Brexit: Reciprocal Healthcare (European Union Committee Report)

Lord Ribeiro Excerpts

Tuesday 3rd July 2018 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I thank my noble friend Lord Jay—I use that term advisedly, as he chaired our committee with great skill—for securing and introducing this debate.

It is clear that the major issue still to be resolved in the Brexit negotiations is the border arrangements between Northern Ireland and Ireland. From a medical perspective, that border does not exist and healthcare has been freely exchanged for some time. Indeed, it predates the UK and Ireland joining the EU.

In my role as secretary of the Association of Surgeons of Great Britain and Ireland in the early 1990s, I met a young trainee surgeon in Dublin who was blazing a trail for the adoption of laparoscopic surgery for gall-bladder disease and hernia repairs. He subsequently transferred to the Central Middlesex Hospital as a consultant general surgeon and, soon after, was invited to become professor of surgery at St Mary’s Hospital in London. That surgeon was the noble Lord, Lord Darzi, from whom we will hear more on Thursday when he presents the debate on the NHS at 70.

Free movement of people allowed many surgical trainees to gain experience of laparoscopic surgery in Ireland. This was to the benefit of the UK, which was a little slower to adopt the technique of laparoscopic cholecystectomy. Free movement is a two-edged sword and, as our report demonstrates, children in Belfast have benefited from having their cardiac surgery performed in Dublin after the service ceased in Belfast in 2015. They are now in the all-Ireland children’s heart surgery centre.

Here I must declare an interest. When I was chairman of the Independent Reconfiguration Panel, we reviewed the report of the Joint Committee of Primary Care Trusts on children’s heart surgery in England. The report was called Safe and Sustainable and was published in 2012. It proposed a mandatory standard of four full-time surgeons and 400 paediatric surgical procedures per centre, driving a need for reconfiguring services. We concluded that centres providing surgery and interventional cardiology must have,

“at least four full-time consultant … surgeons”,

to provide,

“comprehensive … round the clock care, training and research”.

Although the Joint Committee of PCTs found the unit at the Royal in Belfast safe, it was not sustainable. The decision to centralise on one site in Dublin justifies its recommendations at the time.

In our report on reciprocal healthcare, we noted that there were probably as many people using directly agreed services through bilateral arrangements as there were using the EHIC, S1, S2 or patient rights’ directive. Services across the border serve both communities and reach enough patients to achieve economies of scale, and make it possible to recruit consultants to work in rural areas and communities which, on their own, would not justify a consultant appointment. I can testify to this, having visited Northern Ireland as president of the Royal College of Surgeons and seen the services provided at that time.

We also noted that joint services included oral and maxillo-facial services and a radiotherapy centre at the Altnagelvin Hospital, which opened in 2016 and was co-funded and co-planned by both jurisdictions. This form of co-operation would be threatened by a lack of agreement in the run-up to Brexit. One of our witnesses, Ms Bernie McCrory, described how co-operation in the ENT services had led to improved access to healthcare on both sides of the border. As is quoted in our report, she said:

“Children were waiting for maybe four years for their first appointment if they had hearing difficulties, with all of the problems that that would have thrown up education-wise and so on. There was a very robust ENT service in the southern trust in Northern Ireland where we had four ENT surgeons working on a rota. The EU money allowed us to employ two more ENT surgeons. The surgeons rotated into the south of Ireland, into Monaghan, where they did out-patient and day-case work. Then the patients travelled to Northern Ireland, to Craigavon and Daisy Hill Hospitals in the southern trust, to receive more complex surgeries that were not possible in a small rural hospital … [In 2016] 155 patients travelled from the south of Ireland to Northern Ireland for complex surgery, but the consultants who travelled down to the Republic saw over 2,000 patients in both out-patient and day-case procedures”.


We also heard evidence of how patients’ lives have been saved because of free and open access to emergency services across the border. They made the case for not returning to the bad old days of the Troubles when ambulances would park on one side of the border while the patient was transferred across to another ambulance on the other side. The Belfast agreement took years to broker and cross-border healthcare was described as one of the success stories of the Good Friday agreement. Surely nothing should be done to jeopardise this agreement. I know that my noble friend the Minister and the Government share this view.

