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.

National Health Service: Workforce Race Equality Standard

Lord Prior of Brampton Excerpts

Wednesday 24th February 2016 Lords Chamber

[Baroness Hussein-Ece]

To ask Her Majesty’s Government what progress has been made to improve race equality at senior management and board level in the National Health Service since the introduction of the National Health Service Workforce Race Equality Standard.

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

My Lords, It is outrageous that we have so few people from BME backgrounds in senior management and on NHS boards. We need to take action to improve the experiences of BME staff and their representation.

NHS trusts submitted their baseline data against the workforce race equality standard indicators in July 2015, and NHS England will publish an analysis of those data in April. Reports will then be published annually, outlining the progress that NHS organisations are making.

[Baroness Hussein-Ece (LD)]

I thank the noble Lord for that reply. Can he say why, since the report by Roger Kline on the,

“snowy white peaks of the NHS”,

progress in ensuring that senior management and trust boards are more equal has been so disappointing? It does not reflect the diverse workforce and local populations. Will he ensure that trusts walk the walk and use NHS Executive Search rather than commercial recruitment agencies which all too often, apart from a few exceptions, present all-white shortlists, normally with no people with disabilities, drawn from a very narrow pool for senior positions at enormous financial cost to the health service?

[Lord Prior of Brampton]

My Lords, I shall give the House a few figures. Some 22% of all staff in the NHS are from BME or minority ethnic backgrounds, 28% of all doctors and 40% of hospital doctors. Yet only 3% of medical directors are from BME backgrounds and 7% are in senior management roles. We have two chief executives and six chairmen from BME backgrounds out of 250 trusts. So the performance across the NHS is, as the noble Baroness has mentioned, absolutely terrible and we have to take some serious action to change it. The noble Baroness has given one example but I think that there are many others. The NHS workforce race equality standard is a new initiative which, by introducing some transparency into the health service, will improve matters.

[Lord Patel of Bradford (Lab)]

My Lords, I congratulate the noble Lord because I know that, as chair of the WRES committee, he is very committed to this issue. But does he agree that the targets set will be incredibly difficult to meet in the space of a couple of years? It will mean making changes to tackle the huge inequality that has existed in the NHS for a number of years. I suggest that one way of achieving this is to ask CQC inspectors, when they carry out their inspections, to target specifically the WRES and look for action plans that show improvement year on year. If the improvement is not there, no trust should be getting a “good” on the CQC’s well-led domain without addressing this specific issue.

[Lord Prior of Brampton]

My Lords, the whole purpose of the WRES is to shine a light on the performance of each trust in the country. The CQC will be including it in its well-led domain from March of this year and has already begun to incorporate it into its inspection processes. As the noble Lord knows, in Bradford where he is the chairman of a trust, we have a huge amount of progress to make.

[Baroness Walmsley (LD)]

My Lords, what is being done to ensure fair career progression further down the ladder? Unless we get people moving up, we will never have BME medical directors. Further, is he prepared to comment on diversity among the personnel in the recruitment agencies themselves that work for the NHS?

[Lord Prior of Brampton]

My Lords, the noble Baroness makes a good point. In a way the WRES focuses very much on the more senior grades in the NHS, but we need to focus on progression from band 4 into 5 and 6 as well. It is an important point that needs to be taken on board. As far as recruitment is concerned, it is very important that we have people from BME backgrounds on the recruitment panels. Getting the right people is crucial, and if that means going to external recruitment agencies when we have to, we should not rule that out.

[Lord Tebbit (Con)]

My Lords, can my noble friend say whether or not appointments in the National Health Service will continue to be made on the basis of the ability to undertake the duties of that post?

[Lord Prior of Brampton]

My Lords, the ability to undertake the duties of a post is absolutely fundamental. The tragedy is that so few people from BME backgrounds are encouraged to put their names forward. It is more important that we get the actual recruitment process right.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister should be commended on his approach to this issue. Has he seen the survey undertaken in 2015 which shows that when looking at the national bodies of the NHS such as NHS Executive Search, Monitor and the NHS Trust Development Authority, none of their boards had any BME representation at all? Given that those appointments are made by Ministers, can the Minister tell us what they are doing to rectify that?

[Lord Prior of Brampton]

My Lords, I am not sure that the noble Lord is quite right. I can certainly think of two people from BME backgrounds on the board of NHS England. We can influence this, but it is important that the appointment process is independent of political bias. We have to rely on the chairs and the boards of these arm’s-length bodies to make those appointments.

[The Earl of Listowel (CB)]

My Lords, I am stretching the point rather, but given the increasing awareness that not only the education needs but the health needs of looked-after children and care leavers have been neglected in the past, might the Minister consider looking at how many care leavers and care-experienced adults are represented at senior levels of governance in the health service to ensure that these young people and adults get better support in the future?

[Lord Prior of Brampton]

I think we are probably straying quite a long way from the Question, but I will certainly consider what the noble Earl said.

[Baroness Howells of St Davids (Lab)]

My Lords, I would like to put this on record so that some of the answers to the Question do not keep coming up. No self-respecting person, black or white, will accept a job that they are not capable of. No person who served the National Health Service from any Caribbean country has ever been sacked because of lack of ability. They have suffered racism, but they contributed immeasurably in the days when there were very few white people entering the service. When the Queen gave out her medals to mark the 60th year of her reign, the black community was left out. I appealed on their behalf and they were given medals. There were articles in the newspapers that showed that most of the women who went into the health service as nurses were overqualified.

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, I agree entirely with the noble Baroness’s sentiments. If it was not for the huge number of people with black and minority ethnic backgrounds, the NHS would fall over tomorrow.

Pharmacy (Premises Standards, Information Obligations, etc.) Order 2016

Lord Prior of Brampton Excerpts

Wednesday 24th February 2016 Lords Chamber

Moved by

[Lord Prior of Brampton]

That the draft order laid before the House on 21 January be approved.

Considered in Grand Committee on 22 February.

Motion agreed.

Accident and Emergency Services: Staffing

Lord Prior of Brampton Excerpts

Tuesday 23rd February 2016 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so I refer to the register of my interests.

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

My Lords, it is the responsibility of NHS trusts to ensure that they have the right number of staff with the right skills in the right place to deliver high-quality, safe and efficient care. There are already almost 32,000 more clinical staff working in the NHS than in May 2010, including almost 6,000 more nurses and 1,280 more doctors within the specialty of emergency medicine.

[Baroness McIntosh of Pickering]

My Lords, I thank the doctors who have been looking after my broken wrist. Does my noble friend agree that the problem is not that junior doctors are not working at weekends, but that there are simply not enough junior doctors on the books at this time, and that no other specialists such as therapists, radiologists and so forth are working over the weekend? What will the true cost of seven-day-a-week hospital opening be to the National Health Service going forward?

[Lord Prior of Brampton]

My Lords, seven-day working clearly goes far beyond junior doctors; it requires senior doctors, pharmacists, social workers, and primary care as well as acute care if we are to deliver a full seven-day service. As my noble friend knows, that is our objective over the next five years.

[Baroness Walmsley (LD)]

My Lords, does the Minister endorse the principle of Kirsty Williams’s Private Member’s Bill in the Welsh Assembly, the Safe Nurse Staffing Levels (Wales) Bill, which, having passed with all-party support, now ensures safe staffing levels in all wards in Wales? Will the UK Government follow the example of the Liberal Democrats in Wales?

