Health: Neural Tube Defects

Lord Prior of Brampton Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Rooker]

To ask Her Majesty’s Government whether they will bring forward measures of preventative medicine to reduce the numbers of stillbirths, abortions and live births of babies with serious lifelong disability due to neural tube defects.

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

My Lords, the Government are looking at all aspects of preconception health and preventive medicine. We currently have no plans to introduce the mandatory fortification of flour with folic acid. We plan shortly to engage with relevant stakeholders to identify other measures that can promote good preconception health, including how to redress the low blood-folate levels of women, which can lead to neural tube defects.

[Lord Rooker (Lab)]

The Minister’s Answer is clearer than some of the others, but we now know that the answer is no; that is what he has told us. English Ministers are knowingly doing nothing, basically. They know that half of all women who become pregnant are taking supplements, and only a small percentage of them actually take the correct amount. Moreover, does the Minister know that some food manufacturers are starting voluntarily to reduce the folic acid in their products, which they were going to do on the basis of mandatory levels being introduced following scientific advice? The Government are therefore relying on 80% of pregnancies being sponsored abortions as a management tool. That is the reality of what we are dealing with in England at present. Is this not like English Ministers having a polio vaccine and refusing to use it?

My final point is this. Does the Minister accept that it has never really been made clear that there is a direct and indisputable link between neural tube defects, lifelong serious disability in babies who are born alive and folate vitamin deficiency? It was the UK that told the world this in 1991, and 83 other countries have thanked us by using the policy to reduce the number of abortions and babies born with lifelong disabilities. The Minister should be ashamed of the situation he has been forced into by his colleagues.

[Lord Prior of Brampton]

My Lords, I am not going to argue the science, because the link between folate levels and neural tube defects is fairly well proven. Although our decisions should be informed by scientists and doctors, I do not think that they should be determined by them. The balance between individual responsibility and state responsibility is best left to political judgment.

[Lord Rennard (LD)]

My Lords, given that the Minister accepts the link between a lack of folic acid in the diet and neural tube defects, why will he not look again at the advice from, for example, the Royal College of Obstetricians and Gynaecologists, the Food Standards Agency and the BMA that we should be putting folic acid into food products, as is done in many other countries, including the United States of America?

[Lord Prior of Brampton]

Fortifying bread with folic acid is not a silver bullet that would cure all babies with neural tube defects. The estimate is that it would have an impact on between 15% and 30% of babies. Some 965 babies suffer from neural tube defects a year, so we are talking about fortifying flour for the whole population in order to reach about 120 babies.

[Baroness Gardner of Parkes (Con)]

My Lords, is the Minister aware that we have debated this issue many times and that the view around the House has been almost unanimous that something should be done to deal with this problem? Why, therefore, is it not done? On a previous occasion, I clearly remember someone saying that if you do not want the supplement you can have bread that is specifically made without the additives. In that way, the ordinary population can be catered for. Of course, women need the supplements before they get pregnant, not afterwards, when it is already too late.

[Lord Prior of Brampton]

My Lords, speakers in this House have by and large very much supported the views of the noble Lord, Lord Rooker—I entirely accept that. But I do not think that the case has been made outside this House perhaps as strongly as it has in other areas. If we are going to change the way we produce white bread in this country, a much stronger and broader case has to be made.

[Baroness Hayman (CB)]

But, my Lords, it is not just in this House, is it? It is in the Scottish Government, who I understand are now laying out plans to introduce fortification. They are supported by the Administrations in Northern Ireland and in Wales. Why is England taking this isolationist view when across the world it has not been taken? Is it correct that Sir Nicholas Wald, the leading scientific expert in this field, was granted an audience with the Minister for Health in Scotland, but not in England?

[Lord Prior of Brampton]

My Lords, I cannot answer the latter question, but I will try to find out and write to the noble Baroness. She is right that Scotland is considering this and looking at the practical issues around implementation. She is right that other countries in the world—I think 50—have done this, but many others have not, including all European Union countries.

[Lord Turnberg (Lab)]

My Lords, I realise that the noble Lord is in the hands of his scientific advisory committee and cannot say anything without it, but I ask him to draw to its attention the fact that it may be using outdated research evidence if it believes that adding the small amounts of folic acid to bread has the same metabolic effect as taking 1 milligram of tablet a day. It does not. The very remote possibility that there is danger in taking 1 milligram of tablet a day is eliminated completely if you add it to food and take it during the day. Will he draw that to the committee’s attention and ask it to think again?

[Lord Prior of Brampton]

I will certainly draw that point to the attention of the SACN. It would be surprising if it was not already aware of that fact, but as I said I am addressing not really the science but whether it is right or proportionate to fortify bread for everybody to reach such a small number of people.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord made it clear that this is a political decision, for which we should be grateful. He also made it clear that the Government have decided that it is not going to happen. But does he accept that a 30% improvement is actually a large, positive outcome? The fact is that the voluntary approach that this Government have been wedded to is simply not working. If the answer is no, and if the voluntary approach is not working, what, then, will the Government do?

[Lord Prior of Brampton]

My Lords, the evidence given by the SACN is that it affects between 15% and 30%. My honourable friend in the other House, Jane Ellison, is bringing together a round table of all stakeholders interested in preconception health to discuss this matter.

[Baroness Howarth of Breckland (CB)]

My Lords, does the Minister think that the resistance to this is in the general public or among the food producers? My discussions with many young women across the country do not give me the impression that it is among the general public. If it is among the food producers, of course they would be resistant if it does not benefit their profits. Where does the Minister think that attitude is, and can he advise us where we should put our energies in order to change it?

[Lord Prior of Brampton]

My Lords, I am not aware that the food industry is opposing the introduction of folic acid into white bread flour, but I will investigate that and write to the noble Baroness.

NHS: 111 Service

Lord Prior of Brampton Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the safety and reliability of the National Health Service 111 service.

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

My Lords, NHS 111 is a vital service helping people to get medical advice quickly and easily. It has received more calls this year than in the same period in 2014-15 but continues to perform well overall. The Care Quality Commission has announced that it will inspect all NHS 111 providers by September 2016. The CQC will assess whether the services are safe, caring, effective, responsive to people’s needs and well led.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is not the problem that when the excellent NHS Direct service was replaced, very many experienced nurses ceased to work for the new 111 service and were replaced by call handlers with a few weeks’ training who have to follow instructions on a computer rigidly? The evidence is that there have consequently been misdiagnoses. One ambulance trust fiddled the response time for 999 calls routed through 111 to meet the targets. There have been a number of personal tragedies as a result. Therefore, in addition to the CQC’s inspection, will the noble Lord institute a review of the safety of 111 and return to having qualified nurses handling the calls?

[Lord Prior of Brampton]

My Lords, the decision to stop NHS Direct was, of course, taken in 2008, when I think the noble Lord was in post. He shakes his head, so perhaps he was not, but the decision was taken in 2008, before this Government were in charge, if you like. The new system uses the NHS Pathways algorithms developed by the Royal College of GPs, on which the BMA and the Royal College of Paediatrics and Child Health sit, so we have considerable confidence in the algorithms used. We will also increase the number of clinicians. I accept the noble Lord’s point that we need to have more clinicians answering these calls rather than call handlers, as he puts it. It is our intention progressively to increase the number of clinicians in these 111 hubs.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. What assessment did the Government make of the training needs of the individuals who were to deliver the 111 service prior to its introduction, and what determination have the Government made subsequently of the appropriateness of that training?

[Lord Prior of Brampton]

My Lords, as I said, the decision to set up 111 was made back in 2008. The operation of 111, which includes the training and the capabilities of the people working in it, is carefully monitored by the CCGs—which commission 111 services by the licence under which 111 operates the NHS Pathways algorithms—and, of course, by the CQC.

[Lord Allen of Kensington (Lab)]

My Lords, is the Minister confident that the NHS England workforce development plan will ensure that no chief executive or senior NHS staff can support covert operations, as we saw with South East Coast Ambulance Service, which affected up to 20,000 people? Is the Minister confident that this will be put in place?