The December joint report acknowledges the importance of these cross-border arrangements on health and notes that,

“the UK and Ireland may continue to make arrangements between themselves relating to the movement of persons between their territories (Common Travel Area)”—

the CTA predates our EU membership. We urge the Government to avoid such a hard border for patients and the health professionals who treat them. The continued access under the CTA to emergency, routine and planned care must continue if we are not to destabilise healthcare in the border areas. It is therefore not surprising that our report asks for healthcare to be treated as a priority in the negotiations on the island of Ireland, and the future relations between the EU and the UK.

In parallel to this report, we also took evidence on the impact of leaving the Euratom treaty and how this would affect the movement of radioisotopes, which we rely on for diagnosis and therapeutic treatments. There are some 700,000 nuclear medicinal procedures per year in the case of technetium-99m, which is used in 80% of all diagnostic procedures. We flagged up the importance of developing a new generation of alpha and beta-emitting isotopes for cancer treatment to mitigate any possible interruptions to treatments through delays at the ports, mindful that some radioisotopes have a short shelf life. I would like to ask my noble friend the Minister what the UK is doing to accelerate cyclotron production, in addition to the proposed new plant by Alliance Medical, which the Minister referred to in his letter dated 1 March to the noble Lord, Lord Jay.

Another form of treatment is proton beam cancer treatment. This begins at the Christie hospital in Manchester this August and is a first in the UK, with the University College Hospital in London following in 2020. Hopefully, this will prevent patients such as Ashya King being transferred from Southampton to Prague for treatment—if your Lordships recall, that caused quite a hullabaloo in this country. Can my noble friend say when we can expect more of these to mitigate the impact of leaving the EU and in the event that the S2 arrangements fail to be honoured? After all, nothing is agreed until everything is agreed, but it is difficult to see how we can secure reciprocal healthcare while we continue to oppose freedom of movement of people from the EU, as my noble friend pointed out.

National Health Service: Assaults on Staff

Lord Ribeiro Excerpts

Wednesday 20th June 2018 Lords Chamber

[Lord O’Shaughnessy]

I will look into the specific issue that the noble Baroness mentions. I do not have the details in front of me. I know that all local authorities provide free, taxpayer-funded rehabilitation services for those who are suffering from alcohol addiction. I should also point out that this Government have increased progressive taxation on stronger alcohol, such as white cider, specifically to try to change people’s drinking habits and to reduce alcohol-related violence.

[Lord Ribeiro (Con)]

Following the theme of alcohol, the Minister was kind enough to meet me and members of the Alcohol Health Alliance on 30 April. We stressed that accepting a minimum unit price, as in Scotland, would do much to remove alcohol—and, particularly, cheap alcohol—from vulnerable people, some of whom are responsible for the attacks to which we are referring. When will England accept a minimum unit price and implement it?

[Lord O’Shaughnessy]

I was delighted to meet my noble friend on this topic. I know he cares passionately about it. We have said—and I have said in this House before—that we are looking at the Scottish example with interest now that Scotland has gone ahead with it. There is a growing evidence base to demonstrate the benefits of minimum unit pricing, but we want to see what transpires in Scotland before making any decisions about whether to move ahead.

Long-term Plan for the NHS

Lord Ribeiro Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

I know that the noble Lord no longer serves the Labour Party, but he might be interested to know that the Labour leader said in February that,

“we will use the funds returned from Brussels after Brexit to invest in our public services”.

Clearly, we are not alone in believing that, once we leave the European Union—and, as a party, we are committed to leaving the European Union—we will no longer be sending subscriptions to Brussels but using them for the NHS. For further detail on the funding settlement, the noble Lord will need to wait until the Budget, when the Chancellor will outline the plans.

[Lord Ribeiro (Con)]

My Lords, I welcome this report, but note that the Statement refers to the number of over-75s increasing by 1.5 million, which will prove a challenge in the future. One of the recommendations of the long-term sustainability report was that we should look at other methods for ensuring funding. I was very pleased to hear the noble Baroness, Lady Thornton, say that the review suggests that the public are prepared to pay more towards the NHS. I suggest that if we look at the experience of Japan, where people over the age of 40 start making contributions towards their long-term care, we may well have an opportunity to resolve this problem. If the public are willing, the Government should look seriously at this in the context of social care.