[Lord Prior of Brampton]

My Lords, I can perhaps be excused for not following all that carefully Private Members’ Bills in the Welsh Assembly promoted by the Liberal Democrats. Safe staffing is obviously very important. I quote Mike Richards on this, who says that it is,

“important to look at staffing in a flexible way which is focused on the quality of care, patient safety and efficiency rather than just numbers and ratios of staff”.

That is extremely important.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister tell me why the Government told NICE that they could not publish safe staffing levels for accident and emergency departments, when they accepted fully the recommendations in Sir Robert Francis’s Mid Staffordshire inquiry report, which said that safe staffing levels should be published? Will he also tell me how NHS trusts are enabled to achieve safe staffing levels when they have been told by the regulator, NHS Improvement, that they have to cut their workforce to cut their financial deficits?

[Lord Prior of Brampton]

My Lords, NHS Improvement never said that trusts should cut staffing levels to below safe levels. It has said that there is a right balance between efficient and safe use of staff. Getting that balance right is so important. That is what Mike Durkin, the national patient safety champion at NHS Improvement, is doing. His work will be reviewed by NICE and by Sir Robert Francis.

[The Lord Bishop of Peterborough]

My Lords, will the Minister please tell us what is being done to help hospitals to have enough doctors and nurses on their permanent staff, rather than having to rely on banks and agencies?

[Lord Prior of Brampton]

The right reverend Prelate is right that reliance on agency and non-permanent staff has become far too high. It is something we must reduce, not just because it is very expensive to use agency staff, but because the continuity and quality of care suffers. We are taking strong action to reduce the role of agency staffing in the NHS.

[Baroness Finlay of Llandaff (CB)]

Do the Government accept that demand on services is now outstripping the increasing workforce that they have tried to invest in? The workforce crisis is made worse because of the brain drain, with emergency medicine trainees being attracted to other parts of the world that often have very good working conditions. The Government therefore need to take an urgent look at the whole pinch point of emergency departments, given the increased number of patients who go to where the lights are on all the time and where they know they will be seen properly by someone who is properly trained. The crisis means that they now will often be seen by a locum and the staff are on their knees.

[Lord Prior of Brampton]

My Lords, the noble Baroness raises an important point, but it is not new: 24% of all doctors who work in the NHS have been trained overseas. This problem goes back over 20 to 30 years. We must train more of our own doctors. On the specific point on emergency medicine, I was surprised that, over the last 10 years, there has been an increase in emergency doctors—A&E doctors in the main—of 9% per annum, against growth in demand of between 2% and 3%. That does not fully answer the noble Baroness’s point, but, compared with other parts of the NHS, there has been greater investment in doctors and other staff in emergency medicine.

[Lord Watts (Lab)]

My Lords, will the Minister give us more detail on the action he has taken on the scandalous use of agency staff in the NHS? Will he tell us how long it will take to deal with this problem?

[Lord Prior of Brampton]

My Lords, this is a big problem, and to fully address it will take up to two years. We are addressing it in two respects: first, the number of people coming in through agencies; and, secondly, the mark-up that agencies charge, which is sometimes more than the cost of the person being supplied.

[Baroness Tonge (Ind LD)]

My Lords, will the Minister tell us when the Government are going to come clean about the health service and actually admit that we cannot carry on the way we are doing at the moment? Will he also tell us when we are going to have a national debate about how we fund the health and social care services in the future, and what services we will provide?

[Lord Prior of Brampton]

My Lords, the noble Baroness calls for a national debate but sometimes I feel that, in this House, we talk of almost nothing else. However, I understand the serious point that she makes. The fact is that the Government are committed to investing £10 billion of new money into the NHS. It is a very significant investment and is no more and no less than her own party promised at the last general election.

[Lord Clark of Windermere (Lab)]

My Lords, the Minister has said that we have to train more of our own doctors, and on previous occasions he said that we have to train more of our own nurses. In training the nurses, we are taking a risk in abolishing the bursary system so that when those new nurses are qualified in 15 months’ or 18 months’ time they will have debts of about £40,000. What progress are the Government making in trying to reward those nurses who spend a considerable time in the health service—perhaps 10 or 15 years—so that those debts can possibly be written off?

[Lord Prior of Brampton]

The noble Lord will know that we are consulting on the proposals to remove bursaries and replace them with student loans. All the indications are that this will enable us to increase the number of nurses because the current system means that many young men and women who wish to become nurses are not able to do so. I think that three out of four people who apply are not able to get on the right courses. We hope that the new system will increase the number of nurses available to the NHS.

[Baroness Howarth of Breckland (CB)]

My Lords, will the Minister tell me why, when they are qualified, it is safe for young nurses to do five 12-hour night shifts on the trot when we would not allow lorry drivers to do five 12-hour nights on the trot?

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, I am not aware of that. Some nurses may work five 12-hour night shifts. The standard may be for nurses to work three 12-hour night shifts because many nurses prefer to work 12-hour shifts rather than the more traditional eight-hour shifts. I do not think that it is especially good for nurses to work those long hours, nor is it particularly good for patients. Nevertheless, offering nurses the opportunity to work 12-hour shifts fits round many young people’s—particularly women’s—working lives.

Mental Health Taskforce

Lord Prior of Brampton Excerpts

Tuesday 23rd February 2016 Lords Chamber

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

My Lords, I will now repeat as a Statement the response to an Urgent Question given in another place by my right honourable friend the Minister of State for Community and Social Care on the report of the independent Mental Health Taskforce. The Statement is as follows.

“Achieving parity of esteem for mental and physical health remains a priority for this Government. We welcomed the independent Mental Health Taskforce launched by NHS England last year with a remit to: explore the variation in the availability of mental health services across England; look at the outcomes for people who are using services; and identify key priorities for improvement.

The task force was chaired by Paul Farmer, chief executive of Mind, and I want to thank him, the vice-chair, and his team for all their work. The task force also considered: ways of promoting positive mental health and well-being; ways of improving the physical health of people with mental health problems; and whether we are spending money and time on the right things.

The publication of the task force’s report earlier this month marked the first time a national strategy has been designed in partnership with all the health-related arm’s-length bodies in order to deliver change across the system.

This Government have made great strides in the way we think about and treat mental health in this country. We have given the NHS more money than ever before and are introducing access and waiting time targets for the first time. We have made it clear that local NHS services must follow our lead by increasing the amount they spend on mental health and making sure beds are always available.

Despite these improvements, the task force gives a frank assessment of the state of current mental health care across the NHS, highlighting that one in four people will experience a mental health problem in their lifetime and that the cost of mental ill health to the economy, NHS and society is £105 billion a year. We can all agree that the human and financial cost of inadequate care is unacceptable. Therefore, we welcome the publication of the task force’s report, and the Department of Health will work with NHS England and other partners to establish a plan for progressing the task force’s recommendations for improving mental health.

To make these recommendations a reality, we will spend an extra £1 billion on mental health by 2020-21 to improve access to services so that people receive the right care in the right place when they need it most. This will mean increasing the number of people completing talking therapies by nearly three-quarters, from 468,000 to 800,000; more than doubling the number of pregnant women or new mothers receiving mental health support from 12,000 to 42,000; training around 1,700 new therapists; and helping 29,000 more people to find or stay in work through individual placement support and talking therapies.