[Lord Prior of Brampton]

My Lords, the noble Lord will be aware of the very severe problems at South East Coast Ambulance Service. The chairman has resigned. The chief executive is, I think, on gardening leave at the moment. NHS Improvement is very clear that it needs to sort out the management structure in that ambulance service.

[Baroness Humphreys (LD)]

Will the Minister explain how the 111 service will be improved to ensure that ambulances for life-threatening conditions arrive in a timely fashion and are not delayed or cancelled by 111 call handlers?

[Lord Prior of Brampton]

My Lords, the 999 service runs in parallel with the 111 service. If you have an emergency, you should ring 999; if you have an urgent request you should ring 111 and a decision will be made then on whether to call an ambulance. Interestingly, of the 27% of people who ring 111 who would otherwise have gone to A&E, only 8% are actually referred to A&E.

[Lord Campbell-Savours (Lab)]

My Lords, the Minister’s response is astonishing. Has he not been reading in the national media the repeated reports of a breakdown in the service all over the country? Has he not read these reports? I am astonished by his responses.

[Lord Prior of Brampton]

There have been a number of terrible tragedies. The most recent of these was William Mead, a very young baby who died as a consequence of not getting the right treatment quickly enough. NHS England has done a root-cause analysis. Some of the problems lay within 111 but others were with the out-of-hours service and with diagnosis by the GPs concerned. The noble Lord is wrong to say that the 111 service is not operating well throughout the country. Some 90% of all those who use 111 believe they get a good service from it.

[Lord Patel (CB)]

My Lords, what suggestions does the Minister have for improving the performance of the 111 service?

[Lord Prior of Brampton]

My Lords, there are two things which we need to do to improve the 111 service. First—and this is in response to part of the Question asked by the noble Lord, Lord Hunt—we need to have more clinicians within the 111 hubs. Secondly, people need to have access to the patient’s electronic summary care record so that they can see what has gone on before coming to a final judgment.

[Baroness Farrington of Ribbleton (Lab)]

My Lords, the Minister referred to 90% satisfaction. How many people are involved in the other 10%? It does not strike me that 90% is acceptable.

[Lord Prior of Brampton]

My Lords, 100% is clearly the only acceptable level but, realistically, it would be extremely difficult to get to that. Referring back to the charge of complacency, we recognise that significant improvements need to be made to the 111 service, but it can be a vital part of the way that we deliver urgent care in Britain.

[Lord Clark of Windermere (Lab)]

My Lords, we all accept the Minister’s commitment to the NHS. He has just stated that improvements to the service need to be made. When are they going to be made?

[Lord Prior of Brampton]

My Lords, it may sound trite, but we need to make continuous improvement in all aspects of the NHS. We can never be satisfied with where we have got to. Interestingly, the licensing arrangement which underpins the NHS Pathways—the algorithm developed by the Royal College of GPs—has within it an audit to ensure that continuous improvement is being made.

Royal National Orthopaedic Hospital: Redevelopment

Lord Prior of Brampton Excerpts

Thursday 17th March 2016 Grand Committee

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

I thank the noble Baroness, Lady Dean, for bringing forward this debate. I did not know anything about the history of Stanmore until today and the briefing I had beforehand. It has been an extremely good debate. I echo the words of my noble friend Lord Finkelstein that we have reached the stage where everything has been said but not everyone has said it. I fall into that category. Let me put on record that I agree with everything the noble Baroness said in her speech rather than repeating it, as I would otherwise have done.

I wish to address a number of points and themes. First, this is not a PFI. We need not today go into the pros and cons of PFIs, save to say that my sympathies are with my noble friend Lord Tebbit: many of them have been incredibly expensive. When he used the word “pernicious” I think he meant that not only were they expensive but they have hidden liabilities that should appear on the public sector balance sheet. He may like to know that the future costs of the PFI schemes for health alone total £79 billion. This includes some of the soft FM contracts but it is a huge liability that ought to be on the face of the public balance sheet but is not. I say that on PFI, but this is not a PFI scheme.

Secondly, my noble friend Lord Tebbit and others made reference to the land sales that are part of this scheme. We use our property resource in the NHS fantastically badly. I am not saying whether or not the £20 million assumption here is a low level of money but sometimes in the NHS, because we are in a hurry, we sell things off quickly, whereas if we had more time and could explore matters through a joint venture or a more creative arrangement we might be able to bring in a lot more money. That is something I would ask the management to look at, but not as a way of deferring this scheme. I am pleased that Rob Hurd and Professor Goldstone, respectively the chief executive and chairman of the RNOH, are here today listening to this. We do not deal properly with our massive property resource. In gross terms we have £40 billion to £50 billion-worth of property assets within the NHS, which we do not use very well. If we walk around London we can see some of our hospitals in prime residential areas. These are worth a huge amount of money which we could use to redevelop our real estate within the NHS.

Thirdly, Stanmore is not only a beacon of excellence but the work that Professor Tim Briggs is doing to spread his Getting It Right First Time scheme across the NHS is hugely important. If we are going to get long-term sustainable improvement for the NHS we must have clinical engagement. The work that he is doing through his exposure of variation in orthopaedic practice is hugely important. If we can spread the learning that he has gained in orthopaedics into other surgical and medical specialties, it will make a huge contribution to the massive saving programme that we need to achieve over the next five years. Related to that, the fact that the RNOH is leading the National Orthopaedic Alliance vanguard around the country with a view to franchising the excellence in the RNOH into DGHs and other hospitals around the country must be a good thing.

My noble friend Lord Lansley raised the issue about specialist institutions. I agree the evidence is that, from a patient and clinical outcome point of view, specialist institutions are extremely successful. However, there are two caveats to that. One is that they can become insular; and the second is that they can be high cost. Often they are relatively small institutions and, because the tariff does not favour complex specialist work, they can be a disadvantage to the tariff.

The RNOH has addressed that insularity issue in two ways: first, through the tie-up with UCL on the biomedical engineering facility; and, secondly, through developing its work with the Royal Free, which is very important. That may enable it to take some costs out of its existing institutions.

The tariff, which my noble friend also raised, is something that we should address with NHS England and with NHS Improvement to be sure that it does not favour just those more commodity or routine orthopaedic operations at the expense of the more specialised, complex operations. I think—and my noble friend will know more about this than I do—that, originally, the tariff was structured to encourage the private sector to come into the more routine, so to speak, orthopaedic business. It has disadvantaged the more specialist institutions, which is something that we need to address. If I were coming here to say, “No, we’re not going to do this”, I would have to deal with not just my noble friend Lord Tebbit but an even burlier character in Professor Tim Briggs. He is a fairly typical orthopaedic surgeon and saying no to orthopaedic surgeons is never a happy experience.

I am, as I say, leaving aside the speech I would have made because it would simply repeat what has already been said. The TDA received the trust’s revised outline business case in January last year. Following its review of the business case, the TDA required assurances on two strands of work to be completed. The first was the development of an interdependent estates strategy and land disposal business case for the Stanmore site. The second was the further development of the NHS England vanguard partnership with the Royal Free London NHS Foundation Trust as part of securing the long-term sustainability of the trust. In relation to the vanguard partnership, the trust plans to present a formal report to the TDA on progress ahead of the full business case submission. Negotiations with the Royal Free have gone well, with an MoU between the two organisations signed, which aims to identify the clinical synergies of the two organisations and how their working more closely together could strengthen the clinical model. Those discussions have gone extremely well.

An outline business case for the land sale has been submitted by the trust and approved by the TDA investment committee and will go to the full TDA board. That should not hold up this project. If there is a way of increasing the receipts from the land sale, then clearly the management will be trying to do so. A full business case containing Balfour Beatty’s final proposals for the redevelopment of the hospital is expected to go to the trust’s board on 30 March. In April, the trust is expected to submit a full business case to NHS Improvement for review. In June and July the full business case is expected to go to NHS Improvement’s investment committee and, following that, to the NHS Improvement board. Approval will allow the trust both to clear the site available for sale and to fund the part of the new facility not covered by the land sale receipt. Construction will be completed in December 2017, with the new facility opening to patients in February 2018.