[Lord O'Shaughnessy]

We have in this debate just started the lively conversation that we will be having on taxation in the next few months. Clearly there are a number of ideas; they have been voiced by Members on the Liberal Democrat and Labour Benches as well as those on my Benches and the Cross Benches. We know that there are a number of ways that this could be done; the Prime Minister has shown incredible leadership to admit that this is necessary. These are very difficult decisions: in polls, people say that they want to pay more tax but when it comes to the crunch they often feel slightly differently. True leadership is being able to take us through that situation, and that is what the Prime Minister is showing.

The Long-term Sustainability of the NHS and Adult Social Care

Lord Ribeiro Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, as a member of the committee I join others who have expressed their thanks to the noble Lord, Lord Patel, for producing the report and getting us to where we are today. It is a landmark report and a wake-up call to government to take notice and to act.

When I introduced my Private Member’s Bill on banning smoking in cars with children present, I was accused of invoking the nanny state. We have heard about that today. The Children and Families Act became law in 2014, and the regulations included penalties for the offence. The Mirror newspaper last year branded the ban an absolute failure because of only one conviction in two years. The DoH response was:

“The measure of success is the change of behaviour, not the number of convictions”.


I agree with that.

Recommendation 29 of our report asks the Government to mount a nationwide campaign on obesity and to highlight the many complications that arise from it and its links to chronic disease. It should include the selling of food and drinks and the advertising of junk food before the 9 pm watershed to protect children and support parents.

I will focus on the public health and prevention aspects of our report. The WHO identifies the four most important risk factors for non-communicable diseases as tobacco use, physical activity, the harmful use of alcohol and unhealthy eating. My noble friend Lord McColl will have dealt with obesity, as he has been a champion of this cause for many years. I hope that in his absence I can say a little on obesity and the surgical treatment of the condition. I will also speak on the impact of smoking, despite its falling prevalence, which was estimated in 2015 to cost the NHS £2.6 billion and is a major cause of preventable premature death, with some 80,000 deaths a year. I will end with alcohol which, with obesity, causes significant liver disease.

The Government are to be congratulated on introducing the soft drinks industry levy, or sugar tax, this month. This is a success story that they should be proud to claim. It was estimated that £520 million in tax revenue would result. However, since its announcement in 2016, 50% of manufacturers have reformulated their products to avoid the levy and the current estimate is £240 million. No matter—it has had the desired effect and goaded industry into action to reduce sugar in its products. There can be only one winner, and that is our children and grandchildren. That is what I call a “nanny state” at work—and, ironically, a Conservative nanny state.

It is estimated that, in England alone, a third of our children are obese or overweight when they leave primary school, and it gets worse as they progress through senior school, where there is evidence that 80% of obese children will become obese adults. Obesity is associated with 10 types of cancer, of which breast and bowel cancer are top of the list. So it is not just about size but about the metabolic health problems that lie in store for obese children.

Soft drinks levies work: they have done so in France, Denmark, Finland and Hungary—even though people remain sceptical about its effects in Mexico, where it was introduced in 2014 and has not affected the poor there as much as was expected.

We have the second-largest obesity epidemic in Europe, and the sixth-largest globally. A Cochrane review of 22 randomised controlled trials of bariatric surgery found it to be more effective and cost effective for treating severe obesity than non-surgical methods after two years. Long-term trials favour surgery. So why are others in Europe doing more as we do less? We are 13th out of 17 in EU countries and sixth in G8 countries for performing bariatric surgery. France, with a similar population to that of the UK, does 37,000 cases a year. Belgium, with a population of 11.3 million, does 12,000 per year. The UK does 5,000.

Surveys by the Royal College of Surgeons and the Metabolic Surgery Society suggest that some CCGs are not commissioning surgery unless a patient’s BMI is more than 50. This is unsafe and puts patients at risk when they finally earn their surgery. About 2.6 million people in the UK meet the NICE criteria for bariatric surgery. We cannot operate on them all, so the NHS must target patients with high BMIs and those with type 2 diabetes. What are the Government doing to increase the rate of bariatric surgery and to reduce the variation in access across the UK?