I can assure all Members of the House that they will have ample opportunity to ask questions and debate issues as we work together to progress the task force’s recommendations”.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister for repeating this Statement. The final report, which came out recently, gave a very frank assessment of the state of current mental health services and describes a system which is said to be ruining some people’s lives. It is entirely consistent with the report by the noble Lord, Lord Crisp, on acute in-patient psychiatric care. It makes a number of recommendations which, if implemented in full, could make a significant difference to services that have had to contend with funding cuts and staffing shortages as demand has continued to rise, leaving too many vulnerable people without the right care and support.

We return to a question which was debated yesterday: the £1 billion by 2021. A number of questions remain unanswered. Can the Minister confirm that there is no actual, additional money other than the existing £8 billion that has been set aside for the NHS up to 2020, as previously announced by Her Majesty’s Treasury? Given that mental health services receive just under 10% of the total NHS budget, surely these services would actually expect to receive much of this additional money anyway, as part of the NHS settlement. Will the Minister explain how this can be expected to deliver the transformation that he and the task force say is urgently required?

In a recent Oral Question, there was the usual discussion of whether there should be a national debate about NHS funding. The Government need to get on, not just to debate it but to ensure that the NHS has enough money. Has the Minister studied the advice given by Professor Don Berwick, the Government’s safety adviser? He said, “I know of no nation that is seeking to provide healthcare at the level that western democracies can at 8% of GDP, let alone 7% or 6.7%. That may be impossible”. His advice to the Secretary of State was that it is crucial that the Government reflect on whether they have overshot on austerity. What is the Minister’s response to his own safety adviser?

[Lord Prior of Brampton]

My Lords, we have strayed somewhat from the subject. On the money, the Prime Minister announced an extra £1 billion in January. It is the same £1 billion and is within the £8 billion—or £10 billion—that was in the settlement in November. The Government asked Paul Farmer to set out in his report where the priorities are and where the money should be spent, and that is exactly what has happened. Interestingly, I saw Don Berwick last week. He is a very distinguished American with a lot of experience in patient safety and health improvement. There is no question: it is going to be tough. It will be very difficult to do on around 7% of GNP, but there is absolutely no doubt, from the work of the noble Lord, Lord Carter, and others, that there is a lot to go at. If it was not tough, we would not be going at it. We must take advantage of the fact that it is going to be tough by addressing some of the difficult issues which we should perhaps have addressed in the past but did not.

[Baroness Tyler of Enfield (LD)]

My Lords, the task force report, which I greatly welcome, points out that, while mental health activity accounts for some 23% of what the NHS does, it accounts for roughly half of that in NHS spending. Worse still, years of low prioritisation within the NHS have meant that clinical commissioning groups have often diverted money earmarked for mental health spending to areas of physical health, and that is harder to quantify because of obscure methods of data collection. Could the Minister say what steps the Government propose to take to ensure that the extra £1 billion announced, whether entirely new or not, is actually spent on improving mental health services. How will that be monitored in practice?

[Lord Prior of Brampton]

My Lords, that is clearly a very good question. At our level, we will monitor this through the mandate given to NHS England. Within that mandate, it has told all CCGs that they must increase their spending on mental health services by, I think, at least 3.7%. The noble Baroness will be interested to know that in the first six months of this year the increase in spending on mental health has been 5.4%, so it is higher than the stipulated 3.7%. Over the next five years I think we will see a trend towards more money going into mental health and primary care and away from acute care. We should not underestimate the very difficult impact that will have on many of our acute hospital services. The transformation will be very difficult. We may not agree on how much money it will take but I think we all agree in this House on the direction of travel—that it must be right for money to be spent in those areas. I hope that answers the noble Baroness’s question.

[Lord Watts (Lab)]

My Lords, the Minister will be aware of the acute shortage of mental health beds for children. How many new beds will be provided by the Statement?

[Lord Prior of Brampton]

My Lords, this Statement does not deal with children. The Government have promised to spend an extra £1.4 billion on children and young people over the next five years. I cannot recall the impact that it will have on the number of beds but there will certainly be more beds for children experiencing severe eating disorders. I will have to write to the noble Lord with that information if that is all right.

[Baroness McIntosh of Hudnall (Lab)]

No doubt the noble Lord will tell me if I am wrong, but I believe that attracting people who are in training, particularly as doctors, into psychiatry and other mental health-related parts of the profession is still very difficult. What work are the Government doing with the medical training institutions to encourage more people to regard psychiatry and related professions as a proper way to use their skills?

[Lord Prior of Brampton]

The noble Baroness is right: psychiatry is one of the shortage areas, along with general practice and a few other specialties. Premia will be available in the new junior doctor’s contract to encourage people to do psychiatry. That does not answer the noble Baroness’s question all that fully; this is something I should like to look into more myself. However, within the extra spending that has been announced, there will be money for, I think, 1,700 therapists who are experienced in IAPT—cognitive behavioural therapy and the like—which should also help.

[Baroness Finlay of Llandaff (CB)]

Given the problems experienced by emergency departments when they have an acutely distressed and ill mental health patient who cannot be cared for in the community and who needs to have a bed found for them, do the Government recognise that, at the moment, beds in the emergency department have to be blocked off—sometimes for hours, occasionally for days—while a bed is sought for this person, who could not possibly be cared for in the community because they are so acutely disturbed? Will the task force be asked to look specifically at that area of acute provision, separately from some of the other areas of more chronic mental health provision?

[Lord Prior of Brampton]

My Lords, it is very serious when someone going through a severe psychotic episode ends up in an A&E department, there is no local bed available in a mental health hospital, and they therefore spend time being specially guarded by two or three people, often in wholly inappropriate surroundings. This is the issue that the noble Lord, Lord Crisp, addressed in his report which came out a week earlier than the task force’s: people are moved, often many hundreds of miles away, out of their area, to find a bed. Sometimes they get there and the bed is full and they are a long way from their family. It is a highly unsatisfactory, often very dangerous, situation. The approach of the task force is to try to ensure that more money goes into the home treatment and home resolution area, to free up beds in the acute sector. By providing more care in the community, more beds are freed up in acute hospitals, increasing capacity and enabling people who are in A&E departments to be transferred more quickly to the right place. This is clearly a very serious issue.

[Baroness Royall of Blaisdon (Lab)]

My Lords, the response to the Urgent Question makes reference to the needs of mothers with new babies. Will any investment be made in additional mother and baby units, which are critical for mothers, children and families?

[Lord Prior of Brampton]

My Lords, of the £1 billion, £290 million has been earmarked for perinatal spending on pregnant women and mothers suffering from postnatal depression. I cannot tell the noble Baroness how many extra beds that might provide, or how much of that is being provided away from beds, but I will write to her on that matter.

[Lord Lansley (Con)]

My Lords, does my noble friend the Minister agree that in order to secure parity between physical and mental health services, it is important to ensure that mental health service providers are properly and fairly reimbursed for the activity they undertake rather than subject to a block grant system where physical health service providers are paid for the work they do? In that respect, will the Government commit to working with NHS England and NHS Improvement to make progress now in the development of tariff-based systems for mental health services which fairly reimburse for delivering quality in outcomes?

[Lord Prior of Brampton]

My noble friend is absolutely right. I am glad he finished by referring to quality in outcomes rather than just activity. That is the critical thing about getting the tariff right, that it is based not just on activity but on quality in outcomes.

[Lord Patel (CB)]

In responding to the task force report, is it the Government’s intention to produce a mental health strategy that will encompass all the issues, including the funding?