To conclude, this is very much a priority project for the Department of Health and NHS Improvement. The Government fully support the redevelopment of the RNOH and are grateful for the contribution it has made to the Getting It Right First Time project, led by Professor Briggs. I am happy to arrange a meeting, as the noble Lord, Lord Hunt, requested, with NHS Improvement on this issue. If it is all proceeding according to plan, that meeting might not be necessary but, if there is a glitch, I am happy to come back for another debate, but we fully support this and can see no reason why it will not be given the go-ahead according to the timetable that I suggested. Before I sit down, is there anything that noble Lords would like to raise that I have not covered?

[Baroness Dean of Thornton-le-Fylde]

We are not often asked to intervene in a Minister’s contribution so I thank the Minister very much indeed and welcome his contribution. If the hospital reaches any glitches, will his door be open for a meeting with the CEO and chairman of the hospital?

[Lord Prior of Brampton]

Yes, any time. I should have said that I have not had a chance to visit Stanmore but I would certainly like to do that. We are fully behind this case. I will go to the hospital anyway, but I hope that this will go ahead on this timescale.

[Baroness Dean of Thornton-le-Fylde]

They hope to break the land—first spade in—on 7 July. How wonderful it would be if the Minister did it.

[Lord Prior of Brampton]

Perhaps at the same time we could fill in the hole dug by my predecessor.

[The Deputy Chairman of Committees (Lord Brougham and Vaux)]

As an ex-patient of the hospital, I can say that the Committee stands adjourned until 4 pm.

General Practitioners: Appointments

Lord Prior of Brampton Excerpts

Thursday 17th March 2016 Grand Committee

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

My Lords, I also thank my noble friend for raising this issue. General practice has been a golden thread running through the NHS since 1948. It is worth reminding ourselves that although the situation may be dire in some parts of the country, as the noble Lord, Lord Turnberg, mentioned, the NHS is still almost unquestionably the most efficient, highest-value healthcare system in the world. Not long ago, I was with some people from the Mayo Clinic who made that point—we are very self-critical. It is right that we should be but also right that we should remember that much of what we do in the NHS is absolutely world class and we do it with very little resource. My noble friend Lord Bridgeman and other noble Lords made the point that the NHS is, in their own individual experience, absolutely first class. If you read the newspapers every day you might think that everything is going to hell in a handbasket but most people’s individual experience of the NHS is extremely good. I have not seen the Commonwealth Fund report to which the noble Lord, Lord Hunt, referred but I would like to.

We should be extremely concerned if confidence in primary care is diminishing. I will write to the noble Lord, Lord Turnberg, about research. I could answer his question if it was directed at specialist research, but I am not sure how much money or resource is going into research into primary care. The noble Lord, Lord Rennard, raised the issue of hypothecated tax. The argument for hypothecating tax for health is no stronger or weaker than doing so for education or overseas aid, or other areas. He will know, as well as I do, that the Treasury has wrestled with and discussed this issue for many years. Any decision will be made in the Treasury, not by me. I could argue both sides of the case with equal conviction and sincerity, so I cannot give the noble Lord the answer he might want to elicit from me.

The noble Lord, Lord Rennard, and my noble friend Lord Bridgeman raised the issue of variation. We have got thousands of GP practices and there will inevitably be variation. The question is how we reduce that variation and shift the curve to the right in terms of getting a great general practice. I happen to believe that one way of doing that is through networks and federations. The noble Lord, Lord Hunt, referred to Vitality in Birmingham. Unquestionably, it will spread best practice within that group. The good CCGs are measuring the performance of GPs in their area much more intelligently than they used to. My noble friend Lord Bridgeman mentioned that his practice has very low referral rates. That is exactly the kind of information that should be measured on a GP-practice basis across all GP practices in CCG areas. For example, I have seen the metrics that the CCG in Camden looks at. You can see very clearly what the referral rates are from practices. The outliers can be seen and you can manage that down. They have had some very good results. If noble Lords would like to look at the atlas of variation, or at the Right Care model that NHS England is using to try to identify variation on a disease on a population basis to drive down that level of variation, I can well recommend that they do that.

I have come to the view—it is almost a statement of the bleeding obvious—that of all the tools that we have in our toolkit to try to secure improvement, be it in clinical outcomes, performance of trusts or in general practice, the best is identifying variation. The crucial thing about variation is that you have good-quality data. The first thing when you shine a light on clinical practice, for example, is that the clinicians will dispute the data—often rightly—so you have to demonstrate that the data are good. If you can prove the data, GPs, psychiatrists, acute physicians, surgeons and the like will take that as a challenge, because they tend to be competitive individuals. They like their own practice to be better than anybody else’s. Variation based on good-quality data is essential.

I will take away the comments made by my noble friend Lord Bridgeman on PMS. NHS England is committed over the five years to increasing spend on primary care by some 25% in real terms, whereas in the rest of the NHS it will be more like 15%. There will be more resource relative to other parts of the NHS going into primary care. They will want to be sure that they are getting real value out of any premium payments made under the PMS contract, but I will take that away if I can and write to my noble friend on that matter.

Governance is an extremely important issue. I had not thought about it in terms of where a network of general practice is almost the same size as the underlying CCG, which raises another issue about governance. We thought about it in terms of conflict of interest and the award of contracts, but that is a very serious point. NHS England is looking at these governance issues. I will bring this aspect to its attention.

I turn to what I had pre-prepared. My noble friend Lord Attlee is quite right that people should receive the right care from the right professional at a time convenient for them. However, we know that there is variation in people’s ability to access a GP and that those in full-time employment report lower levels of satisfaction with surgery opening hours than other groups. This is one of the reasons why, by 2020, everyone will be able to access routine GP appointments at evenings and weekends as part of our commitment to a seven-day NHS. That does not mean that every practice will be open seven days a week. We hope that by 2020 most general practices will be part of a network or federation and they will be able to offer that kind of service across the federation.

As I am sure my noble friend will understand, it is not possible to make a direct comparison between accessing GPs and other professionals such as solicitors, but he is, of course, right that people should be able to access a GP appointment when they need it. This is why the Government have already invested £175 million in the Prime Minister’s access fund to test improved and innovative access to GP services. I know that it is very spotty across the country still, but there is a growing understanding that the traditional model of GP practice—lots of small practices with two or three partners, as described by the noble Lord, Lord Turnberg —is not a viable model of delivering primary care for the future.

The traditional model is going to change. We will have networks and much bigger practices with 10 to 20 salaried partners supported by a much larger team of skilled people—pharmacists, physios, OTs, physician associates, prescribing nurses and the like. As well as providing extended hours, schemes are also looking at other ways of improving access for patients, including better use of telecare and health apps. This is an issue that noble Lords raised in the debate today. Not only will we see much more use of the telephone but, for example, the Hurley Group has an e-consultant system, and more people will use other ways of accessing primary care rather than being seen by the GP. This has a lot of legs, if you like. Apps such as Babylon, with which noble Lords will be familiar, and many other apps will make a face-to-face consultation with a GP less critical than it has been in the past.

My noble friend also asked about competition between surgeries. Here, I will point to what we are doing to increase choice for patients. In particular, my noble friend raised a concern about having to move from one practice to another when he moved house. I was pleased to hear that he is now aware of the steps that have been taken to make it easier for patients to exercise choice over which practice they are registered with. The GP contract for 2014-15 brought in a measure allowing GP practices to register new patients from outside their traditional boundaries, but without a duty to provide home visits for such patients, which seems reasonable in the circumstances. This measure is designed to increase flexibility in the system and the freedom that patients have to choose a GP practice that suits them. For example, commuters may wish to register with a practice close to their work as opposed to where they live or a patient who moves house may wish for continuity.