Another area touched on earlier is the effect of the sugar tax on the nation’s teeth and, in particular, on our children’s teeth. I spoke in the debate on the Queen’s Speech on the staggering amount of sugar—practically their own body weight—that children can consume in a year. It is time that something was done. To protect our children, the money from the sugar tax should go to nurseries, schools and breakfast clubs to help children brush their teeth and look after them. This is because Public Health England has shown that 141 children a day have their teeth removed in hospital due to dental decay. We should encourage schools to go sugar free, perhaps excluding special occasions such as birthdays.

On alcohol, policies should tackle affordability—hence the need for minimum unit pricing; availability, especially where minors are concerned; and marketing and distribution. A minimum unit price of 50p would have a major effect on white drinks—the cheapest alcohol products which cause the most harm, such as cider—without impacting on the price of drinks usually served in bars and restaurants. The health effects of alcohol abuse cost the NHS £3.5 billion per year. It is possible to exceed the guidance of 14 units per week for less than £2.50. There were 1.1 million alcohol-related admissions to hospitals in England in 2016.

This debate is limited in time. I had prepared something a little bit longer, so I will have to draw it to a close. With alcohol, it is important to focus on reducing demand rather than merely increasing NHS funding. This applies in areas that I have discussed, such as obesity, alcohol and smoking.

Finally, on the matter of public health and prevention, it is important to consider how future generations can take responsibility for their own health and contribute financially to their long-term care. The Prime Minister at PMQs in February 2017 said that,

“we do need to find a long-term, sustainable solution for social care in this country”.—[Official Report, Commons, 8/2/17; col. 420-21.]

As the Secretary of State said in his evidence to us:

“The reality is that putting in place longer-term incentives so that people save more for their social care costs will not make a material difference for decades, but it is still the right thing to do”.


I believe that he is right. Mention has been made of the Japanese and German schemes, and we referred to them in our recommendation 23. I passionately believe that those over the age of 40 should make some contribution to their long-term care.

As a colorectal surgeon, I relied on bowel cancer screening and colonoscopy to detect early colonic and rectal carcinomas. Sadly, far too many patients presented late, with evidence of disease in other organs, making surgery palliative at best. We need more cancer specialists, colonoscopists and pathologists to screen our growing elderly population. The noble Baroness, Lady Redfern, referred to faecal immunochemical testing for bowel cancer. When is that likely to be introduced UK-wide, as it was meant to be this month?

The Government are to be congratulated on introducing the sugar tax to deal with obesity and dental cavities, and the smoking regulations to protect our children from second-hand smoke. Now they must do more to tackle alcohol abuse and, in particular, cheap alcohol by introducing a minimum unit price.

Alcohol: Minimum Unit Pricing

Lord Ribeiro Excerpts

Wednesday 28th February 2018 Lords Chamber

[Lord O’Shaughnessy]

As I said, the Government are looking at this issue and, following the Supreme Court judgment, the Scottish Government can move ahead with their plans. The issue is not about the lack of evidence on whether reducing drinking has health benefits, but about making sure that any new system is implemented in a way that is fair on those who drink sensibly, particularly those on low incomes. The approach we have taken up to now is to use the tax system judiciously, including high duty levels for drinks such as white cider. As we move ahead and look at the evidence, we have to consider not just the health benefits but the economic costs that could be imposed on perfectly sensible drinkers.

[Lord Ribeiro (Con)]

My Lords, liver disease, unlike cancer, is the only major cause of premature death that has increased since 1970. As the Minister rightly says, the Scottish Government have this week introduced minimum unit pricing. Would the Minister be willing to meet me and the chairman of the Alcohol Health Alliance to discuss what we in this country can do to follow the Scottish lead?

[Lord O’Shaughnessy]

I would be very happy to meet my noble friend and the colleague he mentioned.

NHS: Clinical Negligence

Lord Ribeiro Excerpts

Wednesday 31st January 2018 Lords Chamber

[Lord O'Shaughnessy]

I completely agree with the noble Lord and make two points in response. He will know of the Secretary of State’s great passion for this area and of the maternity safety training funding and other training funding. From April, we will introduce the healthcare safety investigation branch, which will investigate each of the 1,000 incidents noted by the Each Baby Counts project which occur at birth, whether brain damage or neonatal death, precisely so that we can learn from that experience and make sure that those who provide these services are properly trained to avoid these incidents wherever humanly possible.