[Lord Prior of Brampton]

Together, the task force report, the report produced by the noble Lord, Lord Crisp, and the earlier report on children and young people really do comprise a strategy for mental health for the next five years.

Health: Adult Psychiatric Care

Lord Prior of Brampton Excerpts

Monday 22nd February 2016 Lords Chamber

[Lord Crisp]

To ask Her Majesty’s Government what is their response to the report Old Problems, New Solutions: Improving acute psychiatric care for adults in England.

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

My Lords, the Government very much welcome this report and are considering its recommendations. We have asked NHS England to reduce out-of-area treatments and eliminate their inappropriate use. NHS England published its independent Mental Health Taskforce report last week, backed by a £1 billion investment announced in January. NHS England will develop standards on access to mental health treatment.

[Lord Crisp (CB)]

My Lords, I thank the Minister for that reply, and I am delighted to see the commitment to parity of esteem between mental and physical health and to the funding allocated last week. Parity of esteem means equal standards for people with mental and physical conditions. The report recommends that requiring people to travel long distances to be treated should be phased out within 18 months, and there is evidence as to why that is a good target; and yet the Government have indicated in their response to the task force that it would take four years to phase it out. Will the Minister explain why that is and say whether there is scope for the Government to reconsider the timing?

[Lord Prior of Brampton]

My Lords, I reiterate my thanks to the noble Lord for his excellent report: it is 134 pages and reads very well and very quickly. It is obviously highly unsatisfactory that so many people have to travel long distances to get in-patient care. The noble Lord’s report shows that, in one month—in September, I think—500 people had to travel more than 50 kilometres to get to in-patient care. It is a priority for the Government and we are considering the noble Lord’s recommendations. I cannot give a commitment that we can reduce the four years to 18 months now. I can only repeat that we fully understand the importance of addressing this issue.

[Baroness Tyler of Enfield (LD)]

My Lords, the noble Lord’s report rightly points to the need to improve both in-patient care and alternative treatment in the community. Given that, as the report says, the cost of one adult acute bed is the same as that of treating 44 people at home, will the Government say what plans they have at this early stage to increase financial incentives to encourage commissioners to get the right balance of provision?

[Lord Prior of Brampton]

My Lords, if we can improve home treatment and crisis resolution at home it will free up in-patient beds and solve the other problem as well, as people will have to travel less far. That is absolutely critical. I cannot tell the noble Baroness today what NHS England is proposing to do with financial incentives, but I can reiterate that treating more people outside hospital, at home, is a priority for the Government.

[Baroness Armstrong of Hill Top (Lab)]

My Lords, does the Minister realise that there are real problems in many regions? I chair a charity which deals with the most vulnerable—people with complex needs. We have evidence that the number of people whose mental health needs have increased has risen significantly over the past five years, and yet three centres in Tyneside—both residential and day care—which deal with the mentally ill are closing this year. How will we meet those people’s needs in such circumstances?

[Lord Prior of Brampton]

My Lords, reading the noble Lord’s report, I was struck that he said in the foreword that he went through times when he was very depressed and times when he was deeply impressed. In a way, that sums up the mental health system—it is fragmented, and there is a high level of variation. We provide fantastic care in one place but terrible care for somebody else, and very often it is not related to cost. I do not know about the particular instances that the noble Baroness has referred to, but I can fully understand that in certain areas it is much worse than in others.

[Lord Bradley (Lab)]

My Lords, I declare my health interests. I, too, welcome the excellent report and recommendations by the noble Lord, Lord Crisp, and his commission, and also the report and recommendations of the Mental Health Taskforce published last week. I would be grateful for clarification from the Minister on the financial commitments that the Government have made on the crucial implementation of the recommendations of both reports. In particular, can he confirm that the announcement of £1 billion each year for mental health services begins in financial year 2016-17; that, for the next four years, that £1 billion will be additional to the £1.5 billion investment in child mental health services which has already been announced; and, finally, whether this £1 billion annually is additional money or part of the £8 billion which has already been announced and allocated to NHS England for all health services?

[Lord Prior of Brampton]

My Lords, that is a complicated question, or number of questions.

[Lord Hunt of Kings Heath (Lab)]

It is very simple.

--- Later in debate ---

[Lord Prior of Brampton]

No, it is not very simple, or at least it is not simple to me; but then I perhaps have a smaller brain than the noble Lord opposite. It is certainly additional to the £1.5 billion for children and young people. I cannot tell the noble Lord now, without fear of making a mistake, whether it will be £1 billion every year from 2016-17 to 2021. It is certainly £1 billion in 2021. If it is all right, I will write to the noble Lord to confirm and clarify that.

[Baroness Finlay of Llandaff (CB)]

How do the Government intend to monitor the efficacy of this investment, and against what performance indicators will this investment be audited?

[Lord Prior of Brampton]

My Lords, that is a very hard question to answer. The talking therapies, for example, seem to be effective in about 50% of the cases, and whether they are effective is clearly a clinical decision. As for other standards, we tend to rely, as the noble Baroness will know, on proxies such as waiting times and the four-hour standard, which the noble Lord recommended in his report. We are considering the introduction of a four-hour waiting-time standard for people suffering from psychotic problems, in the same way as we have for physical health.

[Lord Foulkes of Cumnock (Lab)]

My Lords, can I give the Minister an easy question? What discussions has he or any of his colleagues in the Department of Health had with his counterparts in the Scottish Administration to exchange experience and ideas?

[Lord Prior of Brampton]

My Lords, I am not aware that we have had any discussions in the Scotland Office. However, there is no doubt that in Scotland they are approaching quality improvement extremely effectively. I had a recent meeting with people who have been involved in that, so I can assure the noble Lord that, at that level, if we can learn things from what they are doing in Scotland, we will do so.

[Baroness Farrington of Ribbleton (Lab)]

My Lords, will the Minister give an undertaking that the very good system of encouraging treatment at home is not at the expense of families where children are the primary carers? When children are trying to cope with someone in very difficult circumstances they are often alone for long periods and are unable to cope with a mother or father whose behaviour can even be frightening.

[Lord Prior of Brampton]

My Lords, the noble Baroness raises an important point. So much of this comes down to judgment, and so much of that judgment is judged with hindsight. We put a huge onus on clinicians and people working in health and social care to make the right judgments on where to treat people. In normal circumstances, where people can be treated at home rather than in an in-patient setting, that will be best; but there will be exceptional circumstances such as those that the noble Baroness mentioned, where it may not be.

Pharmacy (Premises Standards, Information Obligations, etc.) Order 2016

Lord Prior of Brampton Excerpts

Monday 22nd February 2016 Grand Committee

Moved by

[Lord Prior of Brampton]

That the Grand Committee do consider the draft Pharmacy (Premises Standards, Information Obligations, etc.) Order 2016.

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

My Lords, this order makes changes to the pharmacy regulators’ powers to regulate pharmacy premises. In broad terms, the intention is to remove the General Pharmaceutical Council’s duty to set standards in rules and, instead, turn them into code of practice-style obligations which are enforced through disciplinary committee procedures. The Northern Ireland regulator, the Pharmaceutical Society of Northern Ireland, will have a statutory duty to set standards for registered pharmacies and the order clarifies what those standards can cover.