I return to the technology point about booking systems raised by the noble Lord, Lord Hunt. Take-up may be low at the moment—I think that 6.5% of bookings are done online—but I have no doubt that it will grow. If you look at the number of people now ordering basic food from supermarkets online, that is the direction of travel and it will speed up as time goes by.

The noble Lord raised the issue of reducing pressure on A&Es. In January, there was an increase of 10% in A&E attendances on the previous year. This is putting huge pressure on hospitals because if the front end of the hospital is being flooded, it makes it increasingly difficult for it to meet its waiting times on elective surgery, for example. Delivering more care to people outside hospital will not only lower the cost but provide better care because going into A&E with a fairly minor problem is not a great way of delivering care.

The noble Earl raised an issue about blood tests. Examples of improved access to diagnostic tests can be seen in both the vanguard sites which NHS England is developing. They are part of the new models of care programme and access fund schemes. For example, a vanguard in Birmingham offers consultant-led outpatient clinics and diagnostic facilities, such as X-rays. We often talk about integrating social care with healthcare, but integrating healthcare is also not a bad way to go. We have talked in the past about collocating GPs in A&Es or just outside them, but there are also many specialist outpatient clinics that can be delivered in primary care settings, so long as the facilities are there. We hope that the £1 billion infrastructure fund that we have announced will deliver better facilities closer to where people live.

We have a lot to be proud of but we are inclined to dwell on areas where we are failing and forget sometimes where we are achieving great success. The workforce is a serious issue. We are committed to finding 10,000 new GPs or GP equivalents in general practice by 2020 and we have increased the number of training places by 3,500 from this year and going forwards. To be honest, there is a risk around whether we will be able to get that number of people into general practice. However, without that kind of workforce commitment it will be difficult to deliver our ambitions.

So, it is a combination of technology, workforce and infrastructure. The five-year forward view is behind the thrust of the comments made by noble Lords and, if I am still here in 2021, I hope that I will be able to say that we have spread the best practice that exists in large parts of the country on a much wider basis. However, I am afraid that we will not have eliminated all variation.

NHS: Hospital Overcrowding

Lord Prior of Brampton Excerpts

Tuesday 15th March 2016 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the latest NHS performance figures and the concerns expressed by the Society for Acute Medicine that overcrowding in hospitals may result in avoidable deaths.

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

My Lords, a significant increase in emergency demand in January put the NHS under great pressure. Compared to January last year, the NHS had almost 175,000 more attendances in A&E in January 2016. We recognise this rise in demand is not sustainable, which is why we have invested £10 billion in the NHS’s five-year forward view.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister, but he will know that the January performance was the worst A&E performance of the NHS on record. The Society for Acute Medicine has warned that this is bound to have an impact on the number of avoidable deaths that take place. Ministers cannot just blame the public for coming to A&E departments. The fact is: they have cut nurse training places; they have cut social care; they have squeezed the NHS budget; and today the Public Accounts Committee says that the NHS has no chance whatever of clearing the financial deficit. I would simply ask the Minister when he thinks the NHS will next meet the four-hour target.

[Lord Prior of Brampton]

My Lords, there was a 10% increase in demand in January, which put the NHS under huge pressure. It is much to the credit of A&E services that we saw 111,000 more people within four hours than we did the previous January. It is also worth mentioning that, over the last five years, the number of consultants working in A&E has increased by 49%. The number of people working in emergency care as a whole has increased by 3.7%. It does not alter the fact, which I recognise, that A&E departments are under tremendous pressure—they often are in winter. We hope that that pressure reduces as spring approaches.

[Baroness McIntosh of Pickering (Con)]

My Lords, will my noble friend the Minister look very carefully at the reasons for delayed discharges, which lead to overcrowding, and to the particular role that community hospitals, such as the Lambert Hospital in Thirsk, play in rehabilitating those who have had a fall, an operation or a stroke? Will he look very carefully at the role of, and allocate sufficient resources to, community hospitals to ensure that they remain in service, playing this crucial role of step-down between the acute hospital and going home?

[Lord Prior of Brampton]

My Lords, clearly, step-down facilities, including community hospitals, have a very important role to play. The whole thrust of the five-year forward view is to treat more people outside acute hospital settings. That is the NHS’s plan, which the Government support.

[Lord Patel (CB)]

My Lords, does the Minister agree that there needs to be a reform of the tariff paid for the workload that A&E departments now bear? If there is an appropriate tariff, the hospitals will invest in better facilities and better staffing, such as collocation of out-of-hour GP services, pharmacies, and even mental health assessment services, alongside A&E departments. Does he therefore agree that there needs to be a reform of the tariff paid to A&E?

[Lord Prior of Brampton]

My Lords, the tariff has been changed. Acute hospitals now receive 70% of the tariff, rather than 50%, for the excess numbers of people coming into A&E departments. The noble Lord is absolutely right, though, that those hospitals that have collocated GPs and A&E departments, and have invested in psychiatry liaison nurses and other people, have seen huge improvement. The question is: do we want to invest? Are A&E departments the right places to invest, or ought we to be putting that investment into primary and community care? That is the big issue that will be decided over the next five years.

[Lord Rennard (LD)]

My Lords, does the Minister agree with the president of the Society for Acute Medicine that there are no more efficiencies to be made and that we must now start to invest in care again to bring us on a par with other developed nations? Does he accept that the planned increases in expenditure for the NHS will not be adequate to deal with the crisis in it, and that we need to consider a hypothecated tax to fund health and social care?

[Lord Prior of Brampton]

My Lords, a lot of what was said by the person, whose name I cannot remember, to whom the noble Lord refers, was absolutely right, but when he said that there were no more efficiencies to be gained he was completely wrong. We can still achieve huge efficiencies throughout the whole healthcare system, in the context that the NHS is one of the most efficient systems in the world, but it can be better. It would be completely wrong to say that no more efficiencies can be achieved.

[Baroness Pitkeathley (Lab)]

My Lords—

--- Later in debate ---

[Baroness Pitkeathley]

My Lords, will the Minister agree that there is bound to be overcrowding in hospitals if we have a point of entry without any guaranteed point of exit? Therefore, unless social care is adequately funded and organised, we will always have this problem of overcrowding, particularly where old people are concerned. I would be very glad if he did not refer me to the better care fund as the answer to this, because it is already oversubscribed many times.

[Lord Prior of Brampton]

My Lords, I will not refer to the better care fund, but I agree with the noble Baroness that flow through a hospital is essential. Blockages at the end of the flow can cause problems further down the line in A&E departments. I entirely agree with the noble Baroness’s analysis, but it is more complex than just looking at social care. Two-thirds of the delayed transfers of care are caused internally within the NHS, compared with only one-third by social care, but the noble Baroness makes a very strong point.

[Lord Vinson]

My Lords, is it not a fact that net immigration into this country is running at over 200,000 people a year, and possibly rising? Surely this has a huge bearing on the ability of the National Health Service to meet demand. That factor should be taken into consideration.

[Lord Prior of Brampton]

My Lords, the demand on the health service is rising for many reasons, of which the growing population is clearly one. However, without the extraordinary contribution made to the NHS by people who have emigrated here from other countries, we would not have an NHS at all.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister comment on how we might prevent people going into hospital through much better structuring of community teams led by nurses? Last week, I was told at the Secretary of State’s conference on patient safety that the mean age of patients on a medical ward at Oxford was 83. When I was a ward sister, it was around 50.

[Lord Prior of Brampton]

My Lords, clearly it must make more sense to provide better treatment for elderly people in their homes, away from hospitals, particularly for those with often multiple long-term conditions. One of the tragedies of government policy since 2000—this goes across both parties—is that, although the rhetoric has been about moving care out of hospitals into the community, it has been extremely difficult to do it.

[Lord Watts (Lab)]

My Lords, does the Minister accept that, although they may not be the only cause, the cuts in social care have had a profound effect on overcrowding in our hospitals? Would it not be a good idea to reverse those cuts and take some of the pressures away from our hospitals?