[Lord Ribeiro (Con)]

My Lords, we need to do something to tackle this issue much more urgently as the total cost of the litigation in the pipeline is some £65 billion—half the NHS budget. Until and unless we do something about changing Section 2(4) of the relevant Act we will have a continuing problem with patients claiming for private care when they should have their care provided by the NHS.

[Lord O'Shaughnessy]

I agree with my noble friend; this is an issue, not least because, when that Act was brought in, the NHS was a very different creature and did not offer the extensive range of care that it does now. We need to make sure that we are not effectively paying twice. However, this is a difficult and complex legal issue. It is important that we take our time to investigate how we tackle it properly so that those who are unfortunately affected by poor care are not put at a disadvantage for the rest of their lives.

NHS: Winter Staffing Levels

Lord Ribeiro Excerpts

Thursday 26th October 2017 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord knows that winter is always a more difficult time for the NHS. I hope he also knows that there are 11,000 more nurses on wards than there were in 2010. Indeed, I was looking at the data on doctors. There has been a 30% uplift in emergency doctors in that time as well. So there are more staff in the NHS—but, of course, there is much more need for winter preparedness. The NHS feels that it is better prepared than ever for winter.

On the issue that the noble Lord refers to—I assume he is talking about the story in the press today—that is, I stress, a local pilot that is being explored. I do not think it is even under way. It is being proposed by a local doctor—indeed, an emergency registrar. For it to go ahead, it is clear that any such pilot would have to abide by the very strict rules that exist on safety, safeguarding quality and so on for any care setting. The head of Age UK said that any new innovation—I think we want to encourage innovation—needs to pass the mum or grandma test. I think that is a very reasonable test to apply to something such as this.

[Lord Ribeiro (Con)]

My Lords, the only way in which to increase staffing levels in anticipation of the flu epidemic is through agency staff, which is going to cost a huge amount of money. Surely, the better thing to do would be to ensure that all health staff are vaccinated so they are at least healthy when the epidemic hits us—if it does.

[Lord O’Shaughnessy]

My noble friend talks with great authority on this issue and he is quite right. The NHS is offering all front-line health staff free vaccinations. NHS England has confirmed that it will also be paying for care workers in social care settings to get free jabs. Furthermore, we are now, for the first time, inoculating in school children aged between two and eight, who are sometimes known as “superspreaders”. This is to ensure that, if such an epidemic were to happen, we would be as well prepared as ever.

Queen’s Speech

Lord Ribeiro Excerpts

Thursday 29th June 2017 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, the election was announced two weeks after the publication of the Select Committee report on The Long-term Sustainability of the NHS and Adult Social Care, thus denying the House the opportunity for an early debate on the report. It became clear during the evidence taking that social care was impacting on the performance of the NHS. The ageing population presents the greatest challenge to the nation and, between 2015 and 2035, the number aged over 75 is projected to increase by 70%.

The gracious Speech identifies the need to improve the social care system and to put it on a more secure financial footing. The committee considered the funding options for social care and looked for examples around the world. In Japan, citizens aged 40 and over pay income-related premiums along with public health insurance premiums. Germany has a similar system, where the principle is that the costs are shared between the employer and the employee, similar to the workplace pension scheme in the UK. We should encourage those who can afford it to make provision for their long-term care and, in particular, social care, and not continue with a system that looks to the state to always pick up the tab. The Minister may wish to say something in relation to the consultation. As recommendation 23 of our report says:

“The Government should also implement as quickly as practicable, and no later than the first session of the next Parliament, new mechanisms which will make it easier for people to save and pay for their own care. The Government should, in the development of its forthcoming green paper on the future of social care, give serious consideration to the introduction of an insurance-based scheme which would start in middle age to cover care costs”.


These are important questions that need to be dealt with and answers provided.

Public health and prevention gets little press in the world of high-tech medicine, but a recent analysis by the Faculty of Dental Surgery at the Royal College of Surgeons should give cause for concern. It shows that there has been a 24% rise in the number of tooth extractions performed on children under the age of four in hospitals in England during the last decade. This is the first time such a long-term study has been done for children under four. Professor Nigel Hunt, the dean of the dental faculty, appealed to parents and the Government to take stronger action over the effects of sugar on our children’s teeth. He noted that the average five year-old eats his or her own weight in sugar in a year. The sugar tax, much derided by the food industry as a nanny-state tax, was introduced in the Budget this year to combat childhood obesity and tooth decay. The Chancellor described it as one tax which will actually reduce revenue. It seems that the threat of the tax and the Government’s legislation on the soft drinks industry levy, due for implementation in April 2018, has already altered behaviour and the food industry is reformulating its products and reducing the sugar content. I hope that the Minister will say more about this and what plans they have to restrict sugar and promote the use of fluoridation nationally to reverse dental caries and prevent obesity and type 2 diabetes.