The order also makes changes to the regulators’ ability to issue interim suspensions from the premises register. The General Pharmaceutical Council’s powers relating to improvement notices are amended. It is enabled to publish reports of pharmacy premises inspections, there are changes to its powers to obtain information from pharmacy owners, and a correction is made to the Pharmacy Order 2010 in respect of the notification of the General Pharmaceutical Council of the death of a pharmacy professional. All the changes have been developed with the agreement of the regulators, the Government and the devolved Administrations. Since the General Pharmaceutical Council’s pharmacy premises standards may relate to the regulation of pharmacy technicians, which is a devolved matter, this order has also been laid in the Scottish Parliament.

I should give the Committee some background. All pharmacists and pharmacy technicians who practise in Great Britain must be registered by the General Pharmaceutical Council. Pharmacists who practise in Northern Ireland are registered with the Pharmaceutical Society of Northern Ireland. Pharmacy technicians are not a registered healthcare profession in Northern Ireland. Unlike most other healthcare regulators, the pharmacy regulators are also responsible for the regulation of registered premises. The regulation of retail pharmacy premises is the subject of the order under debate today.

The key change for the General Pharmaceutical Council, and one of the Law Commission’s recommendations, is that it should no longer be required to set standards for registered pharmacies in rules. Instead, the standards should be aligned with other regulatory standards and be code of practice-style obligations enforced through disciplinary procedures. This supports the General Pharmaceutical Council’s approach, since its inception in 2010, to move to an outcomes-based approach to pharmacy premises regulation. Overall, it will align the legal status of registered pharmacies’ standards with the status of standards for individual registrants.

As a consequence of moving the standards out of rules, they will no longer be included in a statutory instrument that is subject to Privy Council approval. Increasing the autonomy of the General Pharmaceutical Council in this way is in line with government policy. However, the order includes an explicit requirement for the General Pharmaceutical Council to consult Scottish Ministers, as well as English and Welsh Ministers, on changes to pharmacy premises standards.

The General Pharmaceutical Council’s standard-setting powers are being extended to include associated premises; that is, premises at which activities are carried out which are integral to the provision of pharmacy services. This reflects the fact that, in some respects, the traditional model of pharmacy premises being entirely self-contained operations in which all aspects of the retail pharmacy business are carried out is, for some businesses, outdated. Integral parts of their business operations—for example, electronic data storage—may be elsewhere. Very similar changes are being made in relation to Northern Ireland.

The disqualification procedures for pharmacy owners and the procedures for removing premises from the premises register are being amended for both regulators; first, so they apply to retail pharmacy businesses owned by a pharmacist or a partnership, as well as bodies corporate; and, secondly, to clarify that the test to apply sanctions where premises standards are not met is whether or not the pharmacy owner is unfit to carry on the retail pharmacy business safely and effectively.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for his careful explanation of the order. On the whole, the changes seem sensible, and I note that some of them follow the Law Commission’s recommendations. As the noble Lord will know, there has been disappointment that the Government did not bring forward a Bill or a draft Bill in relation to the whole package, and I know from our previous discussions that the Government are considering what further to do in relation to the regulation of individual health professionals. Is he able to update me on where the Government are on that?

On the detail of the order, I noted that overall the consultation outcome showed a great deal of support for the proposals, although perhaps less so in respect of the change in relation to standards for registered practices, which are no longer to be placed in legislative rules. I noted that some concerns were expressed, according to the Explanatory Memorandum,

“that removing the ‘black and white’ rules could lead to unhelpful variation for employee pharmacists in the way pharmacy owners choose to meet the standards”.

I assume that the proposal for an outcomes-based approach would ensure that there will be consistency about the standards themselves but leave more discretion for individual community pharmacies to decide how to meet them. Could the noble Lord confirm that for me?

The noble Lord made a very interesting comment at the end of his speech about the rapid change in the way community pharmacy services are provided. I certainly agree with that. I am sure he is aware that an estimated 1.6 million people visit a pharmacy every day. There is no question but that they have huge potential, not just in dispensing medicines but in many of the other services that are now available in community pharmacies, for example home delivery, compliance aids and other support to help old and frail people in particular live independently. There is also no question about the strong professional advice community pharmacies can give, particularly in relation to medicine management. We know, again, that older and frailer people in particular can be prescribed individual medicines without perhaps the GP or other doctors looking at the whole impact, whereas community pharmacies, through medicine management approaches, can have a very beneficial impact. For instance, this winter, NHS flu vaccines were available for the first time through community pharmacies. Again, that shows the benefit of recognising the professional expertise they have and of trying to ensure that they can relieve some of the load on other pressurised parts of the National Health Service.

The Government have made clear in a number of publications how they value community pharmacies, so I have been puzzled by the reductions that are going to be made in the community pharmacy budget, which is the subject of an Oral Question next week. I am puzzled by the thinking behind that reduction, which I think will start in October 2016, according to a letter that the Department for Health and NHS England sent out to community pharmacies. I just wanted to ask two or three questions about this.

First, in the letter that was sent out to community pharmacists, or to their representative organisations, there was a clear implication that the Government think there are too many community pharmacies at the moment. The letter points out:

“In some parts of the country there are more pharmacies than are necessary to maintain good access. 40% of pharmacies are in a cluster where there are three or more pharmacies within ten minutes’ walk. The development of large-scale automated dispensing, such as ‘hub and spoke’ arrangements, also provides opportunities for efficiencies”.

The department is also looking at ways of online ordering, which will make it easier for the public. The letter also says it is looking at,

“steps to encourage the optimisation of prescription duration”,

which I assume means prescriptions for a lengthier period than currently.

The Pharmaceutical Services Negotiating Committee has told me that it feels that the cut in budget is incompatible with the Government’s ambitions in relation to the contribution of community pharmacy. It wants to know whether it is government policy to see a reduction in community pharmacy premises. It would be a brave Government who said that they wanted to see that, but clearly it would be helpful to know if that is a stated intention. The development of an online pharmacy service is clearly to be encouraged. The record of community pharmacy has been very good in relation to being able to adopt a digital approach. Will that be done in a way that does not bypass the actual value of the advice that pharmacists can give to individual patients, particularly about medicine management?

Finally, on the question of increasing the length of time of a prescription, we know that a lot of medicine is wasted. Often, patients give up the course before they reach the end, even though they are recommended to take the full course. I can see that making the length of a prescription longer will mean that they will need fewer visits to the community pharmacist, thereby reducing the money going to the community pharmacist. However, if it leads to a greater waste of medicine, it might be a false economy. Has the department undertaken any work on that?

Overall, the SI itself is eminently sensible, but it cannot be considered without looking at the context of where community pharmacy is going. When we debated the Health and Social Care Bill in 2012, we discussed whether community pharmacists should be represented, as of right, on the board of a CCG. The Government resisted that, but there is evidence that because community pharmacists are not around the table at CCG level, the contribution they can make is often missed when it comes to issues such as how you make a health economy work effectively together or how you can, say, reduce pressure on A&E. We may be missing a trick here in not embracing community pharmacy rather more than we have been for the past year or two.

[Lord Prior of Brampton]

My Lords, I had a feeling that we might stray beyond the order, and we duly have. The noble Lord raised three broad points. The first was to request an update on the Law Commission’s report into the regulators. I do not have much to say that we have not already said. We think that a lot of what was in the Law Commission’s report was absolutely right, but it was a long and fairly prescriptive approach to the matter. We are considering it and may return to it in this Parliament, but it is not a priority in the short term.

The noble Lord referred to the outcomes-based approach and raised concern about whether the standards will be consistent. The intention is that they will, but there will be more discretion in how the outcomes are achieved. We are at one on the intent that lies behind his question.