[Lord Prior of Brampton]

My Lords, I think it is well understood that the integration of healthcare and social care is hugely important and that the two cannot be seen in isolation. It will be very interesting to see how things develop in Manchester, where we are going to see an experiment in the integration of health and social care on a very large scale.

NHS: Mental Health Services

Lord Prior of Brampton Excerpts

Monday 14th March 2016 Lords Chamber

[Baroness Tyler of Enfield]

To ask Her Majesty’s Government what plans they have to publish data regularly on the availability and quality of NHS-funded mental health services across the country.

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

My Lords, data on mental health have been a bit like a black hole. We are working with the Mental Health Data and Information Board to improve the data, as recommended by the Mental Health Taskforce. A new mental health dataset will be online by April this year. Starting with early intervention in psychosis, it will comprise data on waiting times, availability and outcomes. We will expand the dataset to other pathways once data become more robust.

[Baroness Tyler of Enfield (LD)]

I thank the Minister for his Answer. The Mental Health Taskforce which he alluded to called for a data and transparency revolution in mental health services, specifically in their availability and the spending on mental health. Its actual words were “absolute transparency on spending”. What steps are the Government taking to ensure that the data on spending come into the public domain and how quickly will that happen? Specifically, how does the department intend to respond to the call last week from the Mental Health Commissioners Network for money for children and young people’s services to be ring-fenced so that it is not siphoned off elsewhere?

[Lord Prior of Brampton]

We agree entirely with the recommendations in the task force report regarding the need for a revolution in transparency of information about mental health, and that will include spending. Even when adjusted for need, I think that there is almost a twofold variation in the spending on mental health from one CCG to another, so we entirely accept the recommendations.

[Lord Patel of Bradford (Lab)]

My Lords, going back to the noble Baroness’s comment about children and young people, given that one in 10 six to 15 year-olds suffers from a diagnosable mental health condition but that only 25% to 35% access the support they need, can the Minister provide assurances that there are no plans to change the funding for the training of psychotherapists, who do valuable work with these children in the NHS?

[Lord Prior of Brampton]

My Lords, I can give the noble Lord the assurance he wants. There are no plans to change the way in which funding for the training of psychotherapists is done at the moment.

[Baroness Hollins (CB)]

My Lords, given that people with learning disabilities and autism are at high risk of mental health problems, what specific support, and clarification of that support, will the Government commit to giving to address their needs?

[Lord Prior of Brampton]

My Lords, our strategy for this area was set out in Transforming Care, a paper produced by NHS England some six weeks ago. It shows that we are absolutely committed to treating more and more of these people outside institutional settings and back in the community.

[Lord Bradley (Lab)]

My Lords, I declare my health interests. As we have heard, the collection of financial data on the investment in mental health services is crucial. I am grateful to the Minister for writing to me recently to confirm the Government’s support for the Mental Health Task Force’s priority recommendations at an additional cost of £1 billion a year by 2021, with investment beginning in 2016-17. How much additional investment will be expected each year between 2016 and 2021? What financial reports will be available for each quarter over these four years to ensure that clinical commissioning groups make the additional investment in local mental health services?

[Lord Prior of Brampton]

My Lords, the noble Lord is right: we have committed to support the request of the task force to spend an extra £1 billion by 2021. Perhaps I may write to him about the phasing of that money over the next five years; I have seen it but I cannot recall the exact figures at the moment.

[Baroness Browning (Con)]

My Lords, can my noble friend outline the Government’s position on future in-patient services for children with mental health issues? Given that these are the most severe cases and that a lack of facilities in geographic proximity to where the children live has an effect on the immediate family, particularly parents, how will the Government resolve the problem of children as in-patients miles from home?

[Lord Prior of Brampton]

My noble friend raises a problem which is most acute for children and a serious issue for anyone who requires in-patient facilities. We are committed to reducing the number of children and older people who have to go a long way from home to receive in-patient treatment. We have committed to support the task force’s recommendation to spend a great deal more money on providing crisis resolution closer to home. This should obviate the need for people to go into in-patient facilities.

[Baroness Brinton (LD)]

My Lords, last week there was a well-publicised case of a young autistic man being held in secure mental health accommodation because there were no spaces in the appropriate autistic support facility. It transpires that the principal cause was that there was nowhere for the young people in the other unit to move to. Can the Minister explain what is happening with mental health services to avoid bed-blocking, in the same way as is happening with other social care?

[Lord Prior of Brampton]

On the particular case raised by the noble Baroness, the person involved will now come out of that accommodation. I think he has been an in-patient for six months but he is now due to come out of that place fairly soon. This issue is not confined to mental health. There are too many people who, if the right resources were available outside hospital, would be much better off being treated outside an institution than they are at the moment. We are doing our best to address this general concern, raised by Paul Farmer and his task force.

[Lord Ramsbotham (CB)]

My Lords, can the Minister tell the House whether the data to be published will include the provision of services in prisons and other places of detention, including immigration removal centres?

[Lord Prior of Brampton]

My Lords, it certainly is our intention to include information about people suffering from mental health problems in prison. I will have to check into the immigration removal centres and write to the noble Lord.

[Baroness Afshar (CB)]

My Lords, is there a guarantee that there will be not only no change in funding but a continuation in the training of personnel dealing with children’s psychological problems in particular, and in the number of such personnel? Many minority communities have a tendency to ignore such problems or put them aside, and it is therefore essential to have someone from within the community who is familiar with the process and who can pass on their training. So, will the number of personnel be maintained, as well as the quality of expertise?

[Lord Prior of Brampton]

I agree with my noble friend that it is essential that we have people who come from the communities of those who are suffering and who are receiving mental health care facilities. I cannot give her a specific answer, but I agree entirely with what she is saying.

[Baroness Farrington of Ribbleton (Lab)]

In looking at provision in the community, where people, quite rightly, can be treated for mental health conditions, will the Minister please have regard to the fact that, while the person who is ill may be behaving in an unusual, difficult or even frightening way, those concerned with the patient’s care sometimes disregard the problem of children in the family who are trying to cope 24/7 with this difficulty? Will he ensure that, in looking at services at home, due regard is paid to young people who become carers—in a way that, sometimes, other adults in the family have avoided?

[Lord Prior of Brampton]

The noble Baroness raises a broader point, which is that mental illness and mental health problems can cause chaos in families. Often, those who suffer most are the children of people who are going through a very difficult time, and due regard must of course be given to those children.

E-cigarettes: Regulation

Lord Prior of Brampton Excerpts

Monday 7th March 2016 Lords Chamber

[Viscount Ridley]

To ask Her Majesty’s Government what effect they expect Article 20 of the 2014 EU Tobacco Products Directive, when implemented in May, to have on the rate at which people give up smoking by the use of vaping devices.

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

The tobacco products directive, which will come into force from May this year, will provide a new regulatory framework for vaping devices and e-liquids, assuring their safety and quality. The Government recognise that e-cigarettes can help people to quit smoking and that quitting smoking completely is the best thing a smoker can do for their health.

[Viscount Ridley (Con)]

My Lords, I thank my noble friend for that helpful reply. Given that the Prime Minister said in the other place that 1 million people have given up smoking as a result of taking up vaping— including, I believe, my noble friend Lord Brabazon of Tara—given that the public health benefits are in the order of £74 billion, and given that the main loser from this is the pharmaceutical industry, which is seeing falls in the sales of patches and gums, does he agree with me that pharmaceutical industry lobbying may be behind the attempt to regulate these products too heavily and possibly to shackle them with an excise tax? Could he give a Department of Health estimate of the size of the black market that is likely to result from this directive and whether or not it will result in people going back to smoking?

[Lord Prior of Brampton]

My Lords, the benefits of e-cigarettes are well understood. The figure of 1 million people who have given up smoking by taking up e-cigarettes is a valid and true one. The tobacco regulation that the noble Viscount refers to does not have any proposals for an excise tax—it purely relates to ensuring that these products are used safely and are of a given quality.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister will know that the impact of this directive is to make it much more difficult for e-cigarettes to be promoted. Why is that, given the clear benefit to public health? The answer is that public health programmes can substitute for it—but this Government have slashed those programmes. Given the Prime Minister’s success in EU negotiations about a change in direction, can the Minister confirm that we will not now have to implement Article 20 if we do not want to?