On health, the only planned piece of legislation that I came across in the gracious Speech is the draft patient safety Bill, mentioned by the Minister in his opening speech. In July 2015, the Secretary of State for Health, Jeremy Hunt, announced the creation of the Healthcare Safety Investigation Branch, or HSIB, modelled on the successful Air Accident Investigation Branch used by the airline industry. The no-blame culture which that has cultivated has encouraged and led to a learning culture which has significantly reduced air accidents. The Secretary of State hoped that the HSIB would do the same for health but, despite starting in April this year, it lacks legal powers. In order to encourage staff to share information more freely with HSIB, it needs a safe space which prohibits the disclosure of information. People have challenged this, but if we want NHS staff to speak freely, we need to give them that opportunity to do so without the risk of litigation.

The current ministerial directions for HSIB do not make provision to override existing legislation, which would allow organisations such as the police, coroners and other professional regulators a power to compel disclosure of information. The HSIB’s chief investigator, Keith Conradi, recently came here to the House to give a briefing on what it is doing and has asked for primary legislation to secure HSIB’s independence. I know that my noble friend the Minister was at the meeting when that presentation was given. Can he say what the timeline is likely to be for the draft patient safety Bill, mindful that we now have a two-year Parliament? When can we expect the HSIB to have the same legal powers as the police and coroners?

Finally, I have a word about the Private Member’s Bill on cosmetic surgery standards, to be introduced in July by my noble friend Lord Lansley. It would equip the GMC with the power to show on the specialist register which practitioners have the credentials to undertake cosmetic surgery and other procedures. In January 2017, the Royal College of Surgeons launched a new system of cosmetic surgery certification to help patients identify surgeons with the appropriate training and experience to perform specific procedures. The recommendations of the Keogh review on the regulation of cosmetic intervention in 2013, following the breast implant scandal, is long overdue. Can the Minister say when it can be implemented?

Tobacco Control Plan

Lord Ribeiro Excerpts

Thursday 23rd February 2017 Lords Chamber

[Lord O’Shaughnessy]

I will certainly look at what they are doing in Finland. I was not aware of that, and it is a very ambitious goal. As a former smoker, I have to say I know the benefits both in health terms and in my pocket from reducing smoking. It is essential that we continue on the trajectory of reducing smoking that has been going for a long time. England is a world leader in this area, and we should recognise that. There has been huge success but clearly there is a lot more to do.

[Lord Ribeiro (Con)]

My Lords, in a recent survey the British Thoracic Society found that 72% of hospital patients who smoked were not asked if they wanted to quit. Will my noble friend assure me that the promised tobacco control plan will ensure that hospital patients who smoke will get the support they need to quit?

[Lord O’Shaughnessy]

My noble friend makes an excellent point. Indeed, the Royal College of Surgeons of Edinburgh has just started a campaign to encourage clinicians to help their patients to stop smoking, and making sure that that happens is clearly going to have benefits for the kind of major surgery that some of the people who are suffering severe effects of smoking will need to have.

National Health Service: Nurses

Lord Ribeiro Excerpts

Wednesday 22nd February 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness makes a very good point. In fact, the workforce figures out today, which show the increases I have described, also show an increase in the number of nurses with general qualifications who are capable of working across multiple specialties and different sectors.

[Lord Ribeiro (Con)]

My Lords, mindful of the fact that we have taken the decision to leave the European Union and realising that many of our nurses come from overseas, and more recently from Europe, surely the time to start increasing nursing numbers is now, to make sure that we deal with any shortfall that may come after 2020.

[Lord O'Shaughnessy]

My noble friend makes an excellent point. Currently, around 7% of nurses are EU nationals. There has not been a drop-off in the number of EU nationals joining the NHS workforce since the referendum; nevertheless, it is clearly sensible to reduce our reliance on overseas nurses each year. We are doing that through additional training places and through retention and return to work schemes.