I turn to the much more difficult matter that the noble Lord raised, which does not relate directly to the order, although he is right to say that it provides some context. The first thing to say is that I agree wholeheartedly with what he said about the vital role of pharmacists not just in dispensing but in how we manage medicines, perform vaccinations and look after the old and frail. I was interested by his comment at the end about why pharmacists are not represented on the board of CCGs. When we come to debate our whole approach to community pharmacy in more detail, we will set out our views on how pharmacy should be more integrated with the delivery of health and social care. It may well be that we should revisit whether pharmacists should be on the board of CCGs. Perhaps I can take that away to think about it further.

I do not want to be taken down the route of the number of pharmacists, because we are out to consultation at the moment. It is a fact that 46% of pharmacists are located in very close geographic proximity to each other. That is one reason why we have been looking at the structure of delivery of community pharmacy. On the one hand, we absolutely recognise that in rural areas we must have community pharmacies close by, and we want them to be much more integrated with healthcare delivery; on the other, there must be a question mark about the structure of community pharmacy. The number of outlets has grown from 9,000 to 11,500 in the past seven or eight years, which is a huge increase. Much of that increase has come from people setting up shop in very close proximity to existing pharmacies. It is right that we look at the whole delivery of healthcare by pharmacies, and it will be interesting to see what emerges from the current consultation.

Alcohol Strategy (EUC Report)

Lord Prior of Brampton Excerpts

Wednesday 10th February 2016 Grand Committee

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

My Lords, I also thank the noble Baroness, Lady Prashar, and her committee for the report. It has stimulated a very interesting, balanced and well-informed debate today. We have probably not got time to do justice to all the issues raised. I would suggest that we might meet for a drink afterwards but that would probably not be appropriate in the circumstances.

We are all aware of the impact of alcohol misuse. I was interested in the reflections of the noble Lord, Lord Hunt, on getting the balance right between trying to achieve something—but not doing so in such a blunt way that it will have unintended consequences—and deciding that it is not possible so we will not even try to do it. The way in which successive Governments have tackled the problem of tobacco over a very long period shows that you have to win the argument with the public. We are a long way from winning this argument with the public. Although not everyone likes a drink, most of us do, and so the argument is more difficult than it was with tobacco. On the other hand, the argument is even more difficult with obesity. That is the most difficult argument of all to win. We need to get the balance right.

The noble Baroness was right to raise the issue of the comments of the Chief Medical Officer. The image where every time you take a glass of wine you think of cancer has stuck with me, although it was-directed at women. The noble Lord, Lord Hunt, is shaking his head. However, it has at least raised the issue, even if it has spoiled a glass of wine. We all know that the misuse of alcohol can be hugely damaging and not only from a health point of view. As has been said, misuse of alcohol can lead to domestic abuse, violent crime and the like.

On strategy, the 2012 strategy is extant and we will soon be publishing our life chances strategy and the new crime prevention strategy, which will include a separate chapter on alcohol. We may not be coming up with a specific new alcohol strategy but alcohol is very much part of our approach to a number of different issues. It is good that we are giving our attention to this. Perhaps it would have been better to debate this in the main Chamber but we are dealing with it here.

It is worth prefacing what I am going to say by reminding the Committee that most people drink in an entirely responsibly way. We do not want to penalise people who drink responsibly unnecessarily just because a small minority do not. I was slightly worried by the comment of the noble Baroness, Lady Murphy, about Norfolk. I did not know that we had a particular problem with Norfolk. If we do, perhaps it is in the Brancaster golf club or somewhere like that. I do not know where that problem is.

I want to highlight the UK Government’s position on some of the key areas of our response to the report of the House of Lords committee. Overall, we welcome the report and broadly agree with its recommendations. In particular, we fully agree with the committee that action is worth formulating at an EU level only to the extent that it supplements and supports what member states can do independently. That is important. It is what we do here that is of primary importance. I agree with the comments of the noble Baroness, Lady Prashar, that anything we do at EU level must also be flexible because every country is different—the culture in Norwich is different from that in Rome—and anything we do should reflect that.

The UK Government continue to support the view that member states should drive alcohol policy but that the Commission should complement this by sharing best practice, by providing a common evidence base— which the noble Baroness felt the EU had singularly failed to do—and by dealing with issues that member states cannot deal with on their own.

It is worth mentioning taxation in this context. The UK Government believe that alcohol duties should be directly proportional to alcohol content. This falls into the “bleeding obvious” territory. However, this is a European Union issue but the UK Government will be putting what pressure they can at that level to try to get proportionality into the way that we tax alcohol.

The UK Government are keeping minimum unit pricing under review. I am afraid that I cannot go beyond that. We are monitoring closely what is happening in Scotland with the Scotch Whisky Association. I can do no more than say that we will keep it under consideration. It is a serious issue and anyone formulating a policy on alcohol would be foolish not to keep it under consideration. Whether they decide to do so is another matter. However, it is like a sugar tax land we should keep it under careful consideration.

On marketing, the Government are committed to working with industry to address concerns over irresponsible promotions. We believe that material in the Committee of Advertising Practice’s UK Code of Broadcast Advertising relating to the advertising and marketing of alcohol products is exceptionally robust. For example, it may not be featured in any medium where more than 25% of the audience is under 18. However, if new evidence emerges that clearly highlights major problems within the existing codes, the Advertising Standards Authority has a duty to revisit them and take appropriate action.

A number of noble Lords raised the issue of mandatory labelling. As a result of the responsibility deal, just under 80% of bottles and cans of alcohol were assessed to have the correct health labelling, by which I mean clear unit content, the CMO’s lower-risk drinking guidelines and a warning about drinking when pregnant. I have noticed that the noble Lord, Lord Patel, raised the issue of pregnancy and when we are reviewing our strategy we should consider whether that is enough. The UK also secured a provision to allow voluntary calorie labelling, which some businesses are already using. Supermarkets including Sainsbury’s, Co-op and Waitrose are using voluntary calorie labelling. That is probably as far as we can go at this stage. The possibility of mandating nutritional labelling, including calories and ingredients labelling on alcohol, is still under discussion at EU level. As I say, we are making progress on a voluntary basis in the mean time.

I would like to highlight the other actions that we are taking. As noble Lords have said, sales of alcohol below the level of duty plus VAT were banned in May 2014. We are advised that the minimum unit pricing case does not affect that ban, so I think that it will continue as it is. Later this year, we will publish the new crime prevention strategy, within which alcohol will feature prominently. The noble Lord, Lord Maclennan, raised the issue of drink-driving. We are going to watch what happens in Scotland, where the level is being brought down from 80 milligrams to 50 milligrams—is that per litre of blood?

[Lord Brooke of Alverthorpe]

It is 50 milligrams to 100 millilitres of blood.

[Lord Prior of Brampton]

We will see what impact that has: if it is major, we should clearly take it into consideration.

Since April last year, the standard GMS contract has included delivery of an alcohol risk assessment to all patients registering with a new GP. This has the potential to raise awareness of alcohol as a risk factor with a large percentage of the population. The Government are also continuing to work with Public Health England, which is giving a high priority to alcohol issues by working with local authorities. However, we believe it is right that the primary responsibility for drug and alcohol issues should be with local authorities. PHE will support all local authorities and their partners to put in place high-quality interventions to prevent, mitigate and treat effectively alcohol-related health harm. As noble Lords will know, services include local licensing controls and specialist services to support recovery for dependent drinkers.