[Lord Prior of Brampton]

My Lords, this directive originated partly because a number of European countries wanted to ban these products. The fact that there is a directive, which will lead to a regulated market, means that British manufacturers will have access to those large European markets. As I understand it, the main issue that the noble Lord may be concerned about is that where the nicotine content goes above 20 micrograms per millilitre, there will have to be MHRA approval, which may mean that the higher strength nicotine substitutes are less readily available. But that is done on safety grounds.

[Lord Brabazon of Tara (Con)]

My Lords, I have already been mentioned during this Question. I am one of those who smoked for many years but has not had a cigarette now for two years because I have taken up using one of these devices. Can my noble friend tell me why these devices are included at all in the tobacco products directive, because they are not a tobacco product?

[Lord Prior of Brampton]

I also congratulate the noble Lord on giving up cigarettes and taking up these other products. I do not know whether he has tried unicorn blood or crab leg flavours, but a multitude of flavours is available on the market. The directive has come about purely because of the feeling that although nicotine is better than smoking, it is not perfect.

[Baroness Walmsley (LD)]

My Lords, although these products are clearly much less harmful than smoking tobacco, they are not entirely harmless. They have a lot of noxious chemicals in them. What are the Government doing to inform people about the research on the potential hazards of these products, including the reduction in resistance to infections, reduction in fertility and changes in behaviour patterns?

[Lord Prior of Brampton]

My Lords, as I said, these new products are not perfect but are substantially better than smoking cigarettes. One of the purposes of the new directive is that there should be proper labelling on the products.

[Lord Turnberg (Lab)]

My Lords, the noble Lord dismissed the idea of an excise tax, but there is a strong rumour that the EU intends to impose a tax on these products. Will the Government do everything they can to counteract this counterproductive suggestion?

[Lord Prior of Brampton]

My Lords, as I said, there is no proposal for an excise duty as part of the tobacco directive, as I understand it. I would agree entirely with the intent behind the question, which is that we should be promoting this product not discouraging it.

[Lord Naseby (Con)]

My Lords, is my noble friend aware that, following on from what my noble friend said at the beginning, these vapers ensure that there is no harmful effect from passive smoking, which you normally get from cigarettes? In addition, research in New Zealand shows that they are a far better way to come off smoking than placebos or patches, which saves the NHS money. Is this not just another example of a badly thought through draft directive?

[Lord Prior of Brampton]

My Lords, I think there is evidence that e-cigarettes are more effective than, or as effective as, nicotine replacement therapies, and that my noble friend is right that there is no danger from passive smoking, which is why the inability to smoke in public places does not apply to e-cigarettes.

[Lord Pearson of Rannoch (UKIP)]

My Lords, do we really need this sort of interfering directive from Brussels? Are we incapable of looking after vaping devices ourselves?

[Lord Prior of Brampton]

My Lords, we are capable of looking after vaping devices on our own, but if we ever want to sell into the European market, we will have to abide by those regulations.

[Lord Forsyth of Drumlean (Con)]

My Lords, is it not perfectly obvious that big business is lobbying Brussels to shut out competition, that e-cigarettes cost less, which limits the impact of highly regressive taxes on tobacco, and that they enable people to save their health? Will my noble friend admit that the Government are powerless to do anything about this?

[Lord Prior of Brampton]

No, I do not admit that the Government are powerless to do anything about this. I do not believe that the origins of this directive have anything to do with limiting competition; they are based in trying to have a regulated market where safety and quality are guaranteed.

Pharmacies: Funding

Lord Prior of Brampton Excerpts

Wednesday 2nd March 2016 Lords Chamber

[Baroness Walmsley]

To ask Her Majesty’s Government what steps they will take to ensure that every community continues to be served by a local pharmacy, in the light of their plans to cut funding to pharmacies in October.

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

My Lords, community pharmacies are a vital part of the NHS. The Government believe efficiencies can be made without compromising the quality of services or public access to them. Our aim is to ensure that community pharmacies upon which people depend continue to thrive. We are consulting on a pharmacy access scheme which will provide more NHS funds to certain pharmacies compared to others, considering factors such as location and the health needs of the local population.

[Baroness Walmsley (LD)]

I thank the Minister for his reply. Has he made any assessment of the value of the services provided by pharmacies to the NHS, local communities and local authorities in assisting with their public health responsibilities? In light of the importance of all these services and the potential for expansion in future, is it not rather arbitrary of the Government to make these cuts that I understand could cause the closure of 3,000 pharmacies? Then they will sit back and wait for the survival of the economic fittest.

[Lord Prior of Brampton]

My Lords, it is important that we recognise the fundamental changes happening in the market that community pharmacies operate in. With the growth of online ordering of prescriptions, the large-scale automation of dispensing and the integration of health services within which community pharmacies are absolutely vital, the industry will have to change.

[Lord Cameron of Dillington (CB)]

My Lords, have the Government rural-proofed this policy? Has detailed thinking gone into how people without transport in remote rural communities can access pharmacies for their local, possibly life-saving medicines? I am sure that there are solutions to be had in IT and so on, but has that thinking and even understanding gone into the process?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Lord raises an important point. There is no doubt that community pharmacies are vital to all people, but particularly to those living in isolated rural communities. There will be a pharmacy access fund based around isolation and local health needs of the population. We are consulting with the Pharmaceutical Services Negotiating Committee over that issue at the moment. I assure the noble Lord that we are fully aware of the issue he raises.

[Lord McColl of Dulwich (Con)]

My Lords, the Government’s plans will squeeze all pharmacies, resulting in the closure of the least-viable ones—which are often in the poorest districts where they cannot easily diversify. Why do the Government not undertake a means assessment to find out which pharmacies are essential? Closing pharmacies will put even greater pressure on overworked GPs.

[Lord Prior of Brampton]

I assure my noble friend that not all pharmacies will be squeezed equally, as he put it. A pharmacy access fund will ensure that greater resources go to those pharmacies which serve isolated communities in rural areas, and a pharmacy integration fund will ensure that we encourage pharmacies to work more closely with primary care.

[Lord Clarke of Hampstead (Lab)]

My Lords, does the Minister consider that prisons are communities? If he does, will he give the House an assurance that the NHS pharmacies operating in prisons will not face any cuts because, as I understand it, the pharmacies in some prisons are far below the required standard? Can we be given an assurance that they will be exempt from any cuts?

[Lord Prior of Brampton]

The noble Lord raises a very important issue. I do not have the answer to his question. If it is all right with him, I will investigate the matter and write to him.

[Baroness Greengross (CB)]

My Lords—

--- Later in debate ---

[Baroness Greengross]

My Lords, has the Minister considered the relationship between hospital pharmacies and local community pharmacies? At a hospital I know well 56 people are discharged every day. However, they cannot be discharged until their prescriptions are ready from the hospital pharmacy. As people wait up to four hours, beds are blocked 56 times for four hours while they wait. A closer link—which exists in one or two areas—between the two types of pharmacy might remedy that situation. Has the Minister any plans to look at that issue?

[Lord Prior of Brampton]

The noble Baroness makes a very important point. There are many delayed discharges from hospital because people are waiting for their medications and many hospitals do not have the automation within their in-house pharmacies to meet the demand to which she refers. The big driving force going through healthcare and community pharmacy today is one of integration, which means that community pharmacies must in future work more closely with their local hospitals and GPs.

[Lord Clement-Jones]

My Lords, we all have heard what the Minister has to say, but is not the Government’s policy totally inconsistent in that community pharmacists are being encouraged to do more but, as these drastic cuts are being put into effect, they can only do less?

