to be highly prescriptive: to determine how we should all live and what we should eat and drink.

The noble Lord, Lord Hunt, referred to alcohol, which I will take as an example. The Government could have washed their hands entirely of that issue and left it to individuals—the classic, John Galt, libertarian approach, which he may have read about in Atlas Shrugged in his youth. Alternatively, they could have opted for some form of prohibition, as tried in the USA and as we do with certain drugs today—although with profound unintended consequences, I might add.

In the UK, as in most democracies, the balance as to where responsibility lies has shifted over the years. It has not shifted seismically or even consistently—there have been ebbs and flows of where that line should be drawn over the years—but it has shifted away from government intervention towards the individual. That is not surprising: you would expect that shift as the population becomes better educated, better informed and better able to make good decisions.

[Baroness Flather]

Could the noble Lord give way?

[Lord Prior of Brampton]

I will in a minute but will just finish this point. That is not to say that the Government have no role—far from it—just that the role is different. It is to inform, to educate, to persuade, to nudge, to incentivise, to influence and to cajole but not, I would argue, to dictate, except in the most extreme and difficult circumstances.

[Baroness Flather]

What amazes me is that we are talking about nudging and not doing this or that, but we often have research on issues which are of great importance not only to the individual—as we have been talking about—but to the family and to the country. When a child needs lifelong care, surely it is not a good idea to not do anything about that. We seem to be going round and round, saying that we cannot be led by research, while the Government must have their policy. But what is the policy based on?

[Baroness Walmsley]

The noble Lord has just read out a list of the functions of government. Would he not add protection to that? We chlorinate all our water to protect people from water-borne diseases. Why not put folic acid in flour?

[Lord Prior of Brampton]

I will continue with the example that the noble Lord, Lord Hunt, gave, of alcohol. Clearly, the Government have the responsibility to put the science into the public domain. But should they ban people from drinking more than 14 units of alcohol a week or should they leave it to people to make that choice themselves, on the basis of the information that they have? That is the philosophy that lies behind the Government’s position on folic acid. It is also our thinking on how we address the scourge of obesity and lies behind the way we deal with our smoking and alcohol problems and behind all our prevention strategies. It is about doing all we can to help people make the right choice, but ultimately accepting, outside of extreme circumstances, that the final choice has to be made by them and not by the Government.

This is why the Government agree with the statement made by my honourable friend in the other place, Jane Ellison, when she said that the Government consider that a broad approach to the promotion of good pre-conception health needs to be taken to make sure every child gets the best start in life. On balance, the Government have decided that mandatory fortification is not the right way forward and therefore have no plans to introduce it in England.

We know that good pre-conception health, of both future mothers and fathers, can lead to healthier pregnancies and good infant health. By contrast, poor pre-conception health—for example due to diabetes, poor diet, obesity or smoking—can lead to poor pregnancy outcomes, including gestational diabetes, NTDs, premature births, and poor perinatal and infant mental health.

Many parents make few preparations to improve their health before pregnancy. That is why a more proactive approach which promotes good pre-conception health to reduce the risk of poor pregnancy outcomes for women and their families should be adopted. This is why my colleague Jane Ellison has set up a ministerial round table. She held her first meeting with interest groups on 13 June to help identify additional measures to promote good pre-conception health.

I recognise the tragedy of neural tube defects. I recognise the urgency and passion that lies behind this Private Member’s Bill but, at this time, the Government have decided that, on balance, we are against mandatory fortification of white bread with folic acid and therefore have no plans to introduce it in England. Instead, all our efforts will be directed at promoting good pre-conception health. I realise that that is a disappointing but probably not unexpected reply to the noble Lord, Lord Rooker, and to his colleagues who support the Bill. Of course, that balance may change over time. As the noble Baroness, Lady Hayman, said, he is a formidable opponent and I have no doubt that he will carry on pushing the case for fortifying with folic acid. In time, who knows where that argument will go but, for the time being, the Government’s position is that we will not support the Bill.