In 2014-15, the Department of Health commissioned PHE to review the evidence and provide advice on the public health impacts of alcohol. The review of evidence has been completed and is in the process of being written up as they complete a peer review process. It will be available in due course.

The new alcohol guidelines provided by the CMO are currently out for consultation. That will have an important impact on the debate as we go forward, so I hope that noble Lords in this House will contribute to that consultation. The department recognises that in the light of the new guidelines further work will need to be done on labelling and an appropriate transition period will be put in place to ensure industry can change its labelling in a cost-effective way.

The noble Lord, Lord Brooke, raised the issue of duties and the mixed messages that might come from reducing duties. All Governments face this issue. They have to get the balance right between what is good for people and what people want to do in a free and democratic country. It is a difficult balance to strike. I do not think that the Chancellor has been any more or less responsible in this matter than previous Chancellors. One of the joys of living in a democracy is that these issues are balanced for us. In a world that was less free, a ban might be put in place—prohibition or something—but I do not think that many of us would like to live in that kind of society. So this balance between what is good for you and what people like doing is something that we vote for in general elections.

We recognise the contribution that not just individuals but also businesses and our communities can make to help people better understand the risks associated with alcohol. I am sure that this is an issue to which we will return in due course. Change will not happen overnight. I take very much on board what the noble Lord, Lord Hunt, said about how we approach this issue, and that a nudge can sometimes create a barrier to change.

The noble Baroness, Lady Prashar, has made a very important contribution to this debate and we take that very seriously. Any responsible Government would take this very seriously. How we get the right balance in this debate is very important. Part of getting that balance involves the kind of debate we have had this afternoon.

Allied Health Professionals: Training

Lord Prior of Brampton Excerpts

Monday 8th February 2016 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and I declare an interest as the honorary president of the Chartered Society of Physiotherapy.

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

My Lords, Health Education England plans to commission, overall, 7,554 AHP training places in 2016-17—an increase of 344, or 4.8%, compared to 2015-16. The announcement in the 2015 spending review to move nursing, midwifery and AHP students on to the standard student loan system is for new students commencing their courses from 2017 only and therefore does not affect students commencing their courses in 2016-17.

[Baroness Finlay of Llandaff]

Do the Government recognise that 500 more physiotherapy places will be needed in training each year until 2020 just to meet current needs? With Health Education England proposing cuts in training places in six out of 10 of the allied health professions—cuts ranging from 3.4% to 9.7%—how will the new models of care in prevention, patient treatment and reablement be met, given that they depend on these professionals taking on extended roles? This goes across sectors commissioned by the NHS and by other departments, including the Department for Education, the Home Office and the Ministry of Defence.

[Lord Prior of Brampton]

My Lords, Health Education England is proposing a net increase of 334 places in 2016-17 and we expect a growth in overall numbers of nurses and AHPs from 2017 onwards as a result of moving on to the standard student loan system.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister clarify that? He says that there is to be a net increase, but he will know that in relation to some specialties there is actually to be a reduction next year. This is a shambles. The Government have announced an increase in figures by 2020, but next year we are going to see an actual reduction in some of those places. What is going on?

[Lord Prior of Brampton]

My Lords, as I said, overall there is a small net increase of 334. That is largely for paramedics, where HEE believes that there is a more serious shortage than for other allied health professions. As I said, we have seen a significant increase in AHPs of more than 16% over the last five years and we expect that growth to continue after 2017.

[Baroness Walmsley (LD)]

My Lords, how will the Government achieve their objectives in relation to modernised cancer treatment and an enhanced role for radiographers when Health Education England is cutting the number of training places for therapeutic radiographers by 4.3%?

[Lord Prior of Brampton]

Actually, I think the number of radiographers is going up slightly. I will check, if I can, and write to the noble Baroness. It is also worth mentioning that the number of medical endoscopists is planned to go up by 200 over the next three years.

[Lord Quirk (CB)]

My Lords, while I welcome the 4.8% increase for the allied health professions, I deplore the fact that this increase is accompanied by really quite savage cuts in some of the professions concerned: 6% in the case of speech therapy. Does the Minister accept that our ageing population presents us with an increased incidence of stroke and dementia, and that the skills of speech therapists are essential to maintain and repair the language faculty? As a past president of the Royal College of Speech and Language, I urge the Government to think again. Is the Minister aware that costs would be far exceeded by benefits and that, for example, the west Birmingham rapid response team has saved the NHS more than £7 million a year by making unnecessary 17,000 bed days per annum?

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, I entirely agree with the noble Lord that the role of speech and language therapies, particularly in treating people with stroke and other serious conditions, is absolutely vital. Perhaps I may correct a previous answer that I gave to the noble Baroness, Lady Walmsley. Therapeutic radiographers have gone down slightly but diagnostic radiographers will go up slightly.

[Lord Harris of Haringey (Lab)]

My Lords, the Minister told us that the increase is among paramedics, which presumably balances the cuts in other areas. Is this the Government’s strategy for sorting out the problems in the ambulance service, which around the country is failing to meet emergency targets? Do the Government hope that by training some more paramedics, they will somehow solve the problem and money will magically become available for the ambulance service to function?

[Lord Prior of Brampton]

My Lords, having more paramedics is part of the solution, but the major part of the solution is to treat more people outside A&E departments, so that people do not require ambulances to take them into A&E departments but are treated at home.

[Baroness Howe of Idlicote (CB)]

My Lords, can the Minister tell the House how diabetic patients’ needs will be met by maintaining foot care and thereby decreasing the risk of amputations, given Health Education England’s proposed decrease in training places in podiatry of 9.7%? That is at the top end of the list which my noble friend Lady Finlay was talking about.

[Lord Prior of Brampton]

My Lords, I first extend my congratulations to the noble Baroness: it is her birthday today. I of course understand the vital importance of podiatrists. We are looking at a very small reduction in the planned number of training places next year of some 35 places. I would also make a more general point: in the mandate to Health Education England, we have set it a target of reducing the attrition rate among people starting training by 50%.

Junior Doctors

Lord Prior of Brampton Excerpts

Monday 8th February 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 shall now repeat in the form of a Statement the Answer to an Urgent Question on junior doctor contracts given in the other place by my honourable friend the Minister for Care Quality. The Statement is as follows:

“Mr Speaker, I will be delighted to update the House on the junior doctors’ proposed industrial action.

This Government were elected on a mandate to provide for the NHS the resources it asked for and to make our NHS a truly seven-day service. The provision of consistent clinical standards on every day of the week demands better weekend support services, such as physiotherapy, pharmacy and diagnostic scans, better seven-day social care services to facilitate weekend discharge, and better primary care access to help tackle avoidable weekend admissions.

However, consistent seven-day services also demand reform of staff contracts, including those of junior doctors, to help hospitals roster clinicians in a way that matches patient demand more evenly across every day of the week. In October 2014 the BMA withdrew from talks on reforming the junior doctors’ contract and, despite the Government asking them to return, did not start talking again until the end of November last year, in talks facilitated by ACAS. Throughout December we made very good progress on a wide range of issues and reached agreement on the vast majority of the BMA’s concerns.