[Lord Prior of Brampton]

I think the noble Lord has misunderstood what I said. Interestingly, 40% of all community pharmacies are in clusters of more than three within 10 minutes’ walk. There has been a proliferation in the numbers of community pharmacies at a time when we want a deeper integration of community pharmacy with primary care in particular.

[Lord Mawhinney]

My Lords, talking about the services which pharmacies provide, when do the Government plan seriously to regulate and inspect pharmacies with a view to making sure that their patient record-keeping and consultation facilities for patients are appropriate to the high standards of patient confidentiality which we insist on in every other aspect of the NHS?

[Lord Prior of Brampton]

The noble Lord raises an important point which I regret I cannot answer. I will have to write to him on that matter. However, for community pharmacy to play the important role in primary care that we expect it to do, it will have to have access to integrated patient records. The confidentiality that surrounds those records is very important.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this is all very well but will the noble Lord confirm that one of the ideas of his department is for doctors to prescribe medicines for a longer period so that fewer trips are made to the pharmacy, thereby compensating for the closure of up to 3,000 pharmacies? However, is he aware that it is estimated that £300 million-worth of medicines are wasted every year? I understand that a third of that is in medicines that are never opened by patients. Surely it is not cost-effective to extend the length of the prescription time because all you will do is add to wastage of medicines.

[Lord Prior of Brampton]

My Lords, there is no intention to extend the prescription time just for the sake of it. But there are many people who have stable long-term conditions, for whom a 90-day prescription period might be appropriate. We are not saying that all prescriptions should be for that length of time but some of them might be.

Health: Black and Minority Ethnic Psychiatric Patients

Lord Prior of Brampton Excerpts

Monday 29th February 2016 Lords Chamber

[Baroness Lawrence of Clarendon]

To ask Her Majesty’s Government what steps they are taking to reassure black and minority ethnic patients, carers and users of mental health services that they are not being prescribed higher levels of psychiatric medication than those from other community groups.

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

My Lords, improving the experience, access and outcomes of mental health services for people from black and minority ethnic communities is a government priority. The Five Year Forward View of mental health services recommended the appointment of a new equalities champion. The Government have accepted the recommendations for the NHS and agree with the task force’s vision for the future.

[Baroness Lawrence of Clarendon (Lab)]

I thank the Minister for his reply. In the last month there has been a government announcement on mental health. There is always a broad-brush approach to this subject. What we need to remember is that no two people are the same and that there are different cultures. People from the black and minority ethnic communities are treated differently when it comes to treatment and institutions where they are placed. That is a fact. There are more treatment options becoming relevant for people with severe, enduring mental health problems and it is not clear whether BME patients are getting access to these—for example, talking therapy. BME patients are more likely to be given higher doses of psychiatric medication. My question to the Minister is: what are the Government doing to ensure that BME patients are offered the same access to treatment options as their white counterparts, and not just psychiatric medication?

[Lord Prior of Brampton]

My Lords, although there is evidence that gender and ethnicity affect the efficacy and tolerability of some medicines, there is no evidence that people from black and minority ethnic backgrounds are prescribed a higher dose of antipsychotics. On the other hand, there is considerable evidence that many people from BME backgrounds are detained more, spend more time in in-patient psychiatric facilities and suffer greater seclusion, and that other aspects of mental health treatment for black and minority ethnic people are entirely unsatisfactory.

[Baroness Hussein-Ece (LD)]

My Lords, I welcome the Minister’s comment that this is a priority for the Government, but is it not the case that this whole issue about the overrepresentation of black and minority ethnic people in the mental health services has been going on for decades and is a scandal? For example, Sarah Reed, a black woman who was incarcerated in Holloway when she was well known to the mental health services, was found dead in her cell in January. She was failed by the Prison Service, mental health services and the criminal justice system. Why are black and minority ethnic people far more likely to be locked up in prison instead of getting proper treatment?

[Lord Prior of Brampton]

The noble Baroness makes a very important point and that is why the Prime Minister has asked David Lammy to conduct an inquiry into this precise issue. In his recent report, the noble Lord, Lord Crisp, recommended that there should be a patients and carers race equality standard. The Five Year Forward View for Mental Health, produced recently by Paul Farmer, recommended an equalities champion. I hope that we will be able to do both those things in the near future.

[Baroness Berridge (Con)]

My Lords, the Minister of State, Alistair Burt, said earlier this month that he would be meeting a wide range of stakeholders to look at BME groups and their unequal access to mental health services. Will the Minister confirm that those stakeholders will include faith community leaders? Black and minority ethnic people are also disproportionately members of faith communities. If those leaders could be trained in recognising the early signs of mental illness, perhaps more people would be referred earlier to the mental health services that they need.

[Lord Prior of Brampton]

My Lords, I will certainly have a word with Alistair Burt, the Minister of State for Health, who is having the meeting to which the noble Baroness referred. I will bring her comments to his attention.

[Lord Patel of Bradford (Lab)]

My Lords, the Minister was chairman of the CQC so he will be well aware that the Care Quality Commission has a responsibility to lay before Parliament an annual report on the monitoring of the Mental Health Act, which it took over from the Mental Health Act Commission when it was abolished. The Mental Health Act Commission used to produce a biannual report with a very significant chapter on the details that the Minister just talked about—the disproportionate number of BME detained patients, the disproportionate use of antipsychotic drugs, and their use at levels above BNF recommendations. Why does the CQC not present that level of data and evidence any more on a yearly basis? Without the evidence and data, how can it take steps to tackle this important area?

[Lord Prior of Brampton]

The noble Lord raises an interesting point. I do not have an answer to his question except the straightforward, “I do not know”. I hope that when the WRES data on staff come through, they can be extended to patients and carers as well—as suggested in the recent report by the noble Lord, Lord Crisp. That information and evidence should then be made available.

[Lord Watts (Lab)]

My Lords, the Government seem to be setting great store by the fact that they are waiting for a review. It is well known that mental health services are massively under-resourced. Would it not be a good start to put some resources into those services?

[Lord Prior of Brampton]

My Lords, the Government are committed to putting more resources into mental health. There is a recognition, across all parties in this House, that mental health has been a Cinderella service for ever. We are all committed to parity of esteem between mental and physical health and more resources are now going into mental health.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in his Answer, the Minister mentioned the Mental Health Taskforce report. It points out that, while there is a workforce race equality standard, there is no equivalent standard for access to services. He said that the Government will appoint a champion, but why not agree to set a standard and appoint a national director to make sure that it is implemented?

[Lord Prior of Brampton]

My Lords, there are two separate things there. We are committed to the recommendation of appointing an equalities champion. Extending the workforce race equality standard to carers and patients was recommended by the noble Lord, Lord Crisp, and welcomed by Paul Farmer in his report. I hope that we will adopt that recommendation, but I cannot promise it.

Access to Medical Treatments (Innovation) Bill

Lord Prior of Brampton Excerpts

Friday 26th February 2016 Lords Chamber

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

My Lords, it has been a fascinating debate. I was not here when we have had debates about this Bill or the Bill that preceded it, so I am not as familiar with the arguments as many noble Lords are. However, it has been a very insightful and high-quality debate.

I first thank my noble friend Lord Saatchi. This is his Bill really. Before I was in this place, I remember listening on the radio in a casual way to the arguments being batted around, and, without knowing the details of his earlier Bill, the need for a quantum change in the rate of innovation and adoption of new medicines and products in this country resonated with me.

I have just come back from a trip to the USA, and one always comes back feeling that there is such a sense of dynamism, speed and pace in America that we simply do not have in this country or in Europe, or anywhere else in the world. Partly, of course, that is because they have much more money in the US, but it is a state of mind. Even in a highly litigious society such as America, there is an entrepreneurial, innovative drive and that is something we need. We have so much research capability in this country and yet we seem to be so slow at bringing products to the market for the benefit of patients. The speech by my noble friend Lord Ryder absolutely nailed this issue once and for all.