Regrettably, we did not come to an agreement on two substantive issues, including weekend pay rates, so, following strike action last month, the Secretary of State appointed Sir David Dalton, one of our most respected NHS chief executives, to take negotiations forward on behalf of the NHS. Further progress has been made under Sir David’s leadership, particularly in areas relating to safety and training. However, despite agreeing at ACAS to negotiate on the issue of weekend pay rates, Sir David Dalton has advised us that the BMA has refused to discuss a negotiated solution on Saturday pay.

In his letter to the Secretary of State last week Sir David stated:

‘Given that we have made such good progress over the last 3 weeks—and are very nearly there on all but the pay points—it is very disappointing that the BMA continues to refuse to negotiate on the issue of unsocial hours payment. I note that in the ACAS agreement of 30 November, both parties agreed to negotiate on the number of hours designated as plain time and I hope that the BMA will still agree to do that’.

The Government are clear that our door remains open for further discussion and we continue to urge the BMA to return to the table. Regrettably, the BMA is instead proceeding with strike action over a 24-hour period from 8 am this Wednesday. Robust contingency planning has been taking place to try to minimise the risk of harm to the public, but I regret to inform the House that latest estimates suggest 2,884 operations have been cancelled. I hope honourable Members from all sides of the House will join me in urging the BMA to put patients first, call off its damaging strike action and work with us to ensure we can offer patients consistent standards of care every day of the week”.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister for repeating the Answer given in the other place. Clearly, the current situation is very worrying and we all want a speedy resolution of it, but I have three quick points to put to the Minister. First, he will know that imposing a contract which the overwhelming majority of junior doctors oppose risks industrial action further than that to which he has referred tonight, and more anger among NHS staff at a time when morale is low. If a new contract cannot be agreed, will he now rule out imposing one?

Secondly, the Minister knows that much of the angst among junior doctors has been caused by the Health Secretary’s repeated attempts to conflate reform of the junior doctor contract with the issue of a seven-day NHS. Will the Minister tell the House, for the record, which hospital chief executives have told the Government that the junior doctor contract is a barrier to seven-day service working? Will he tell me why this Health Secretary has gone out of his way to pick a fight with the very people who are already working across seven days?

The Minister is very well acquainted with the NHS and, indeed, with the views of junior doctors, with whom I know he keeps in very close touch. Does he not consider it absolutely appalling that these hugely important people, on whom the health service is going to depend for the next 20 or 30 years, have been so upset by the Health Secretary’s approach that they feel such estrangement from the NHS? Does he not think that the Government need to completely reset this process and what they have been saying about junior doctors and seven-day working, to get a proper resolution of this dispute?

[Lord Prior of Brampton]

My Lords, the noble Lord said he had three questions; I think there were only two questions there, which is unusual, if I may say so. We do not want to impose a contract. We want the BMA to come back and continue the talks and we still hope that that will happen. Clearly, imposing a contract is not what we ever wanted to do when this whole process started. As was said in the Statement, the Secretary of State’s door is open and we hope that we can resolve these difficult issues in a negotiated, consensual way.

On the noble Lord’s second question, he rightly said that this is an appalling situation, but actually I describe it more as a tragedy. Let me quote from a trainee doctor:

“I feel undermined and not valued at work and I have seen how this flagging morale among colleagues has caused more than ever to leave the profession. It is a hard job that takes dedication and stamina to continue. But as we are criticised and treated as ‘cogs in a wheel’ rather than as individual professionals, I think we will see ever increasing numbers of people leaving this profession”.

That was in 2005, after the contract came in. The issues facing the junior doctors go back a long way. It is not just about plain time on Saturdays or this particular contract but about how we value, reward, train and trust junior doctors. That is the issue we must come to when the current dispute is resolved.

[Baroness Walmsley (LD)]

My Lords, I think that the Minister did not answer the question from the noble Lord, Lord Hunt, about which hospital chief executives believe that the junior doctors’ contract is what is getting in the way of seven-day services. Surely the state of primary care, which is stretched all over the country, and the lack of diagnostics, laboratory services, X-rays and so on in hospitals are much more significant.

My own question is about plain time, which I believe is the sticking point. It occurs to me that the best way of ensuring patient safety is to make sure that we do not have tired doctors. Can the Minister convince me about the fact that we are being told that junior doctors will not have to work any more hours than they do now? If you are extending plain time from 8 am until 10 pm, instead of 7 pm, and into Saturdays, then it strikes me as quite possible that they will work much longer hours. I would be very interested to know what the average working week of a junior doctor is now compared to 20 years ago, because it strikes me that we are in danger of going backwards.

[Lord Prior of Brampton]

My Lords, I apologise for not replying to the question earlier about the number of chief execs. The point is that this is not just about junior doctors; I think we all understand that totally. We are hoping to have more primary care, more social care, more diagnostics and more senior consultant cover at weekends, which will support junior doctors and make their lives better at night time and over the weekend. As far as the hours are concerned, the new contract proposal puts far greater safeguards over the amount of time that junior doctors will be working. I think that is largely accepted by the junior doctors. Going forward, the maximum number of consecutive nights will be down from seven to four; the maximum number of long shifts—that is, over 10 hours—will be down from seven to five; the number of consecutive late shifts will be down from 12. We are putting in those safeguards to ensure that we do not go back to the bad old days of very long hours. They were the bad old days on one level but if you actually talk to most doctors, they did get tired and it affected safety but it built a sense of teamwork, camaraderie and purpose in hospitals. We need to be careful about rubbishing the old days when they built up a lot of really serious, good professional work.

[Lord Warner (Non-Afl)]

My Lords, can the Minister clarify whether this dispute has to be settled within the Government’s pay guidelines of a 1% annual increase for the rest of this Parliament?

[Lord Prior of Brampton]

It was always agreed that the package offered to junior doctors would be cost-neutral.

[Lord Lansley (Con)]

My Lords, does my noble friend the Minister recall, as I do, that it was a Conservative Administration who introduced the new deal for junior doctors and established a process by which unsafe, excessive hours for doctors were not to be pursued? That started happening in the early 1990s and no one is thinking that we would go back to that. I was delighted that my noble friend was able to make it clear how the negotiations can introduce additional guarantees about not having unsafe hours for junior doctors. However, I put it to him that at this stage in the negotiations there may be an alternative approach—an objective of enabling seven-day rostering for junior doctors, in this instance but also more widely, and an overall financial envelope. It might be put to the BMA that rather than it standing aside from the negotiations, it should take responsibility and say how it proposed that junior doctors should be remunerated within that financial envelope to meet those objectives.

[Lord Prior of Brampton]

My Lords, we certainly do not want to go back to the days when junior doctors were working very long and unsafe hours but nor should we ignore the fact that they do not, by and large, like being treated as shift workers. The continuity of care is very important to most professional doctors. As for the actual negotiations, I have not been directly involved with them so I do not know to what extent the junior doctors have been asked to consider what my noble friend Lord Lansley has suggested. However, what he says has much merit.

[Baroness McIntosh of Hudnall (Lab)]

May I take the Minister back to an answer which I think he gave to the noble Baroness, Lady Walmsley? He referred to his hope that other medical professionals will in due course be included in seven-day working in order, as I think he put it, to support the junior doctors. Can he say whether those people who are involved in the lab work, the diagnostics and so forth will also be asked to work on contracts comparable to those which the junior doctors are currently being asked to accept?

[Lord Prior of Brampton]

My Lords, I think that they will be different for different people but we already have seven-day working in some of our hospitals. Salford Royal is a case in point where we have a lot of seven-day working. This is something which will evolve over the next three years.