I also thank Chris Heaton-Harris, who is still here—he has stood here throughout this whole debate. The work that he and my colleague in the Department of Health, George Freeman, have done to win cross-party consensus for this Bill has been hugely impressive. I also pay tribute to the noble Lord, Lord Hunt, who brought an amendment for a registry in the previous Bill. That has been changed in the new Bill but, nevertheless, has been very important in bringing the Bill to us today.

Before I come to my main speech, I will pick up a few of the particular questions asked by noble Lords. The noble Baroness, Lady Masham, raised the critical point in many ways, which is this balance between innovation and patient safety. That went to the heart of the debate on the original Bill. She raised a particular question about the guardianship of the database. The database will be established with a quality-control mechanism to ensure its oversight. HSCIC is very experienced in databases of this kind and it will have responsibility for that guardianship. It will establish an independent committee to overview the database to make sure that it will not breach patient confidentiality and the like. That is obviously critically important.

The noble Baroness also raised the issue of who could have access to the database. This may disappoint some noble Lords, but access to the database, certainly to start with, will be for doctors rather than members of the public. Again, that is largely based around the need for proper information governance and patient confidentiality. There is a risk, particularly with rare diseases, which the noble Lord, Lord Freyberg, raised, that individuals can be identified if one is not careful.

The noble Lord, Lord Murphy, and others raised the issue of off-label drugs. I can assure noble Lords that the database can include medicines being used off label as well as the use of unlicensed or off-patent medicines.

The noble Lord, Lord Patel, asked what was the definition of medical innovation—or “innovative medical treatment”, which is the right expression. The short answer to that is that, under the Bill, an “innovative medical treatment” is defined as,

“medical treatment for a condition that involves a departure from the existing range of accepted medical treatments for the condition”.

There is clearly a much longer, more technical answer to his question, but I hope that that will satisfy him today.

My noble friend Lord Blencathra raised a number of important issues. It will cost money to establish this database. The estimate is between £5 million and £15 million. That money will be found by HSCIC and ultimately through the Department of Health. Both my noble friend and the noble Baroness, Lady Masham, thought that it would be wonderful if this database could extend to the USA and worldwide. They are absolutely right—in time, but not immediately.

The noble Lord also raised an important issue about whether, if doctors put their results on to a database and they had failed, it would open them up to legal challenge. The establishment of the database will not change whether or not a doctor would face a successful negligence claim. If a doctor acts responsibly, they will not face a successful claim even if the outcome for that patient is negative. I hope that I will pick up other issues that were raised by noble Lords in what I had pre-prepared to say.

The Bill we have considered today is not the same as my noble friend Lord Saatchi’s original Medical Innovation Bill, but it shares the same desired outcome—to create a culture that promotes greater use of innovative medicines and gives us the best chance of improving outcomes for patients. In response to a point that my noble friend made in his introduction, it is very much going in the same direction as the accelerated access review, which is being conducted by Sir Hugh Taylor. We will see that later in the year. That will, of course, address some of the issues raised by my noble friend Lord Ryder.

The Bill before us today seeks to give doctors access to a database as a source of learning where they can both share their innovations and search for those that other doctors have used. The purpose of the database is to promote access to innovative treatments for patients by giving doctors access to information that they may not otherwise be aware of. Doctors will be able to search the database for innovations, see who else is using new techniques, and which ones are effective for patients. The database could ultimately result in better care and health outcomes for patients, and potentially in the fast uptake of new treatments which are shown to work.

I do not think any of us should be under the illusion that this is going to solve the problem; rather, this is us setting out our stall and saying how important the issue is. It will facilitate things, and it is a stake in the sand to show that we, the Government, and the country take this matter seriously. It is also important to state for the avoidance of doubt that the Bill does not contain any provisions relating to the law of clinical negligence. Those provisions have been removed and are not part of this Bill. The Access to Medical Treatments (Innovation) Bill is concerned solely with conferring a power on the Secretary of State to make regulations requiring the HSCIC to set up and manage a database of innovative treatments.

There are two matters that I would like to address in a little more detail, given the degree of discussion there has been around them. The first is how the database will operate and the consultation that will surround it. The detailed design of the database will be worked out by the HSCIC as the expert organisation in this field working in conjunction with professional and patient bodies, a point raised by the noble Baroness, Lady Masham, and others, and other interested stakeholders. On Report in the other place, the Minister for Life Sciences gave an assurance that should the Bill receive Royal Assent before the establishment of such a database, there will be a period of consultation to inform its detailed design. I would like to clarify that this would not take the form of a government consultation, but rather, engagement to be worked out jointly between the HSCIC, the relevant statutory bodies and stakeholders from the medical community representing those who will be using the database.

The second matter is compulsory recording in the database. I am aware that during the passage of my noble friend Lord Saatchi’s original Bill, the issue of mandatory recording and the data registry was the subject of lengthy debate. I know that the noble Lord, Lord Hunt, tabled an amendment seeking to ensure that doctors would be required to record all outcomes, positive and negative, in the registry. I also understand that the Government opposed the amendment on the basis that including a mandatory registry would change the test of negligence under the Bill. As has been covered extensively, the Bill we are discussing today differs significantly from the Medical Innovation Bill. On the issue of recording, it is important to highlight that the principal difference between the data registry and the database of innovative treatments is that the database will both capture and disclose information, while the data registry is concerned with the registration of a patient linked to a disease, or a specific cohort. Crucially, it is intended that information relating to innovative medical treatments and the outcomes of those treatments carried out by doctors in England will be passed to the HSCIC through the use of coding in patient notes.

While there is nothing in the Bill to compel doctors to record their innovations on the database, it is intended that policy guidance on implementation will be issued to providers of NHS-funded services requiring them to ensure that their staff record information on the database. The Government have subsequently liaised with NHS England as to whether this could be made a contractual requirement. NHS England has confirmed that once such guidance has been issued, it could consult on introducing a new condition in a future version of the NHS standard contract with the intention of making compliance with the guidance a contractual duty for provider organisations. Providers of NHS services need to demonstrate to their commissioners that they are complying with their obligations under the standard contract, so they would need to be able to show that they are implementing any condition that required doctors to record in the proposed database.

I hope that what I have outlined will satisfy noble Lords on the issues associated with mandatory recording.

[Baroness Masham of Ilton]

My Lords, before the noble Lord finishes, will he agree that the excuse of confidentiality can be a stifling block to innovation? Les Halpin was an example of openness. Surely patients and doctors should be sharing and working together. Therefore, they should have the information.

[Lord Prior of Brampton]

My Lords, all my experience over the last 15 years is that openness and transparency are critical to get improvement and innovation into the NHS, but we have to accept that patient confidentiality is also extremely important. If we in any way compromise or give people reason to think that patient confidentiality will be in any way intruded on, we may unwittingly undermine everything else that we are trying to do. We have seen that in other areas in the health service in the last year or so. We have to be very careful in this area, but I understand the importance of the noble Baroness’s point.

The Bill does not seek to add an extra burden on doctors, as the GMC’s guidance already sets out requirements on doctors to record their work clearly in clinical records. Doctors are required to have regard to such guidance as part of maintaining their licence. However, through the use of NHS contract guidance, doctors will be required by their providers to have regard to the requirement to record their innovations and, crucially, all associated outcomes.

[Lord Blencathra]

I appreciate that no Minister at the Dispatch Box would dare make any commitment about more time for a Bill or rescheduling, which is the complete province of the Chief Whips and Leaders on both sides, but will my noble friend the Minister make some representations to the usual channels that we seem to be in complete agreement here and that we need to find, within the rules of the House and without creating precedents, some means of making sure that we get the Bill through before the shutters of the House of Commons come down at 2.30 pm on Friday 11 March?

[Lord Prior of Brampton]

I was going to come to that point right at the end. The noble Lord, Lord Hunt, raised it as well. I give complete assurance that the Government will do everything they can to work with the noble Lord opposite and others to ensure that the Bill goes through. It clearly commands the full support of the House. It is a hugely important Bill, which the Government fully support, both in the other place and here. I certainly give that undertaking.